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Lec.4 Fluid and Electrolyte

Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Fluid and Electrolyte
Dr. Sabah Abdullah
Inter- Between
Intra- Within
Extra- Outside
Hypo- Under, beneath, deficient
Hyper- Above, beyond, excessive
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Body fluids: the term refers to both fluid and electrolyte.
Homeostasis: is the state of equilibrium of internal body environment and balance of body
Fluid compartments: The body’s fluid is contained within three compartments:
1. Cells (Cars)
2. Blood vessels. (The lines)
3. Tissue space (space between the cells and blood vessels).(space
between cars)
Distribution of body fluid:
1. Intracellular fluid: fluid found inside the
2. Extracellular fluid: fluid found outside the
a. Intravascular fluid: plasma
b. Interstitial fluid: fluids surround the
Movement of Body Fluids and Electrolytes
Small particles such as ions, oxygen, and carbon dioxide move easily across cells
larger molecules such as glucose and proteins have more difficulty moving between
fluid compartments.
Solutes ‫ محلول مذاب‬are substances dissolved in a liquid.
For example, when sugar is added to coffee, the sugar is the solute.
Solute: crystalloids + colloids
A solvent ‫مذيب‬is the component of a solution that can dissolve a solute.
In the body, water is the solvent; the solutes include electrolytes, gases such as oxygen and
carbon dioxide, glucose, urea, amino acids, and proteins
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Osmosis: the movement of water molecules from a less concentrated area to a more
concentrated area in an attempt to equalize the concentration of solutions on two sides of a
Osmolality: The concentration of solutes in body fluids
Tonicity: refer to the osmolality of one solution in relation to another solution.
Electrolytes: charged ions capable of conducting electricity, are present in all body fluids and
fluid compartments.
Sodium (Na+), Potassium (K+), Calcium (Ca2+), Magnesium (Mg2+), Chloride (Cl− )
Electrolytes Functions is:
• Maintaining fluid balance.
• Contributing to acid–base regulation .
• Facilitating enzyme reactions.
• Transmitting neuromuscular reactions.
Regulating Body Fluids:
Average adult drinks about 1,500 mL/day
The additional 1,000-mL volume is acquired from foods and from the oxidation of
these foods during metabolic processes. The thirst mechanism is the primary
regulator of fluid intake. The thirst center is located in the hypothalamus of the
The routes of fluid output include:
Urine Normal urine output for an adult is 1,400 to 1,500 mL per 24 hours, or at
least 0.5 mL per kilogram per hour.
• Feces 100–200 ml 24
• Insensible losses (through the skin as perspiration and through the lungs as water vapor
in expired air).
Insensible losses Lungs 350–400
Skin 350–400
Sweat 100
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Age : can create critical fluid imbalances in children much more rapidly than adult
Infants 28 days-1 year: because their higher metabolic rate increases fluid loss.
Kidney: immature kidneys are less able to conserve water.
Respiratory rate : increases insensible fluid losses.
Sex and Body Size: Water accounts for approximately 60% of an adult man’s
weight, but approximately 52% of an adult woman’s weight. In someone who is
obese this percentage may be even lower, with water accounting for only 30% to
40% of the person’s weight.
6. Environmental Temperature: People with an illness and those participating in
strenuous activity are at increased risk for fluid and electrolyte imbalances when
the environmental temperature is high. Both electrolytes and water are lost
through sweating. When only water is replaced, electrolyte depletion is a risk
7. Lifestyle : Lifestyle factors such as diet, exercise, stress, and alcohol consumption
affect fluid, electrolyte, and acid–base balance.
Fluid imbalance:
FLUID VOLUME DEFICIT: occurs when the body loses both water and electrolytes from
the ECF in similar proportions.
(a) abnormal losses through the skin, gastrointestinal tract, or kidney.
(b) decreased intake of fluid.
(c) bleeding.
Example on fluid volume deficit:
Hypovolemia: fluid is initially lost from the intravascular compartment.
Loss of water and electrolytes from: • Vomiting • Diarrhea • Excessive sweating • Polyuria •
Fever • Nasogastric suction • Abnormal drainage or wound losses.
Dehydration: occurs when water is lost from the body, leaving the client with excess
Dehydration clinically detected with the patients:
have a prolonged fever, are in
diabetic ketoacidosis,
receiving enteral feedings with insufficient water intake.
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
FLUID VOLUME EXCESS: occurs when the body retains both water and sodium in similar
proportions to normal ECF.
Hypervolemia :fluid is initially increased blood volume.
(a) excessive intake of sodium chloride.
(b) administering sodium-containing infusions too rapidly, particularly to clients with
impaired regulatory mechanisms.
(c) disease processes that alter regulatory mechanisms, such as heart failure, renal failure,
cirrhosis of the liver
EDEMA: Excess interstitial fluid
Overhydration: occurs when water is gained in excess of electrolytes, resulting in low
serum osmolality and low serum sodium levels. Water is drawn into the cells, causing them
to swell.
Electrolyte Imbalances
Sodium (Na+)It is found in most body secretions, for example, saliva,
gastric and intestinal secretions, bile, and pancreatic fluid.
Function: regulating water balance.
Hyponatremia is a sodium deficit, or serum sodium level of less than
135 mEq/L
Gastrointestinal fluid loss
Use of diuretics
Clinical manifestation:
Lethargy, confusion, apprehension Muscle twitching Abdominal cramps Anorexia, nausea,
vomiting Headache Seizures, coma.
Nursing Interventions:
Monitor fluid intake and output. Monitor laboratory data (e.g., serum sodium). Assess client
closely if administering hypertonic saline solutions. Encourage food and fluid high in
sodium if permitted (e.g., table salt, bacon, ham, processed cheese). Limit water intake as
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Hypernatremia: is excess sodium in ECF, or a serum sodium of greater than 145 mEq\L.
Loss of Water • Insensible water loss (hyperventilation or fever) • Diarrhea • Water
deprivation Gain of Sodium • Parenteral administration of saline solutions • Hypertonic
tube feedings without adequate water • Excessive use of table salt (1 tsp contains 2,300 mg
of sodium) ,Conditions such as: • Diabetes insipidus • Heat stroke
Clinical manifestation:
Thirst Dry, sticky mucous membranes Tongue red, dry, swollen Weakness
Severe hypernatremia: • Fatigue, restlessness • Decreasing level of consciousness •
Disorientation • Convulsions.
Nursing Intervention:
Monitor fluid intake and output. Monitor behavior changes (e.g., restlessness,
disorientation). Monitor laboratory findings (e.g., serum sodium). Encourage fluids as
ordered. Monitor diet as ordered (e.g., restrict intake of salt and foods high in sodium).
Hypokalemia: is a potassium deficit, defined as a serum potassium level of less than 3.5
Loss of Potassium • Vomiting and gastric suction • Diarrhea • Heavy perspiration • Use of
potassium-wasting drugs (e.g., diuretics) • Poor intake of potassium (as with debilitated
clients, alcoholics, anorexia nervosa) • Hyperaldosteronism
Clinical manifestation:
Muscle weakness, leg cramps Fatigue, lethargy Anorexia, nausea, vomiting Decreased
bowel sounds, decreased bowel motility Cardiac dysrhythmias Depressed deep-tendon
reflexes Weak, irregular pulses Laboratory findings: Serum potassium < 3.5 mEq/L Arterial
blood gases (ABGs) may show alkalosis T-wave flattening and ST-segment depression on
Nursing intervention:
Monitor heart rate and rhythm. Monitor clients receiving digitalis (e.g., digoxin) closely,
because hypokalemia increases risk of digitalis toxicity. Administer oral potassium as
ordered with food or fluid to prevent gastric irritation. Administer IV potassium solutions
at a rate no faster than 10–20 mEq/h; never administer undiluted potassium
intravenously. For clients receiving IV potassium, monitor for pain and inflammation at
the injection site. Teach client about potassium-rich foods. Teach clients how to prevent
excessive loss of potassium (e.g., through abuse of diuretics
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Hypocalcemia is a calcium deficit, defined as a total serum calcium level of less than 8.5
mg/dL or an ionized calcium level of less than 4.5 mEq/L.
• Hypoparathyroidism • Acute pancreatitis • Hyperphosphatemia • Thyroid carcinoma
Inadequate Vitamin D Intake • Malabsorption • Hypomagnesemia • Alkalosis • Sepsis •
Alcohol abuse
Clinical manifestation:
Severe depletion of calcium can cause tetany with muscle spasms and paresthesias
(numbness and tingling around the mouth, hands, and feet), and can lead to seizures.
Two signs indicate hypocalcemia: Chvostek’s sign is a contraction of the facial muscles
in response to tapping the facial nerve in front of the ear.
Trousseau’s sign is a carpal spasm in response to inflating a blood pressure cuff on the upper arm to
20 mmHg greater than the systolic pressure for 2 to 5 minutes
Nursing intervention:
Closely monitor respiratory and cardiovascular status. Take precautions to protect a
confused client. Administer oral or parenteral calcium supplements as ordered. When
administering intravenously, closely monitor cardiac status and ECG during infusion.
Hypercalcemia is a calcium excess, defined as a total serum calcium level greater than
10.5 mg/dL, or an ionized calcium level of greater than 5.5 mEq/L
• Prolonged immobilization Conditions such as • Hyperparathyroidism • Malignancy of the
Clinical manifestation:
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Lethargy, weakness Depressed deep-tendon reflexes Bone pain Anorexia, nausea, vomiting
Constipation Polyuria, hypercalciuria Flank pain secondary to urinary calculi
Dysrhythmias, possible heart block
Nursing intervention
Increase client movement and exercise. Encourage oral fluids as permitted to maintain a
dilute urine. Teach clients to limit intake of food and fluid high in calcium. Encourage
ingestion of fiber to prevent constipation
Hypomagnesemia is a magnesium deficiency, defined as a serum magnesium level of less
than 1.5 mEq/L.
•Chronic alcoholism • Pancreatitis • Burns •Diarrhea
Clinical manifestation:
Neuromuscular irritability with tremors Increased reflexes, tremors, convulsions Positive
Chvostek’s and Trousseau’s, Tachycardia, elevated blood pressure, dysrhythmias
Disorientation and confusion Vertigo Anorexia, dysphagia Respiratory difficulties
Nursing intervention:
•Assess clients receiving digitalis for digitalis toxicity. Hypomagnesemia increases the risk
of toxicity. Take protective measures when there is a possibility of seizures: • Assess the
client’s ability to swallow water prior to initiating oral feeding. • Initiate safety measures to
prevent injury during seizure activity. • Carefully administer magnesium salts as ordered.
Encourage clients to eat magnesium-rich foods if permitted (e.g., whole grains, meat,
seafood, and green leafy vegetables)
Hypermagnesemia is a magnesium excess, defined as a serum magnesium level above 2.5
mEq/L, due to increased intake or decreased excretion.
• Renal failure • Adrenal insufficiency • Treatment with magnesium salts.
Clinical manifestation:
Peripheral vasodilation, flushing Nausea, vomiting Muscle weakness, paralysis
Hypotension, bradycardia Depressed deep-tendon reflexes Lethargy, drowsiness
Respiratory depression, coma Respiratory and cardiac arrest if hypermagnesemia is
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Nursing intervention:
• Monitor vital signs and level of consciousness when clients are at risk. • Assess the
reflexes if absence notify the physician.
Hypochloremia is a chloride deficit, defined as a serum chloride level below 95 mEq/L,
and is usually related to excess loss of chloride through the GI tract, kidneys, or sweating.
Hypochloremic clients are at risk for alkalosis, and may experience muscle twitching,
tremors, or tetany.
Hyperchloremia is a chloride excess, defined as a serum chloride level above 108 mEq/L.
Excess replacement of sodium chloride or potassium chloride is a risk factor for high serum
chloride levels, as are conditions that lead to hypernatremia. The manifestations of
hyperchloremia include acidosis, weakness, and lethargy, with the risk of dysrhythmias or
Nursing Process: Fluid and Electrolyte disorders
Include data collection: subjective and objective data
1. Physical Assessment for Fluid, Electrolyte:
Possible Abnormal Findings
Flushed, warm, very dry Moist or diaphoretic Cool and pale
Mucous membranes
Mucous membranes dry, dull in appearance; tongue dry and
Fontanels (infant)
Cardiovascular system
Eyeball feels soft to palpation
Fontanel bulging, firm
Fontanel sunken, soft
Tachycardia, bradycardia; irregular; dysrhythmias Weak
and thready; bounding Hypotension Postural hypotension
Respiratory system
Increased or decreased rate and depth of respirations
Decreased LOC, lethargy, stupor, or coma Disoriented,
confused; difficulty concentrating
Facial muscle twitching including eyelids and lips on side of
stimulus Carpal spasm: contraction of hand and fingers on
affected side
Fundamentals of Nursing\ Theory
2. Clinical Measurements:
A. Daily Weights
B. Vital Signs
C. Fluid Intake and Output
1) Oral fluids
2) Tube feedings
3) Parenteral fluids
4) IV medications:
5) Catheter or tube irrigants
6) Urinary output:
7) Vomitus and liquid feces
8) Tube drainage
9) Wound and fistula drainage
10) Foods that are or become liquid
Fluid and Electrolyte
II. Nursing Diagnosis:
1. Deficient Fluid Volume: Decreased intravascular, interstitial, and/ or intracellular
fluid. This refers to dehydration, water loss alone without change in sodium.
2. Excess Fluid Volume: Increased isotonic fluid retention.
3. Risk for Imbalanced Fluid Volume: Vulnerable to a decrease, increase, or rapid shift
from one to the other of intravascular, interstitial, and/or intracellular fluid, which
may compromise health. This refers to body fluid loss, gain, or both.
4. Risk for Deficient Fluid Volume: Vulnerable to experiencing decreased intravascular,
interstitial, and/or intracellular fluid volumes, which may compromise health.
5. Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide
elimination at the alveolar-capillary membrane.
6. Impaired Oral Mucous Membrane related to fluid volume deficit
7. Impaired Skin Integrity related to dehydration and/or edema
8. Decreased Cardiac Output related to hypovolemia and/or cardiac dysrhythmias
secondary to electrolyte imbalance (K+ or Mg2+)
9. Ineffective Tissue Perfusion related to decreased cardiac output secondary to fluid
volume deficit or edema • Activity Intolerance related to hypervolemia
10. Risk for Injury related to calcium shift out of bones into extracellular fluids • Acute
Confusion related to electrolyte imbalance.
III. Planning:
Maintain or restore normal fluid balance.
• Maintain or restore normal balance of electrolytes in the intracellular and extracellular
compartments. • Maintain or restore gas exchange and oxygenation.
• Prevent associated risks (tissue breakdown, decreased cardiac output, confusion, other
neurologic signs).
Implementing: (intervention)
1) Enteral Fluid and Electrolyte Replacement
- Fluid Intake Modifications
Fundamentals of Nursing\ Theory
Fluid and Electrolyte
Dietary Changes
Oral Electrolyte Supplements
2)Parenteral Fluid and Electrolyte Replacement
Intravenous Solutions
- 0.9% NaCl
(normal saline)
- Lactated -Ringer’s
(a balanced
- 5% dextrose in
water (D5W)
- 0.45% NaCl (half
normal saline)
- 0.33% NaCl (onethird normal
- 5% dextrose in
normal saline
(D5NS) 5%
- dextrose in 0.45%
NaCl (D5 1/2NS)
- dextrose in
lactated Ringer’s
- Isotonic solutions such as normal saline (NS) and
lactated Ringer’s initially remain in the vascular
compartment, expanding vascular volume. Assess
clients carefully for signs of hypervolemia such as
bounding pulse and shortness of breath.
- 5W is isotonic on initial administration but
provides free water when dextrose is metabolized,
expanding intracellular and extracellular fluid
volumes. D5W is avoided in clients at risk for
increased intracranial pressure (IICP) because it
can increase cerebral edema
- Hypotonic solutions are used to provide free water
and treat cellular dehydration. These solutions
promote waste elimination by the kidneys.
Hypertonic solutions draw fluid out of the
intracellular and interstitial compartments into the
vascular compartment, expanding vascular volume.
Do not administer to clients with kidney or heart
disease or clients who are dehydrated. Watch for
signs of hypervolemia.