Fluid & Electrolyte Imbalance
How to keep things flowing along!
Lisa B. Flatt, RN, MSN, CHPN
Body Fluids
• Body mostly composed of:
▫ fluid –water
▫ solutes - electrolytes
• Osmolality- the balance between fluid and
solutes – This is a delicate balance! Every organ
and system reacts differently to an imbalance.
Swollen feet and ankles – water is
attracted to sodium!
• Semi-permeable membrane – selected particles move by
passive diffusion – that’s how sodium follows water.
• Osmotic pressure is the strength of the solution to draw
the water across the SPM.
• Passive diffusion – solutions of greater concentrations
moves solutes to solutions of less concentration
• Filtration – fluid and solutes move across a membrane
from area higher pressure to lower pressure
• Active transport – substances are moved from low to
high concentration areas (metabolic energy & enzymes
are used, ie. Sodium potassium pump)
Let’s see… what are the differences….
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Osmosis –
Diffusion –
Filtration –
Active transport -
Where you can find Body Fluid
Intracellular Fluid
Extracellular Fluid
• Is 2/3 to ¾ of total body fluid
• Found inside the cells
• Outside the cells
• Divided into compartments
▫ Intravascular fluid
Plasma- vascular system
▫ Interstitial fluid
Surrounds cells – lymph
▫ Transcellular fluid
Epithelial cells (synovial
fluid)
Potassium
• Potassium (3.5 – 5.0 meQ/l)
• Found and for: intracellular- cardiac, skeletal and smooth muscle activity
• Hyperkalemia- high K
▫ Causes-renal failure & (drug induced)
S/S – tetany, irritability, parasthesia, GI hyperactivity, cardiac
arrhythmias
Nursing interventions: Kayexelate (po and pr), D50 and
Insulin, dietary intake
• Hypokalemia- low K
▫ Causes-drug induced, N&V&D, gastric suctioning, exercise (shin splints)
S/S – weak, fatigued, cardiac arrhythmias
Nursing Interventions: IV and PO K, po and iv fluids, dietary intake
Magnesium
• Magnesium (1.5 – 2.5 mEq/l)
• Found and For: intracellular metabolism, protein and DNA synthesis
• Hypermagnesia – high Mg
▫ Causes-drug induced,
S/S – lethargy, coma, impaired respirations
Nursing Interventions- medication, diet
• Hypomagnesia- low Mg
▫ Causes – alcoholism
S/S – confusion, disoriented, tremors, irritability
Nursing Interventions – medications, diet
Sodium -- Salt sucks
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Sodium (135 - 145meQ/l)
Found and For: intra&extracellular – Na and K balance needed in body – key electrolyte
Hypernatremia – high sodium
▫ Causes – increased dietary intake, body system imbalances (kidney) – dehydration of the
cells, water gets sucked from the cells and into the tissue
S/S – edema, thirst, confusion, dry mucus membranes, mental status changes
Nursing Interventions- fluid restrictions, diet restrictions
Hyponatremia – low sodium
▫ Causes- exercise and too much water “water toxicity” – water gets sucked from the cells into
the tissue (how most people die in the Grand Canyon – they need to take salt pills **Thank
you Wes for the fun fact**)
S/S – muscle cramping, N&V, postural hypotension, mental status changes, hallucinations of
oasis!
Nursing Interventions – medications, iv fluids, electrolytes
Calcium
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Calcium (8.5 – 10.5 meQ/l)
For: blood coagulation, neuromuscular activity and bone growth
Found: Located in Bones
Hypercalcemia – high Ca
▫ Causes – cancer with met’s to bone, drugs, parathyroid glandular issue
S/S – kidney stones, lethargy, weakness, decreased muscle tone
Nursing interventions: safety, iv fluid
• Hypocalcemia – low Ca
▫ Causes-alcoholism, low serum Mg, parathyroid gland removal
S/S – numbness, tremors, cardiac arrhythmia, osteoporosis
Nursing Interventions: iv fluids, medications, diet
**Calcium and Phosphate work together – form bone and teeth --- if one is high the
other is lower
Phosphates
• Essential for function of: muscles, nerves and RBC
• Involved in PRO, Fat and CHO metabolism
• Hypophosphatemia - TPN, glucose & insulin can cause phosphates to shift into
cells
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Alcohol withdrawal
Antacid use (acid base imbalance)
S/S – weakness, pain, mental changes, seizures
Hyperphosphatemia – Phosphates shift out of cell (trauma, chemo, malignant tumor),
at risk – infants fed cow milk ((Fleets phosophosoda))
S/S – numbness, tingling **Around mouth and fingers** muscle spasm, tetany
Nursing interventions: Diet, Medications, IV Fluids, Education
Chloride
• Imbalances occur with Na imbalances
• Hypochloremia – low Chloride
▫ Causes: sweating, kidney loss, GI tract losses
S/S – twitching, tremors, tetany
• Hyperchloremia – high Chloride
▫ Causes: Na retention or high potassium
S/S – tremors, acidosis, weakness, lethargy,
arrhythmias, coma
NURSING INTERVENTIONS: Medication, IV
Fluids
Electrolyte Imbalances Universality
• Nursing Interventions: diet, med’s, iv fluids,
education, assessment, labs
• Causes: Diet, Medication issues, metabolism
(cancers, diseases)
• S/S – muscle tremors, twitches, LOC, Mental
status, cardiac affects
Look at your patient- be a spy
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Previous history? Alcoholic = mg or K
Malnourished?
Objective and Subjective findings?
Labs – the blood
EKG
Homeostatic Mechanisms
• Control the levels of fluids and electrolytes
• Found throughout the body
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_kidneys________
__endocrine_______
__cardiovascular_______
___GI______
_____Lungs____
Kidneys (not kidney beans!)
• Regulate what?
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__water____
__electrolytes____
__acid/base content of blood____
__all body fluids____
• Adjust what? Reabsorption of water
• Excrete what? Water and waste == pee pee
Antidiuretic Hormone
ADH
• ADH regulates water excretion
• Increases in response to increased serum (blood)
osmolality
• Ducts become more permeable to water and it is
reasborbed easier into the blood and urine
output will decrease
Renin-angiotensin-aldosterone system
• Renin (enzyme) splits Angiotensinogen into
angiotensin I and this transforms to angiotensin
II (with the help of an ACE inhibitor).
• Angiotensin II – stimulates vasoconstriction and
secretes aldosterone
• Aldosterone – increases Na reabsorption to
regulate BP and electrolyte levels
Put it together
• Increased osmolality – need more water in
blood so: ADH secretion increases and water
travels to the blood
• R-A-A system – renin excreted to make
angiotensin II and secrete aldosterone
• Aldosterone causes vasoconstriction increase bp
Give ACE inhibitor – stops angiotensin I to II and
aldosterone (thereby lowers BP). This may also
affect the ability of the body to maintain
extracellular fluid (without edema).
Atrial Natriuretic Factor ANF
• Secreted from atrial heart tissue
• Increases sodium and water elimination (urine)
• Lowers the blood volume and decreases cardiac
output
• Decreases the workload of the heart
• OPPOSITE EFFECT OF ADH
pH acids and bases
• Acid = substance that releases Hydrogen ion in a
solution
• Base = low hydrogen ion concentration
• Buffers prevent excessive ph changes by:
adjusting the ions
• **Major buffer is H2CO3***
▫ Kidneys and Lungs play a key
Factors that affect fluid and
electrolyte balance
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Sex
Body size
Age
Diet
NPO
General adaption syndrome (GAS) hehe
Altered LOC
More factors…….
• Body temperature
• Renal, cardiac, pulmonary system
• Medications
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Steroids
NSAIDs
Diuretics
Laxatives
Electrolyte supplements
More factors…… just when you thought
you were done!
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Dehydration
Surgical procedures
Vomiting
Diarrhea
Exercise
Culture and traditional foods MSG
Religious practices
Socioeconomic
Emotional
Definitions and conditions
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Fluid volume deficit is__hypovolemia_______
Fluid volume excess is__hypervolemia____
Ascites__fluid in the abdominal cavity______
Edema _fluid in the interstitial space_______
Hypovolemia
• Define: low fluid volume
• Causes: increased sodium chloride intake (po,
iv), dehydration, CHF, Renal failure, Cushing’s,
trauma
• Nursing ramifications: identify cause and
educate, medications, iv’s, etc…
• S/S: weak, nausea, low pulse, SOB, low BP
Hypervolemia
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Define: increased volume in vascular system
Causes: water toxicity, iv fluids, disease states
Nursing ramifications: medication, educate
S/S: elevated BP, moist crackles in lungs,
bounding pulse, SOB
Ascites
• Define: serous fluid in peritoneal cavity (3rd spaced)
• Causes: liver – cardiac dx, sodium retention, some
cancers
• Nursing ramifications: educate, diet, fluids, albumin
(pulls fluid from 3rd space, interstitially back into the
blood stream). Albumin has high osmolality.
• S/S: swelling, fluid shift – the wave~~~~~~~
• Treatment: Albumin and Pericentesis
Edema
• Define: fluid in the tissues
• Causes: increased sodium, electrolyte imbalances, poor
cardiac output, kidney failure, hypervolemia, diseases
• Nursing ramifications: fluid restrictions, educate &
elevate body parts, sodium restrictions, medications
• S/S: swelling (LOL), weeping skin, pain, numbness, cool
skin, bruised/discolored
Edema
• Pitting – leaves a small depression or pit
• Areas of edema: body parts, periorbital edema,
axillary, groin, generalized
▫ Note how many seconds it takes for pit to
disappear (normally 10-30seconds)
What’s the Difference?
Dehydration
Overhydration
• Define: loss body fluid, normal
electrolytes
• Causes: decreased fluid intake
• Nursing ramifications: IVF,
educate, diet, assessment
• S/S: jugular vein distention,
tachycardia, mental status
changes, confusion, weight
loss, dry skin, poor skin turgor,
dry mucus membranes,
increased thirst
• Define: water intake is greater
than electrolyte intake
• Causes: increased fluid intake
• Nursing ramifications:
education, diet, medications,
assessment
• S/S: altered mental status,
edema, SIADH (water
toxicity), possible decreased
urine output
Acid-Base Balance
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Normal pH of blood:_7.35-7.45____
Acidic pH of blood: __<7.35_____
Alkaline pH of blood (basic):_>7.45___
Blood is acidotic if the pH is __low__
Blood is alkalitic if the pH is __high__
Metabolic condition
Metabolic Alkalosis
Metabolic Acidosis
• HCO3 – high
• Causes: excess intake of
baking soda (antacid) or
alkalitic substances; lots of
puking
• The body compensates:
▫ CO2 is retained and
carbonic acid levels increase
to help balance the excess
HCO3
• HCO3 – low
• Causes: starvation, renal
impaired, DM
• The body compensates:
▫ Stimulates respiratory
system and eliminates CO2
Respiratory condition
Respiratory alkalosis
Respiratory acidosis
• HCO3 – high
• Causes: hyperventilation,
fever, anxiety, pulmonary
infections
• The body compensates:
kidneys excrete HCO3 (or stop
hyperventilation ASAP)
• HCO3 – low
• Causes: hypoventilation, lung
dx, asthma, COPD
• The body compensates:
▫ Kidneys retain NAHCO3
**may take hours or days
to restore pH
Intrepretation practice!
Nursing Interventions Include:
• Dietary education
▫ Menus
▫ Special diets
• Oral fluid/food intake
▫ Restrictions
• Administering medications as ordered
▫ IVF
▫ Diuretics
▫ Electrolyte supplements
• Education on medication uses/side effects and
complications
Educating on Diuretics
• Loop diuretic – Lasix/Furosemide
• Thiazide sparing – HCTZ
• Potassium sparing - Aldactone
Educating on Electrolyte supplements
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Potassium
Magnesium
Sodium Bicarbonate
Others? Gatorade, Power waters, Coconut water
What do we recommend if you are exercising in
the heat? Water and Power/Gatorade, etc…
• Babies who have diarrhea need? Pedialyte
• We use __kayexelate, D50 and Insulin_to
reduce Potassium
Intravenous Fluids - Types
• Hypotonic solutions: .45%NS, .33%NS, 2.5%Dextrose – lower
osmotic pressure than plasma –DO not give if at risk for IICP
• Hypertonic solutions:D5NS, D51/2NS, D5LR D5W – higher osmotic
pressure than plasma – kidney, cardiac and dehydration
• Isotonic solutions:0.9 NS, LR – expand vascular volume – LR has
extra ingredients, treats metabolic acidosis
• Electrolyte replacement: Potassium, KCL, MG, Banana bags!
Ethical consideration with IVF
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Life sustaining?
Religious and/or cultural issues?
Comfort measure?
Emotional?
Calculations (oh no….not math!)
Assessing the patient
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Urine
Skin
Mental state
MS
Bowel status
Further Assessment
• Labs
▫ BUN 7-18 mg/dl
Increased indicates- renal failure
Decreased indicates - malnutrition, over hydration,
liver damage
▫ Creatinine 0.6 – 1.5 mg/dl
Increased indicates – renal failure, CHF, shock
Decreased indicates – fluid status, dehydration
Let’s do a care plan! CHF Patient See
pg 98-100
