This document discusses fluid and electrolyte imbalances. It begins by outlining how water enters and leaves the body, and the mechanisms that maintain homeostasis of total fluid and electrolyte volume, including the endocrine, gastrointestinal, renal, and nervous systems. It then discusses fluid volume deficit/hypovolemia and excess/hypervolemia, their causes and nursing considerations. Next, it covers sodium, potassium, chloride, and calcium imbalances, outlining the normal levels and causes of deficits and excesses for each electrolyte. Nursing interventions are provided for managing various electrolyte imbalances.

2. FLUID AND ELECTROLYE
IMBALANCES

3. Routes by which water enters & leaves the body
Water enters the body in consumed liquids & additional water
present in solid foods
Water is lost from the body by way of skin,
lungs, in the urine & faeces

11. FLUID PRESSURE:
The hydrostatic pressure in the intravascular space (Pc) is
the principle force driving water and electrolytes out of the
capillary into the interstitial space.
Oncotic Pressure
Oncotic pressure is the osmotic
pressure generated by large molecules
(especially proteins) in solution. It tends to
reabsorb fluid & electrolytes from the
extracellular space.

13. The sodium-potassium pump system moves sodium and potassium
ions against large concentration gradients. It moves two potassium ions
into the cell where potassium levels are high, and pumps three sodium
ions out of the cell and into the extracellular fluid.

20. MECHANISMS THAT MAINTAIN HOMEOSTATSIS OF TOTAL FLUID
AND ELECTROLYTE VOLUME
1)The endocrine system as a
homeostatic regulator
2) The gastrointestinal tract as a Homeostatic regulator
3) The renal system as a homeostatic regulator
4) The nervous system as a Homeostatic regulator

21. FLUID VOLUME DEFICIT/ HYPOVOLEMIA
1) Loss of both water & electrolytes in the same
proportion as they exist in normal body fluids –
hypovolemia.
2)Loss of body fluid water alone with increased
sodium level- dehydration.

23. Nursing process of a patient
with fluid volume deficit
Assessment

24. Body sites for assessment of FVD
•1) General appearance: - thirsty, restless or lethargic
but irritable when touched.
•2)Vital signs:
o Pulse: weak, rapid pulse
o Blood pressure: postural hypotension
o Temperature: increased
o Respiration: unchanged or increased.

27. •Laboratory findings:
•Elevated hematocrit
above 50%.
•Elevated hemoglobin.
•Elevated serum sodium
above 150meq/litre.
•Elevated BUN

28. Nursing diagnosis:
 Fluid volume deficit related to loss of fluid though
diarrhea, vomiting.
 Fluid volume deficit related to osmotic diuresis.
 Fluid volume deficit related to inadequate intake or
high protein intake, high salty foods.

29. Goals:
o To have fluid replacement.
o To prevent complications of deficit-shock, renal
failure, fever, coma.
o To prevent complications of therapy-high blood
sugar, water intoxication.

30. INTERVENTION:
o Check weight on admission & daily weight.
o Keep an accurate record of intake/output.
o Report: Oliguria, anuria.
o Check vital signs on admission, every 2 to 4hrly.
o Carefully check IV infusions for proper flow rate guard against
infiltration & infection.
o Administer adequate fluids by route ordered-oral, tube feeding. IV
etc.
o Monitor serum sodium & hemoglobin values.
o Ensure the patients with high solute intake receive adequate water.
o Preserve the integrity of the skin & mucous membrane.
o Decreased salivation, so repeated gargling.

31. In case of renal failure:
o Check the urinary output/2hrly
o Report a urinary output of less than
30ml/hr or 500ml in 24hrs period
In case of Shock:
o Check vital signs every 2 hrly.
o Report a drop of blood pressure below
normal
o Any increase in pulse rate/respiratory
rate.
In case of fever:
• Report any elevation of temperature over
38.2°Cor 101F.
In case of coma:
• Report any decreased in level of consciousness
Prevent the complications: Watch for indications of high blood sugar
Ensure the following actions

32. Evaluation:
o Patient exhibits normal turgor of skin
o Excretes increased amount of urine with normal
specific gravity
o Exhibits return of pulse & blood pressure to
normal
o Exhibits clear sensorium, is oriented to
time/place/person
o Exhibits absence of precipitating risk factors.
o Drinks fluid as prescribed.

33. • FLUID VOLUME EXCESS
• Fluid volume excess refers to an
isotonic expansion of the ECF.
• It is always secondary to an
increase in the total body Na
content which in turn, leads to
an increase in total body water.

34. Etiology of fluid volume excess
o Diminished function of the homeostatic mechanism.
o Congestive heart failure.
o Cirrhosis of the liver.
o Overzealous administration of Na containing fluids to persons with impaired
regulatory mechanisms.
o Administration of steroids.
o Abnormal secretion of ADH.
o Excessive ingestion of table salt.
o Malnutrition-Hypoproteinemia.
o Repeated tap water enema.
o Lymphatic obstruction.

35. Nursing process for the patient with fluid volume excess:
Assessment: For proper assessment, the data are collected from primary
sources & secondary source.
Primary source is the patient; data is collected by taking nursing history,
physical examination, measurements.
The secondary source includes the significant others, health team members,
clinical records, laboratory, and diagnostic reports & literature.

36. Specific measurements for fluid
volume excess
• Weight gain over the last few
days of 2.2 lbs (0.998kg) will be
equal to 1Lt of retained fluid.
• Weight gain of 2.5% of the body
weight indicate mild
overhydration.
• 5-8% weight gain indicates
moderate over hydration.
• 8-10% weight gain indicates
severe over hydration.

37.  Vital signs:
o Body temperature: subnormal temperature
o Pulse: increased, bounding pulse (not easily obliterated)
o Respiration: shortness of breath, moist rales
o Blood pressure: Hypertension.
 Thirst: absence of thirst.
 Urinary output: increased urinary output.
 Facial appearance: full, swollen face with puffy eyelids.
 Level of consciousness: disorientation & confusion.

38.  Muscle tone: convulsions.
 Tissue turgor: pitting edema, finger imprinting on sternum,
dependent edema, standing position-feet & ankles and lying on
down-back & buttocks.
 Fluid accumulation in tissues: pulmonary edema, ascites,
hydrothorax and hydropericardium.
 Skin: warm, moist, flushed.

39. • Laboratory findings:
• Urine specific gravity: decreased, less than 1.010.
• Hemoglobin: decreased.
• Serum sodium: decreased 130 mEq/litre.
• The hematocrit remains relatively unchanged
because the swelling of the red cells is
proportional to the increased plasma volume.

40. Nursing diagnosis: Fluid volume excess related to the specific
condition. e.g., cardiac failure, sodium retention.
GOAL: Major goal is the prevention of fluid volume excess in patient at risk.
Detecting early fluid volume excess so that the therapeutic interventions can be
implemented.

41. Intervention:
o Check weight on admission daily.
o Keep an accurate record of intake/output chart.
o Check vital signs every 2 to 4 hrly.
o Sodium restricted & fluid restricted diet as prescribed.
o Providing rest as it favors diuresis of edema fluid.
o Close monitoring of parental fluid therapy.
o Semifowlers position to favor lung expansion.
o Patient turned & positioned at regular intervals since edematous tissue is
more prone to skin breakdown than normal tissue.

42. Evaluation
o Patient exhibits absence of edema & normal skin turgor.
o Excretes increased amount of urine.
o Demonstrates return of body weight to normal.
o Demonstrates no distention of jugular veins.
o Exhibits normal breath sounds without adventitious sounds.
o Maintains bed rest when prescribed.

43. • ELECTROLYTE IMBALANCES
• SODIUM IMBALANCE
• Sodium is a mineral element and an
important part of the human body. The
concentration ranges from 135 to 145
mEq/It.

44. The functions of sodium:
o It maintains the osmotic pressure and water balance.
o It is a constituent of buffer & involved in the maintenance of acid-base
balance.
o It maintains muscle & nerve irritability at the proper level.
o Sodium is involved in cell membrane permeability.
Dietary food sources: Table salt, salty foods, animal foods, milk, baking
soda, baking powder, some vegetables.

45. SODIUM DEFICIT (HYPONATREMIA)
The concentration of sodium in the blood lower than135 mEg/It is
hyponatremia.
A low sodium level in the blood can indicate either a deficit of sodium or an
excess of water.
Low salt levels can be caused by eating too little salt or excreting too much
sodium or water, and by diseases that impair the body's ability to regulate
sodium and water.
Keeping to a low-salt diet for many months or sweating too much during a
race on a hot day, can make it hard to keep sodium levels high enough.

46. Causes of hyponatremia can be grouped under two main causes
Loss of sodium:Patients taking diuretic drugs who eat a low-sodium diet may
have hyponatremia. Diuretic drugs get rid of sodium into the urine, but excreting
too much sodium can cause hyponatremia
2) Retention of water: Drinking too much water may cause low sodium levels,
because when the water is absorbed into the blood, it can dilute the sodium

47. Clinical manifestation:
Symptoms of hyponatremia usually don't appear until serum sodium falls
below 125 mEq/liter.
Common complaints include headache, nausea, vomiting, diarrhea, abdominal
cramps, muscle tremors, twitching, and weakness.
If severe, hyponatremia can cause confusion, seizures, and coma; even mild
hyponatremia can cause-confusion in the elderly.

48. • Treatment:
• The treatment for hyponatremia is usually the administration of sodium
supplements as prescribed

49. • SODIUM EXCESS (HYPERNATREMIA)
• A serum sodium level greater than 145mEg/It is known as
hypernatremia.
• Causes can be grouped under as:
• 1. Water depletion: High sodium levels may occur in diabetes insipidus, a
disease that causes too much urine to be produced.

51. 2. Excessive sodium intake or retention:
Hypernatremia can also occur in rare diseases in which the thirst impulse is
impaired.
Hypernatremia also can occur accidentally in the hospital when patients are
given solutions containing sodium.
IV administration of hypertonic saline or excessive use of sodium bicarbonate
also causes hypernatremia.

52. Clinical manifestations of hypernatremia:
1. Confusion, coma, paralysis of the lung muscles, and death.
2. If the levels build up suddenly, the brain cells can't adapt to their new high-
sodium environment. Due to increase in sodium concentration, water moves
out of the cell into the ECF, resulting in cellular dehydration.
3. Hypernatremia is especially dangerous for children and the elderly.
4. Moderately low sodium levels may trigger fatigue, confusion, headache,
muscle cramps, and nausea.
5. If hypernatremia is severe, permanent brain damage can occur, especially in
children. Brain damage is due to subarachnoid hemorrhages that result from
brain concentration.

54. Medical treatment:
Primary treatment of hypernatremia is administration of salt-free solutions to
return serum sodium levels to normal
Followed by infusion of 0.45% sodium chloride to prevent hyponatremia.
Dextrose in water is indicated when water needs to be replaced without sodium.
As a general rule, the serum sodium level is reduced at a rate no faster than 0.5 to
1 mEq/lit to allow sufficient time for readjustment.
Other measures include a sodium restricted diet and discontinuation of drugs that
promote sodium retention.

55. Nursing consideration for patients with hypernatremia:
o Monitor for fluid losses or gains in patients who are at risk for increased
sodium level.
o Note patient's thirst or elevated body temperature & its relation to other
clinical signs.
o Patients with diabetes insipidus, adequate water intake must be ensured.
o Avoid salty foods, salt tablets, or salty liquids, such as sports drinks.
o Drink plenty of water during exercise.
o Drink plenty of water when taking diuretics.
o Keep follow-up appointments with the doctor for chronic disease treatment.
o A person who has flu and uncontrollable vomiting needs to be monitored
carefully.

56. CHLORIDE IMBALANCE
o It is the major anion in the extracellular fluid space.
o In the normal adult body, chloride is about 30meq/kg of body weight.
o Approximately, 88% of the chloride is found in the ECF space, 12% in the ICF
space.

58. POTASSIUM IMBALANCE:
The normal concentration of potassium in the serum is in the range of 3.5 to
5.0 mEq.

60. •POTASSIUM DEFICIT
(HYPOKALEMIA):
•Hypokalemia means
serum or plasma
levels of potassium
ions that fall below
3.5 mM.

61. Causes of hypokalemia:
Causes of hypokalemia:
1)Drug inducednduced

62. 2. Gastrointestinal losses

63. 3. Alcoholism
4. Renal disorders

66. Medical
Management

67. Nursing consideration for hypokalemia
• Check serum potassium and other electrolyte levels in patients who
are likely to develop a potassium imbalance
• Carefully assess intake and output.
• Give I.V. potassium only after it's diluted in solution; may cause
phlebitis or tissue necrosis if it infiltrates.
• Infuse potassium slowly (no more than 20 mEq/L/hour) to prevent
hyperkalemia.
• Never administer it by I.V. push or bolus; it may cause cardiac
arrest.
• Monitor cardiac rhythm, and be alert for irregularities.

69. Causes of hyperkalemia:
1.Renal failure: the failure of the kidneys to normally excrete
potassium ions into the urine
2.Mineralocorticoid deficiency:The adrenal gland produces the
hormone aldosterone that promotes the excretion of potassium into
the urine by the kidney.
3.Cell damage:Hyperkalemia can also result from injury to muscle or
other tissues.
4.Acidosis:Acidosis, which occurs in a number of diseases, is defined
as an increase in the concentration of hydrogen ions in the
bloodstream.

72. CLINICAL TIP:

73. CALCIUM IMBALANCE:
Calcium is the most abundant mineral in the human body and is critical to good
health. The normal total serum calcium level is 8.6 to 10.2 mg/dil

75. CALCIUM DEFICIT (HYPOCALCEMIA)
Hypocalcemia, an insufficiency of serum calcium levels
can be caused by hypoparathyroidism, by kidney failure, by low levels of
plasma magnesium (hypomagnesia).
by failure to get adequate amounts of calcium or vitamin D in the diet.

76. Causes of hypocalcemia:
 Hypoproteinemia
 Hypoparathyroidism
 Renal disease
 Vitamin D deficiency
 Pseudohypothyroidism

78. • A mild calcium deficit may require nothing more than an adjustment
in diet to allow adequate intake of calcium, vitamin D, and protein,
possibly with oral calcium supplements.
• Acute hypocalcemia is an emergency that needs immediate correction
by I. V. administration of calcium gluconate or calcium chloride.
Treatment

79. Nursing consideration for patient with hypocalcemia
• Monitor serum calcium levels every 12 to 24 hours; a calcium
level below 4.5 mEg/L requires immediate attention.
• Slowly administer I.V. calcium gluconate in dextrose 5% in water
(never in saline solution, which encourages renal calcium loss).
• Don't add I.V. calcium gluconate to solutions containing
bicarbonate; it will precipitate.
• The IV site must be observed often for any evidence of infiltration
• Low Calcium can cause postural hypotension
• Observe seizure precautions for patients with severe hypocalcemia
that may lead to seizures.
• Airway status is closely monitored because laryngeal stridor can
occur.

80. CALCIUM EXCESS (HYPERCALCEMIA)
Hypercalcemia is an abnormally high level of calcium in the blood, usually
more than 10.5 milligrams per deciliter of blood.

81. Causes of hypercalcemia
Malignant disease
Hyperparathyroidism
o Excessive intake of vitamin D.
o Overuse of antacids.
o Diseases or conditions which cause bone loss or deterioration, such as Page's
and paralysis of the arms and legs can also lead to hypercalcemia.
o Secondary to immobility occur after severe or multiple fractures of spinal cord
injury.

83. Treatment

84. Nursing
consideration
for patient
with
hypercalcemia

85. MAGNESIUM IMBALANCE
Magnesium is the second most abundant intracellular
cation after potassium.
The body contains about 25 gm of magnesium, most of
which (55%) is present in the bones in association with
calcium and phosphorous.

86. HYPOMAGNESEMIA:
Abnormally low serum magnesium level
Usually associated with magnesium deficiency in
conditions with general nutritional insufficiency
accompanied by intestinal malabsorption, severe
vomiting, diarrhea or other causes of intestinal loss.

87. Sign and symptoms:
Impaired neuromuscular function such as tetany,
hyperirritability, tremor, convulsions and muscle
weakness.

89. HYPERMAGNESEMIA:
• Is uncommon but is occasionally seen in renal failure.
• Hypermagnesemia may rarely be caused by intravenous
injection of magnesium salts and adrenocortical
hypofunction.
• Depression of the neuromuscular system is the most
common manifestation of hypermagnesemia.

90. Nursing
consideration for
patient with
hypermagnesemia

92. Recapitulization
What are the clinical manifestations of
hyperkalemia?
What is the normal value of sodium?
What does jugular vein distension indicate?

93. Assignment:
1. Develop an information leaflet for patients
with hyperkalemia which includes dietary
instructions.
2. Revise the topic from The Trained Nurses’
Association of India.(2013). Medical surgical
nursing:A nursing process approach.

94. Bibliography:
Black, J., & Hawks, J. H. (2015). Medical–Surgical Nursing.
Springer eBooks.
Hinkle, J. L., & Cheever, K. H. (1996). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing.
Lewis, S. M., Bucher,et al. (2017). Medical-surgical Nursing:
Assessment and Management of Clinical Problems. Mosby.
Nettina, S. M. (2020). Lippincott Manual of Nursing Practice. Lippincott Williams & Wilkins.
The Trained Nurses’ Association of India.(2013). Medical surgical nursing:A nursing process
approach.