FLUID AND ELECTROLYTES DISTURBANCES

Learning Outcomes:
 Describe the role of the kidneys, lungs, and endocrine glands in regulating the body’s
fluid composition and volume.
 Describe the etiology, recognize clinical manifestations, management, and nursing
interventions for fluids and electrolytes disturbances.
 Compare metabolic acidosis and alkalosis with regard to causes, clinical
manifestations, diagnosis, and management.
 Interpret arterial blood gas measurements.
 Plan effective care of patients with fluids and electrolytes, acid-base imbalances.
 Correctly answer prometrics questions regards fluids and electrolytes, acid-base
imbalances.

Description

Fluid and electrolyte balance is a dynamic process that is crucial for life and homeostasis.
 Fluids make up a large portion of the body, which is approximately 50%-60% of the
total body weight.
 Body fluids are divided between two main compartments: the intracellular fluid and
the extracellular fluid compartments.
 Intracellular fluid. Intracellular fluid functions as a stabilizing agent for the parts of
the cell, helps maintain cell shape, and assists with transport of nutrients across the
cell membrane, in and out of the cell.
 Extracellular fluid. Extracellular fluid mostly appears as interstitial tissue fluid and
intravascular fluid.
 Electrolytes in body fluids are active chemicals or cations that carry positive charges
and anions that carry negative charges.
 The major cations in the body fluid are sodium, potassium, calcium, magnesium, and
hydrogen ions.
 The major anions are chloride, bicarbonate, sulfate, and proteinate ions.

Homeostasis
Is the dynamic process in which the body maintains balance by constantly adjusting to
internal and external stimuli.

Fluid Regulation Mechanisms

a. The thirst center. The thirst center in the hypothalamus stimulates or inhibits the
desire for a person to drink.
b. Antidiuretic hormone. ADH regulates the amount of water the kidney tubules
absorb and is released in response to low blood volume or in response to an increase
in concentration of sodium and other solutes in the intravascular fluids.
c. The RAA system. The RAA system controls fluid volume, in which when the blood
volume decreases, blood flow to the renal juxtaglomerular apparatus is reduced,
thereby activating the RAA system.
d. Atrial natriuretic peptide. The heart also plays a role in correcting overload
imbalances, by releasing ANP from the right atrium.
Negative and Positive Feedback
Feedback is the relaying of information about a given condition to the appropriate organ or
system.
a. Negative feedback. Negative feedback occurs when the body reverses an original
stimulus for the body to regain physiologic balance.
b. Positive feedback enhances or intensifies the original stimulus.
Examples. Blood pressure control and maintenance of normal body temperature are
examples of negative feedback while blood clotting after an injury and a woman in
labor are examples of positive feedback.
Systems Involved in Feedback
a. Nervous system. The nervous system regulates homeostasis by sensing system
deviations and sending nerve impulses to appropriate organs.
b. Endocrine system uses the release and action of hormones to maintain homeostasis.

Fluid and Electrolyte Transport

Total electrolyte concentration affects the body’s fluid balance.
 The body cells. Nutrients and oxygen should enter body cells while waste products
should exit the body.
 The cell membrane. The cell membrane separates the intracellular environment
from the extracellular environment.
 Permeability. The ability of a membrane to allow molecules to pass through is
known as permeability.
Permeability of Membranes
 Freely permeable membranes. These membranes allow almost any food or
waste substance to pass through.
 Selectively permeable. The cell membrane is selectively permeable, meaning
that each cell’s membrane allows only certain specific substances to pass
through.

1. Passive Transport
a. Diffusion. Diffusion, or the process of “being widely spread”, is the
random movement of molecules from an area of higher concentration to
an area of lower concentration.
b. Osmosis. Osmosis is the diffusion of a pure solvent, such as water, across
a semipermeable membrane in response to a concentration gradient in
situations where the molecules of a higher concentration are non-
diffusible.
c. Filtration. Filtration is the transport of water and dissolved materials
concentration already exists in the cell.

2. Active Transport - require specific enzymes and an energy expenditure in the form
of adenosine triphosphate (ATP).
Active transport processes can move solutes “uphill”, against the normal rules of
concentration and pressure.
Normal Intake and Output
 Daily intake. An adult human at rest takes appropriately 2,500 ml of fluid daily.
 Levels of intake. Approximate levels of intake include fluids 1, 200 ml, foods 1, 000
ml, and metabolic products 30 ml.
 Daily output. Daily output should approximately equal in intake.
 Normal output. Normal output occurs as urine, breathing, perspiration, feces, and in
minimal amounts of vaginal secretions.

Acid-Base Balance
Acid-base balance is another important aspect of homeostasis.
 Acid. An acid is one type of compound that contains the hydrogen ion.
 Base. A base or alkali is a compound that contains the hydroxyl ion.
 Salt. A salt is a combination of a base and an acid and is created when the positive
ions of a base replace the positive hydrogen ions of an acid.
 Important salts. The body contains several important salts like sodium chloride,
potassium chloride, calcium chloride, calcium carbonate, calcium phosphate, and
sodium phosphate.

Potential of Hydrogen
 pH. The symbol of pH refers to the potential or power of hydrogen ion concentration
within the solution.
 Low pH. If the pH number is lower than 7, the solution is an acid.
 High pH. If the pH is greater than 7, a solution is basic or alkaline.
 Neutral pH. If the pH is 7, then the solution is neutral.
 Changes. A change in the pH of a solution by one pH unit means a tenfold change in
hydrogen concentration.

Buffers
 Buffers. A buffer is a chemical system set up to resist changes, particularly in
hydrogen ion levels.
 Bicarbonate buffer system. Sodium bicarbonate and carbonic acid are the body’s
major chemical buffers.
 Carbon dioxide. The major compound controlled by the lungs is CO2, and the
respiratory system can very rapidly compensate for too much acid and too little acid
by increasing or decreasing the respiratory rate, thereby altering the level of CO2.
 Bicarbonate. Bicarbonate ions are basic components in the body, and the kidneys
are key in regulating the amount of bicarbonate in the body.

Classification of Disturbances:
There are different fluid volume disturbances that may affect an individual.

1. Fluid volume deficit or hypovolemia occurs when loss of ECF volume exceeds the
intake of fluid.
2. Fluid volume excess or hypervolemia refers to an isotonic volume 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.
Disturbances in electrolyte balances are common in clinical practice and must be corrected.
1. Hyponatremia refers to a serum sodium level that is less than 135 mEq/L
2. Hypernatremia is a serum sodium level higher than 145 mEq/L.
3. Hypokalemia usually indicates a deficit in total potassium stores.
4. Hyperkalemia refers to a potassium level greater than 5.0 mEq/L.
5. Hypocalcemia are serum levels below 8.6 mg/dl.
6. Hypercalcemia is calcium level greater than 10.2 mg/dl.
7. Hypomagnesemia refers to a below-normal serum magnesium concentration.
8. Hypermagnesemia are serum levels over 2.3 mg/dl.
9. Hypophosphatemia is indicated by a value below 2.5 mg/dl.
10. Hyperphosphatemia is a serum phosphorus level that exceeds 4.5 mg/dl in adults.

Causes
Causes of fluid and electrolyte imbalances are discussed below in general.

1. Fluid retention. Retention of sodium is associated with fluid retention.

2. Loss of sodium. Excessive loss of sodium is associated with decreased volume of
body fluid.
3. Trauma. Trauma causes release of intracellular potassium which is extremely
dangerous.
4. Loss of body fluids. FVD results from loss of body fluids and occurs more rapidly
when coupled with decreased fluid intake.
5. Fluid overload. Fluid volume excess may be related to a simple fluid overload or
diminished function of the homeostatic mechanisms responsible for regulating fluid
balance.
6. Low or high electrolyte intake. Diets low or excessive in electrolytes could also cause
electrolyte imbalances.
7. Medications. There are certain medications that could lead to electrolyte imbalances
when taken against the physician’s orders.

Clinical Manifestations
Signs and symptoms that occur in fluid and electrolyte imbalances are discussed below.

 Fluid volume deficit. Clinical signs and symptoms include acute weight loss,
decreased skin turgor, oliguria, concentrated urine, orthostatic hypotension, a weak,
rapid heart rate, flattened neck veins, increased temperature, thirst, decreased or
delayed capillary refill, cool, clammy skin, muscle weakness, and cramps.
 Fluid volume excess. Clinical manifestations for FVE include edema, distended neck
veins, and crackles.
 Hyponatremia. Signs and symptoms include anorexia, nausea and vomiting,
headache, lethargy, dizziness, confusion, muscle cramps and weakness, muscular
twitching, seizures, dry skin, and edema.
 Hypernatremia. The signs and symptoms are thirst, elevated body temperature,
hallucinations, lethargy, restlessness, pulmonary edema, twitching, increased BP and
pulse.
  Hypokalemia. Clinical manifestations are fatigue, anorexia, muscle weakness,
polyuria, decreased bowel motility, paresthesia, ileus, abdominal distention, and
hypoactive reflexes
 Hyperkalemia. Signs and symptoms include muscle weakness, tachycardia,
paresthesia, dysrhythmias, intestinal colic, cramps, abdominal distention, and
anxiety.
 Hypocalcemia. The signs and symptoms are numbness, tingling of fingers, toes, and
circumoral region, positive Trousseau’s sign and Chvostek’s sign, seizures,
hyperactive deep tendon reflexes, irritability, and bronchospasm.
 Hypercalcemia. The signs and symptoms include muscle weakness, constipation,
anorexia, nausea and vomiting, dehydration, hypoactive deep tendon reflexes
lethargy, calcium stones, flank pain, pathologic fractures, and deep bone pain.
 Hypomagnesemia. Clinical manifestations include neuromuscular irritability, positive
Trousseau’s and Chvostek’s sign, insomnia, mood changes, anorexia, vomiting, and
increased deep tendon reflexes.
 Hypermagnesemia. Signs and symptoms are flushing, hypotension, muscle
weakness, drowsiness, hypoactive reflexes, depressed respirations, and diaphoresis.
 Hypophosphatemia. Signs and symptoms include paresthesia, muscle weakness,
bone pain and tenderness, chest pain, confusion, seizures, tissue hypoxia, and
nystagmus.
 Hyperphosphatemia. Clinical manifestations are tetany, tachycardia, anorexia,
nausea and vomiting, muscle weakness, and hyperactive reflexes.

Complications
Fluid and electrolyte imbalances could result in complications if not treated promptly.
 Dehydration. Fluid volume deficit could result in dehydration of the body tissues.
 Cardiac overload. Fluid volume excess could result in cardiac overload if left
untreated.
 SIADH. Water is retained abnormally in SIADH.
 Cardiac arrest. Too much potassium administered could lead to cardiac arrest.

Assessment and Diagnostic Findings

The following are laboratory studies useful in diagnosing fluid and electrolyte imbalances:
 BUN. BUN may be decreased in FVE due to plasma dilution.
 Hematocrit. Hematocrit levels in FVD are greater than normal because there is a
decreased plasma volume.
 Physical examination. Physical exam is necessary to observe the signs and symptoms
of the imbalances.
 Serum electrolyte levels. Measurement of electrolyte levels should be performed to
check for presence of an imbalance.
 ECG. ECG changes can also contribute to the diagnosis of fluid and electrolyte
imbalance.
 ABG analysis. ABG analysis may reveal acid-base imbalances.
Medical Management
Treatment of fluid and volume imbalances needs accuracy to avoid consequences that can
result in complications.
 Isotonic electrolyte solutions. These solutions are used to treat the hypotensive
patient with FVD because they expand plasma volume.
 Accurate I&O. Accurate and frequent assessments of I&O should be performed
when therapy should be slowed or increased to prevent volume deficit or overload.
 Dialysis. Hemodialysis or peritoneal dialysis is performed to remove nitrogenous
wastes and control potassium and acid-base balance, and to remove sodium and
fluid.
 Nutritional therapy. Treatment of fluid and electrolyte imbalances should involve
restrictions or enforcement of the concerned electrolyte.
 Pharmacologic therapy
 AVP receptor agonists. These are new pharmacologic agents that treat
hyponatremia by stimulating free water excretion.
 Diuretics. To decrease fluid volume in FVE, diuretics are administered.
 IV calcium gluconate. If serum potassium levels are dangerously elevated, it
may be necessary to administer IV calcium gluconate.
 Calcitonin. Calcitonin can be used to lower the serum calcium level and is
particularly useful for patients with heart disease or heart failure who cannot
tolerate large sodium loads.

Nursing Management
Nurses may use effective teaching and communication skills to help prevent and treat
various fluid and electrolyte disturbances.

A. Nursing Assessment
Close monitoring should be done for patients with fluid and electrolyte imbalances.
 I&O. the nurse should monitor for fluid I&O at least every 8 hours, or even
hourly.
 Daily weight. Assess the patient’s weight daily to measure any gains or
losses.
 Vital signs. Vital signs should be closely monitored.
 Physical exam. Physical exam is needed to reinforce other data about a fluid
or electrolyte imbalance.
B. Diagnosis
The following diagnoses are found in patients with fluid and electrolyte imbalances.
 Excess fluid volume related to excess fluid intake and sodium intake.
 Deficient fluid volume related to active fluid loss or failure of regulatory
mechanisms.
 Imbalanced nutrition: less than body requirements related to inability to
ingest food or absorb nutrients.
 Imbalanced nutrition: more than body requirements related to excessive
intake.
 Diarrhea related to adverse effects of medications or malabsorption.
 C. Nursing Care Planning & Goals
Planning and goals for fluid and electrolyte imbalances include:
 Maintenance of fluid volume at a functional level.
 Display of normal laboratory values.
 Demonstration appropriate changes in lifestyle and behaviors including
eating patterns and food quantity/quality.
 Reestablishment and maintenance of normal pattern and GI functioning.

D. Nursing Interventions
There are specific nursing interventions for fluid and electrolyte imbalances that can
aid in alleviating the patient’s condition.
 Monitor turgor. Skin and tongue turgor are indicators of the fluid status of
the patient.
 Urine concentration. Obtain urine sample of the patient to check for urine
concentration.
 Oral and parenteral fluids. Administer oral or parenteral fluids as indicated
to correct the deficit.
 Oral rehydration solutions. These solutions provide fluid, glucose, and
electrolytes in concentrations that are easily absorbed.
 Central nervous system changes. The nurse must be alert for central nervous
system changes such as lethargy, seizures, confusion, and muscle twitching.
 Diet. The nurse must encourage intake of electrolytes that are deficient or
restrict intake if the electrolyte levels are excessive.

E. Evaluation
Evaluation of the care plan can check the effectiveness of the treatments. The
interventions are deemed effective if the client has:
 Maintained fluid volume at a functional level.
 Displayed normal laboratory results.
 Demonstrated appropriate changes in lifestyle and behaviors including eating
patterns and food quantity/quality.
 Reestablished and maintained normal pattern and GI functioning.

Discharge and Home Care Guidelines

After hospitalization, treatment and maintenance of the condition must continue at home.
 Diet. A diet rich in all the nutrients and electrolytes that a person needs should be
enforced.
 Fluid intake. Fluid intake must take shape according to the recommendations of the
physician.
 Follow-up. A week after discharge, the patient must return for a follow-up checkup
for evaluation of electrolyte and fluid status.
 Medications. Compliance to prescribed medications should be strict to avoid
recurrence of the condition.
Documentation Guidelines
Data should be documented for future medical and legal references. The nurse must
document:
 Individual findings, including factors affecting ability to manage body fluids and
degree of deficit.
 I & O, fluid balance, changes in weight, urine specific gravity, and vital signs.
 Results of diagnostic testing and laboratory studies.