The Body’s H20 Balancing Act
Judy Sabel BSN RN
sabelja@alverno.edu
Alverno College
MSN 621
Outcomes
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Describe signs and symptoms of fluid
volume deficit and fluid volume overload
Identify risk factors, laboratory findings &
nursing interventions for patients with fluid
imbalance
Recognize the body’s mechanisms involved
with fluid maintenance
Identify factors which can affect fluid
balance
Tutorial directions
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Return to the table of contents by clicking :
Table of
Contents
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Table of Contents
Dehydration
Scenario
Control of Fluid
Balance
Kidney Functions
H20 Balance
Puzzle
Stress Response,
Inflammation &
Genetics
Evaluating Edema
Common
Laboratory Values
References
Nursing
Interventions
*Note all images are microsoft clipart
unless otherwise noted
Fluid Overload
Scenario
Dehydration Scenario
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Noah Watter a 81 yr. old recent widower was admitted
today with dehydration. He was mowing his lawn when
his neighbor found him lying on the ground with slurred
speech. The outside temperature was 92⁰ with 80%
humidity. He has a history of hypertrophic
cardiomyopathy and hypertension. You will be his nurse
today.
iStock_000007337705XSmal
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The following is your nursing assessment of
Noah Watter:
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Noah is alert and oriented x 3
Temperature 99.8, HR 118, BP 88/60, RR 30
SpO2- 92 on room air, breath sounds clear bilaterally
Skin diaphoretic, capillary refill <3 seconds
Peripheral pulses are thready and 1+
Color is ashen, skin cool and clammy
Skin turgor poor, and tongue is dry
Urine output is decreased
Microsoft clipart
Which of your assessment findings are abnormal
and need to be reported to Noah’s physician?
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Incorrect
Capillary refill < 3 seconds
Incorrect
SPO 92 on room air
Incorrect
Correct!!
Alert and oriented x 3
HR 118, B/P 88/60
Correct!
HR and BP
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Tachycardia is usually the earliest sign of
decreased vascular volume. (Taylor, 2011)
Blood pressure is related to the amount of
blood the heart pumps and the extent of
vasoconstriction present. Fluid volume
affects these elements, making blood
pressure measurement key in assessing a
patients fluid status.
(Thompson, 2008)
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Evaluating your patient’s pulse amplitude can give you clues
to their hydration status.
Number
Definition
Description
0
Absent pulse
No pulsation felt despite
extreme pressure
1+
Thready pulse
Pulsation is not easily
felt, and slight pressure
causes it to disappear
2+
Normal
Stronger than a thready
pulse; light pressure
causes it to disappear
3+
Strong
Pulsation easily felt,
takes moderate pressure
to cause it to disappear
4+
Bounding pulse
The pulsation is strong
and does not disappear
with moderate pressure
(Taylor, 2011)
*When dehydrated your patient’s
pulse may be thready.
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The following assessment findings in Noah
Watter are also significant for dehydration
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Skin diaphoretic, temperature 99.8
Peripheral pulses are thready and 1+
Color is ashen, skin cool and clammy
Skin turgor (elasticity) poor and tongue is
dry
Urine output is low
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Noah’s physician ordered lab work with the
following results
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CBC: WBC 7,000/mm³, Hgb 17g/dl, Hct 57%,
Platelets 350,000/mm³
Chemistry: Na 162meq/L, K 5.0meq/L, CL 115meq/L,
HCO3 15meq/L, BUN 23mg/dl, Creatinine 1.0mg/dl,
Glucose 90mg/dl
Used with permission by the Washington
Endocrine Clinic
Click here to view
common lab values
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Which lab values were abnormal for Noah?
Correct!!
HCT 57% and Na 162
Incorrect
K+ 5.0
Incorrect
WBC’s -7,000
Incorrect
Glucose 90
Correct!
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Increased HCT – higher proportion of RBC compared to water in the
blood. 57% means that a 100ml sample contains 57ml of packed
RBC’s.
Increased electrolytes-elevated serum sodium level (above
145mEq/L). If more water is lost than NA+, serum sodium may be
high.
High urine specific gravity result of renal vasoconstriction and
increased secretion of ADH and aldosterone.
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Increased BUN- reflects kidney’s decreased excretion of urea.
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Low urine output & concentrated urine.
(Eckman 2008 ) (Pagana 2006)
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Noah Watter (an elderly male) was at risk for
dehydration because….
Incorrect
The elderly have a lower proportion of water
in their bodies
Incorrect
The elderly have decrease in kidney function,
thirst sensation, and functional sweat glands
Incorrect
He was mowing his lawn in 90⁰ weather
Correct!!
All of the above
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Correct!
Dehydration is a more serious problem for
the elderly.
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Lack significant fluid reserves
Lack ability to conserve fluid quickly
Watch for changes in mental status (Ackley 2006)
Prevalence of acute and chronic diseases makes them
more susceptible to fluid imbalances
Skin may lack elasticity in the elderly
Used with permission from Pethum Madusanka
skin turgor may be an unreliable sign
Check skin turgor of the elderly client on the forehead, sternum or
inner thigh
Presence of longitudinal furrows (deep grooves on tongue) or dry
mucous membranes is a good indication of dehydration
(Woodrow 2002)
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Which nursing intervention is not necessary when
monitoring Noah Watter’s condition?
Incorrect
Monitoring vital signs and cognitive function
Incorrect
Providing frequent oral hygiene and mucous membrane
assessment
Correct!!
Placing a urinary catheter to assess intake and output
Incorrect
Daily weights
Correct!
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Although it is necessary to monitor intake and output it is
not necessary to place a urinary catheter if your patient is
continent.
**It is especially important to monitor elderly clients
for excess fluid volume during the treatment of
dehydration:
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Listen for adventitious lung sounds
Assess for edema
Monitor vital signs
Monitor daily weights (Ackley, 2006 )
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The kidneys play a major role in fluid balance and
maintaining homeostasis in the body. This amazing
organ performs the following functions:
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Removes wastes and water from the blood
Balances chemicals in the body
Release of hormones
Helps to control blood pressure
Helps to produce red blood cells
Activates vitamin D
Click screen
to view video!
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The body holds fluid in two compartments. To maintain
fluid balance the distribution between the two
compartments must remain relatively constant.
1. Intracellular (ICF)- inside the cells.
2. Extracellular (ECF)- outside the cells
Broken down further:
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Intravascular fluid or plasma 25%
Interstitial fluid-surrounds the cells 75%
Infants have a greater percentage of body water
stored inside interstitial spaces compared to
adults . Many older people have less muscle but
more fat and so have fewer water stores.
Fluids help maintain body temperature & help in
transporting nutrients, gases, and wastes. To maintain
this balance the amount of fluid gained throughout the
day must equal the amount lost.
Entering (ml)
Losses (ml)
Liquids
1200ml
Urine
1400ml
Solid foods
1000ml
Feces
200ml
Cell metabolism
Total
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300ml
2500ml
(Gould, 2011 )
Insensible losses
Lungs
400ml
Skin
500ml
2500ml
*Insensible losses can’t be measured or
seen.
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In order to maintain fluid balance the body relies
on sodium and albumin to prevent too much fluid
from leaving the capillaries.
 Sodium-promotes water retention. Water follows
sodium.
*Maintains the osmotic pressure of extracellular fluid
*Regulates renal retention and excretion of water
*Maintains systemic blood pressure

Albumin-(magnet) for water. Water follows
albumin. Large molecule which draws fluid to it keeping fluid in the vascular space. This is called
plasma colloid osmotic pressure.
(Eckman, 2008)
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Many mechanisms in the body work together to maintain
fluid balance. The following make this amazing
balancing act possible:
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Thirst mechanism in the hypothalamus.
Kidneys- filter electrolytes, wastes & water into urine.
Hormonal systemsAntidiuretic hormone (ADH)- Also known as vasopressin.
Produced by the hypothalamus.
Renin- from the kidneys activates the renin-angiotensinaldosterone (RAA) system.
Atrial natriuretic peptide ANP-produced and stored in the
atria of the heart.
Brain natriuretic peptide BNP-secreted from the cardiac
cells.
(Eckman, 2008)
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Antidiuretic hormone (ADH)- this water retainer is
also called vasopressin.
The hypothalamus senses
low blood volume and
signals the pituitary
gland.
Pituitary gland
secretes ADH into
bloodstream
Holds water when fluid
levels drop and releases it
when fluid levels rise
ADH causes kidney
to retain water
Water retention
boosts blood volume
and decreases serum
osmolality.
(Eckman, 2008)
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Renin-angiotensin-aldosterone (RAA) systemthrough a complex series of steps, renin leads to the
production of antiotensin II.
Angiotensin 1
is converted to
angiotensin II
.
Blood flow to
the kidney
decreases
Renin converts
angiotensinogen
formed in the
liver to
antiotensin I
Kidney secretes
renin into the
bloodstream
(Eckman, 2008)
Angiotensin II
stimulates the
adrenal glands
to produce
aldosterone
Aldosterone causes the
kidneys to retain sodium
and water
Sodium and water
retention leads to
increases in fluid
volume and sodium
levels
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Atrial natriuretic peptide (ANP) & Brain natriuretic
peptide (BNP)-counteracts the effects of the RAA system
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When blood volume and blood pressure increase the heart’s
ANP & BNP shut off the renin-angiotensin-aldosterone system,
which stabilizes blood volume and blood pressure. Na+ and
water will be lost in the urine BP.
BP
(Eckman, 2008)
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When your patient is dehydrated does his ADH
secretion increase?
Correct!!
True
Incorrect
False
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TRUE!!
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Because his body was dehydrated , it would
try to retain as much fluid as possible
(Like a dam)
To retain fluid, ADH secretion increases
ADH
Click on arrow
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When your patient’s blood pressure
drops their kidneys respond by:
Correct!!
Secreting renin
Incorrect
Producing aldosterone
Incorrect
Slowing the release of ADH
Incorrect
Secreting ANP
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Correct! The kidneys secrete renin in
response to low blood flow or a low sodium
level. The eventual effect of renin secretion is
BP.
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Aldosterone is produced by the adrenal
glands
Pituitary gland secretes ADH
ANP is produced and stored in the atria of
the heart
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Fluid Overload Scenario
Noah Watter a 81 yr. old recent widower was
admitted today with dehydration. He has a history of
hypertrophic cardiomyopathy and hypertension. You
will be his nurse today. Noah’s physician orders the
following treatments:
iStock_000007337705XSmal
 IV Fluids
 Daily CBC, electrolytes, BUN and
creatinine levels
 Orthostatic blood pressures daily
a 15mm Hg drop in blood pressure when
upright or an increase of 15 beats/min in
pulse rate is seen with dehydration
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Noah Watters puts on his call light at the end of your shift….
“I’m having problems breathing.”
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Your Nursing Assessment
Temperature 98.6, HR 70, BP 180/90, RR 32
Skin pale, +2 pedal edema
Lung sounds have bilateral rales & patient
coughing
Bounding pulses 4+
Urine output 500ml
Noah asks for you to call his wife
Your assessment of Noah leads you to
believe…..
Correct!!
Noah is now fluid overloaded
Incorrect
Noah is showing s/s of pneumonia
Incorrect
Noah has adequate tissue perfusion
Incorrect
Noah needs to be transferred to the ICU
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Correct! Noah is showing signs of fluid
overload
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BP increased to 180/90 is the result of excess
volume- blood contains more water than normal,
increasing the pressure on the blood vessels
Shortness of breath, rales and cough- as left side of
the heart becomes overloaded fluid backs up into
the lungs
Pulse amplitude is increased in fluid volume
excess
Change in mental status is often seen in the elderly
(Taylor, 2011 )
If your patient has poor heart function the body
can’t compensate for the extra volume which can
lead to pulmonary edema.
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Click lungs 3 times!
Hydrostatic
pressure forces
fluid out of
pulmonary
blood vessels
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Interstitial
Space
When amount of
fluid is excessive,
fluid is forced into
the aveoli resulting
in pulmonary
edema
As left side of the heart becomes fluid overloaded and
pump efficiency declines , fluid backs up into the lungs.
Patient is SOB, tachypneic, cough
You may hear rales on auscultation of the lungs
(Eckman 2008)
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You report your assessment to Noah Watter’s
physician who orders the following:
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Discontinue IV fluids
Chest X ray stat
CBC, electrolytes, BUN, Creatinine & UA stat
Results:
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CBC: WBC 8,000/mm³ Hgb 19g/dl , Hct 36%, Platelets 350,000/mm³

Chemistry: Na 135meq/L, K 3.2meq/L CL 115meq/L, HCO3 15 meq/L
BUN 5, Creatinine 0.5mg/dl , Glucose 88
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Give 40mg Lasix IVP now.
Give K-Dur 20 Meq PO BID
Oxygen at 2L
Click here to view
common lab values
Table of
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Which lab values are abnormal for
Noah Watter?
Incorrect
BUN 5mg/dl and Creatinine 0.5mg/dl
Incorrect
Hct 36%
Incorrect
K+ 3.2meq/dl
Correct!
All of the above
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Correct! all of the laboratory values are
abnormal
Hct , serum potassium and BUN levels are low
due to hemodilution.
 Lower proportion of RBC compared to water
in the blood.
***Very important to monitor K+ levels
especially when receiving Lasix (potassium
depleting diuretic)

(Eckman 2008)
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Fluid overload how it happens
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Usually body compensates and restores
fluid balance (hormones)
If patient has poor heart function the
body can’t compensate for the extra
volume (will see increased BP)
Fluid is forced out of the blood vessels
and moves into the interstitial space
causing edema of the tissues
(Eckman, 2008)
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It is important to evaluate your patients hydration
status by monitoring edema and weight gain.
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Edema results as hydrostatic (fluid pushing) pressure builds in the
vessels, forcing fluid into the tissues
Skin looks puffy and feels cool, pits when touched
Patient gains weight (each 17oz.of fluid= 1lb)
If area is palpated with the fingers an indentation may remain after the
pressure is released
0
No edema
Daily weights
Visual assessment
Trace 2mm
+1
Measurement of affected part
+2
Moderate 4mm
+3
Deep 6mm
+4
Very Deep 8mm
(Taylor, 2011)
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Factors affecting fluid balance:
the stress response
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1.
2.
3.
Body’s attempt to adapt to stimuli
Hormones and neurotransmitters that are released during the stress
response function to:
Alert individual to a threat to homeostasis
Enhance cardiovascular and metabolic activity in order to manage
stressor
Focus energy of the body by suppressing the activity of systems not
immediately needed
(Porth 2009)
Click “stress” to
view video!
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Neuroendocrine responses to stress

Sympathetic nervous system- (fight or flight
Click face 4 times!
response)
SNS
Adrenal
medulla
Epinephrine &
Norepinephrine
•Activates the RAA system
•Increased heart rate
•Increased blood
pressure
•Pupil dilation
•Dry mouth
•Increased blood
coagulability
•ADH- also known as vasopressin increases water retention by
the kidneys and produces vasoconstriction of blood vessels
•Corticotropin releasing factor (CRF )increases ACTH which
increases cortisol & aldosterone
(Porth 2009)
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Inflammatory response also affects
fluid balance.
Click on the ball to see the how the inflammatory response can lead to
decreased blood volume and edema
Tissue Damage
Damaged cells
release prostaglandins and
leukotrienes
Increased
capillary
permeability
Hypovolemia
( decreased
blood
volume)
Exudate leaks out of
capillaries into
tissues
Click 8 times!
Edema of
tissues
(Bowne, 2011) (Porth, 2011)
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Genetics can also affect fluid balance and
heart function.

Your patient, Noah Watter has a history of Hypertrophic
cardiomyopathy (HCM) . This is an autosomal dominant heart disease
caused by mutations in the genes encoding proteins of the cardiac
muscle. These mutations impact his heart function which can
negatively impact his ability to maintain fluid balance. His heart is
affected in following ways:

Left ventrical hypertrophy

Disproportionate thickening of the ventricular septum

Abnormal diastolic filling

Cardiac arrhythmias
(Porth 2009)
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HCM is just one example of how genetics can affect fluid balance.
Any genetic mutation which affects the mechanisms by which the
body maintains fluid balance can alter this delicate balance..
The following are genetic
conditions affecting the
kidneys. Place mouse
over condition for
definition!
Nephronophthisis
-medullary cystic
disease complex
(Venes, 2009)
(Porth, 2011)
Polycystic Kidney
Disease
Joubert Syndrome
Ren -Related
Kidney Disease
Alport Syndrome
Hypoaldosteronism
Click on the “nurse” to see
appropriate nursing interventions
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•Assess for presence or worsening of FVD
•Administer oral fluids if indicated
•If patient unable to eat and drink,
anticipate TPN or tube feedings to be
ordered
•Monitor patient’s response to fluid intake,
either oral or parenteral
•Be alert for signs of fluid overload
(Taylor, 2011)
•Provide appropriate skin care
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Click on the “nurse” to see
appropriate nursing interventions
(Taylor, 2011)
•Assess for presence or worsening of FVE
•Encourage adherence to sodiumrestricted or fluid restricted diet if
ordered
•Avoid OTC drugs or check with physician
or pharmacist about sodium content
•Encourage rest periods
•Monitor patient’s response to diuretics
•Teach self-monitoring of weight and
intake and output
•Attentive skincare
•Monitor respiratory status
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Click on puzzle piece!
Common Laboratory Values
HEMATOLOGIC
MEN
WOMEN
Hgb
Hct
Rbc
ESR
WBC
Platelets
PT
PTT
CHEMISTRY
13.5–18 g/dL
40–54%
4.6–6.2 million/mm3
C20 mm/hr
5000–10,000/mm3
150,000–450,000/mm3
9.6–11.8 sec
30–45 sec
MEN
12–16 g/dL
38–47%
4.2–5.4 million/mm3
C30 mm/hr
5000–10,000/mm3
150,000–450,000/mm3
9.5–11.3 sec
30–45 sec
WOMEN
Sodium
Potassium
135–145 mEq/L
3.5–5.0 mEq/L
135–145 mEq/L
3.5–5.0 mEq/L
Chloride
HCO3
Glucose
Protein
Albumin
RENAL
95–105 mEq/L
19–25 mEq/L
65–99 mg/dL
6–8 g/d
4–6 g/dL
MEN
95–105 mEq/L
19–25 mEq/L
65–99 mg/dL
6–8 g/d
4–6 g/dL
WOMEN
BUN
Creatinine
Uric acid
ARTERIAL BLOOD GASES
6–20 mg/dL
0.6–1.3 mg/dL
4.0–8.5 mg/dL
MEN
6–20 mg/dL
0.5–1.0 mg/dL
2.7–7.3 mg/dL
WOMEN
ph
Po2
Pco2
O2 saturation
Hco3
7.35–7.45
80–100 mm Hg
35–45 mm Hg
95–97%
22–26 mEq/L
7.35–7.45
80–100 mm Hg
35–45 mm Hg
95–97%
22–26 mEq/L
(Pagana , 2006)
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to dehydration
scenario
Click here to return
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scenario
References
Benelam, B. (2010). Recognizing the signs of dehydration. Practice Nursing, 21(5), 230-234.
Table of
Contents
Bowne, P. (2011). Pat Bowne’s patho. Retrieved from http://faculty.alverno.edu/bowneps/
Eckman, M., Lavine, J., & Thompson, G. (eds). (2008). Fluids & electrolyes made incredibly easy.
Lippincott.
Gould, B. E., & Dyer, R. M. (2011). Pathophysiology for the health professions. Saunders Elsevier.
Licastro, F., Candore, G., Lio, D., Porcellini, E., Colonna-Romano, G., Franceschi, C. et al. (2005, May).
Innate immunity and inflammation in ageing; a key for understanding age-related diseases.
Immunity & Aging, 2(8), 1-14.
Moorhead, S., Johnson, M., Mass, M. L., & Elizabeth, S. (eds). (2008). Nursing outcomes classification
(NOC). Mosby.
Pagana, K., & Pagana, T. (2006). Mosby's manual of diagnostic and laboratory tests (third edition).
Mosby.
Porth, C. M., & Matfin, G. (2009). Pathophysiology concepts of altered health states. Lippincott.
Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing the art and science of
nursing care. Lippincott.
Venes, D. (eds). (2009) Tabers cyclopedic medical dictionary. 21 edition. F.A. Davis.
Woodrow, P. (2003). Assessing fluid balance in older people: Fluid replacement. Nursing Older People,
14(10), 29-30.