INDEX

Sl. No. CONTENT Pg. No.

1. Introduction 3
2. Body fluid and electrolytes 3
3. Distribution of body fluids 4
4. Composition of body fluids 5
5. Movement of body fluids and electrolytes 6
6. Regulating electrolytes 7
7. Regulation and function of electrolytes 7
8. Sodium (NA+) 8
Potassium (K+)
Calcium (Ca2+)
9. Magnesium (Mg2+) 9
10. Chloride (CI-) 10
Phosphate (PO¬4-)
Bicarbonate (HCO¬¬3)
11. Electrolyte imbalances 11-26
12. Summary 26
14. Conclusion 27
15. Bibliography 27

1
 OBJECTIVES

General objectives:

By the end of the seminar the students will be able to gain in

depth knowledge about fluid and electrolyte imbalance and its management and
develop skills towards the management of fluid and electrolyte imbalance.

Specific objectives:

By the end of the seminar, the students will be able to

 Define normal electrolyte balance

 Recall the body fluid distribution and regulation
 List the factors affecting electrolyte balance
 Define electrolytes and its distribution in the body
 List down the electrolytes and their imbalances
 Discuss sodium, potassium, calcium, magnesium, phosphate, chloride and
bicarbonate imbalances and their management in detail.

2
Introduction

Fluid and electrolyte balance is a dynamic process that is crucial for the life.
Potential and actual disorders of fluid and electrolyte balance occur in every
setting, with every disorder, and with a variety of changes that affect well people
(e.g., increase fluid and sodium loss with strenuous exercise and high
environmental temperature; inadequate intake of fluid and electrolytes) as well
as those who are ill. The nurse needs to understand the physiology of fluid and
electrolyte balance and acid-base balance to anticipate, identify and respond to
possible imbalances in each.

In good health, a delicate balance of fluids, electrolytes, and acids bases is

maintained in the body. This balance, or physiologic homeostasis, depends on
multiple physiologic processes that regulate fluid intake and output and the
movement of water and the substance dissolved in it between the body
compartments.

Almost every illness has the potential to threaten this balance. Even in daily
living, excessive temperature or vigorous activity can disturb the balance if
adequate water and salt intake is not maintained. Therapeutic measures, such as
the use of diuretics or nasogastric suction, can also disturb the body’s
homeostasis unless water and electrolytes are replaced.

Body fluids and electrolytes

The proportion of the human body composed of fluid is surprisingly large.

Approximately 60% of the average healthy adult’s weight is water, the primary
body fluid. In good health this volume remains relatively constant and the
person’s weight varies by less than 0.2kg (0.5lb) in 24 hours, regardless of the
amount of fluid ingested.

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 Water is vital to health and normal cellular function, serving as

 A medium of metabolic reaction within cells,

 A transporter of nutrients, waster products and other substances,
 A lubricant,
 An insulator and shock absorber
 One means of regulating and maintaining body temperature.

Age, sex and body fat affect total body water. Infants have the highest
proportion of water, accounting for 70% to 80% of their body weight. The
proportion of body water decreases with aging. In people older than years of
age, it represents only about 50% of the total body weight. Women also have a
lower percentage of body water than men. Women and the elderly have reduced
body water due to decreased muscle mass and a greater percentage of fat tissue.
Fat tissue is essentially free of water, whereas lean tissue contains a significant
amount of water. Water makes up a greater percentage of a lean person’s body
weight than an obese person’s.

Distribution of Body Fluids

The body’s fluid is divided into two major compartments, intra cellular and
extracellular. Intracellular fluid (ICF) is found within the cells of the body. It
constitutes approximately two-thirds of the total body fluid in adults.
Extracellular fluid (ECF) is found outside the cells and accounts for about one-
third of total body fluid. It is subdivided into compartments. The two main
compartments of ECF are intravascular and interstitial. Intravascular fluid, or
plasma, accounts for approximately 20% of the ECF and is found within the
vascular system. Interstitial fluid, accounting for approximately 75% of the
ECF, surrounds the cells. The other compartments of ECF are the lymph and
transcellular fluids. Examples of transcellular fluid include cerebrospinal,
pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial
fluids.

4
 Intracellular fluid is vital to normal cell functioning. It contains solutes such
as oxygen, electrolytes, and glucose, and it provides a medium in which
metabolic processes of the cell take place.

Although extracellular fluid is in the smaller of the two compartments, it is

the transport system that carries nutrients to and waste products from the cells.
For example, plasma carries oxygen from the lungs and glucose from the
gastrointestinal tract to the capillaries of the vascular system. From there, the
oxygen and glucose move across the capillary membranes into the interstitial
spaces and then across the cellular membranes into the cells. The opposite route
is taken for waste products, such as carbon dioxide going from the cells to the
lungs and metabolic acid wastes going eventually to the kidneys. Interstitial
fluid transports wastes from the cells by way of the lymph system as well as
directly into the blood plasma through capillaries.

Composition of Body Fluids

Extracellular and intracellular fluids contain oxygen from the lungs, dissolved
nutrients from the gastrointestinal tract, excretory products of metabolism such
as carbon dioxide, and charged particles called ions.

Many slats dissociate in water, that is, break up into electrically charged ions.
The salt sodium chloride breaks up into one ion of sodium (Na +) and one ion of
chloride (CI-). These charged particles are called electrolytes because they are
capable of conducting electricity. The number of ions that carry a positive
charge, called cations, and ions that carry a negative charge, called anions,
should be equal. Examples of cations are sodium (Na+), potassium (K+), calcium
(Ca2+), and magnesium (Mg2+). Examples of anions include chloride (CI-),
bicarbonate HCO3-, phosphate HPO4 2-, and sulphate SO4 2-.

Electrolytes generally are measured in milliequivalents per litter of water

(mEq/L) of milligrams per 100 millilitres (mg/100 mL). The term
milliequivalent refers to the chemical combining power of the ion, or the

5
capacity of cations to combine with anions to form molecules. This combining
activity is measured in relation to the combining activity of the hydrogen ion
(H+). Thus, 1 mEq of any anion equals 1 mEq of any cation. For example,
sodium and chloride ions are equivalent, since they combine equally: 1 mEq of
Na+ equals 1 mEq of CI-. However, these cations and anions are not equal in
weight: 1 mg of Na+ does not equal 1 mg of CI-; rather, 3 mg of Na+ equals 2
mg of CI-.

The composition of fluids varies from one body compartment to another. In

extracellular fluid, the principle electrolytes are sodium, chloride, and
bicarbonate. Then other electrolytes such as potassium, calcium and magnesium
are also present but in much smaller quantities. Plasma and interstitial fluid, the
two primary components of ECF, contains essentially the same electrolytes and
solutes, with the exception of protein. Plasma is a protein rich fluid, containing
large amounts of albumin, but interstitial fluid little or no protein.

The composition of intracellular fluid differs significantly from that of ECF.

Potassium and magnesium are the primary cations present in ICF, with
phosphate and sulphate the major anions. As in ECF, the other electrolytes are
present within the cell, but in much smaller concentrations. Normal and unusual
fluid and electrolyte losses must be replaced if homeostasis is to be maintained.

Other body fluids such as gastric and intestinal secretions also contain
electrolytes. This is of particular concern when these fluids are lost from the
body. Example vomiting, diarrhoea, or when gastric suctioning. It can also result
from excessive loss through these roots.

Movement of Body Fluids and Electrolytes

The body fluid compartments are separated from one another by cell membranes
and the capillary membrane. While these membranes are completely permeable
to water, they are considered to be selectively permeable to solutes as substances
move across them with varying degrees of ease. Small particles such as ions,

6
oxygen, and carbondioxide easily move across them, but larger molecules like
glucose and protein have more difficulty moving between fluid compartments.

The methods by which electrolytes and other solutes move are

 Osmosis
 Diffusion
 Filtration
 Active transport

Regulating Electrolytes

Electrolytes charged ions capable of conducting electricity, are present in all

body fluids and fluid compartments. Just as maintaining the fluid balance is vital
to normal body function, so is maintaining electrolyte balance. Although the
concentration of specific electrolytes differs between fluid compartments, a
balance of cations (positively charged ions) and anions (negatively charged ions)
always exist.

Electrolytes are important for

 Maintaining fluid balance

 Contributing to acid – base regulation
 Facilitating enzyme reactions
 Transmitting neuro muscular reactions

FACTORS AFFECTING BODY FLUID BALANCES:

The ability of the body to adjust fluids, electrolytes, and acid-base

balance is influenced by age, gender and body size, environmental temperature,
and lifestyle. Age, sex, and body fat affect total body water. Infants have the
highest proportion of water, according for 70% to 80% of their body weight.
The proportion of body water decreases with aging. In people older than 60
years of age, it represents only about 50% of total body weight. Women also

7
have a lower percentage of body water than men. Women and the elderly have
reduced body water due to decreased muscle mass and a greater percentage of
fat tissue. Fat tissue is essentially free of water, whereas lean tissue contains a
significant amount of water. Water makes up a greater percentage of a lean
person’s body weight than an obese person’s.

AGE: Infants and growing children have much greater fluid turnover than
adults because their higher metabolic rate increases fluid loss. Infant lose more
fluid through the kidneys because immature kidneys are less able to conserve
water than adult kidneys. In addition, infant respirations are more rapid and the
body surface area is proportionately greater than that of adults, increasing
insensible fluid losses.

In elderly people, the normal aging process may affect fluid

balance. The thirst response often is blunted. Antidiuretic hormone levels
remain normal or may even be elevated, but the nephrons become less able to
conserve water in response to ADH. Increased level of atrial natriuretic factor
seen in older adults may also contribute to this impaired ability to conserve
water. These normal changes of aging increase the risk of dehydration. When
combined with the increased likelihood of heart diseases, impaired renal
function, and multiple drug regimens, the older adult’s risk for fluid and
electrolyte imbalance is significant. Additionally, it is important to consider that
the older adult has thinner, more fragile skin and veins, which can make an
intravenous insertion more difficult.

GENDER AND BODY SIZE: Total body water also is affected by gender and
body size. Because fat cells contain little or no water, and lean tissue has higher
water content, people with a higher percentage of body fat have less body fluid.
Women have proportionately more body fat and less body water than men.
Water accounts for approximately 60% of an adult man’s weight, but only 52%
for an adult woman. In an obese individual this may be even less, with water
responsible for only 30% to 40% of the person’s weight.

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ENVIRONMENTAL TEMPERATURE: People with an illness and those
participating in strenuous activity are at risk for fluid and electrolyte imbalances
when the environmental temperature is high. Fluid losses through sweating are
increased in hot environments as the body attempts to dissipate heat. These
losses are even greater in people who have not been acclimatized to the
environment. Both salt and water are lost through sweating. When only water is
replaced, salt depletion is a risk. The person who is salt depleted may
experience fatigue, weakness, headache, and gastrointestinal symptoms such as
anorexia and nausea.

LIFE STYLE: When the nutritional intake is inadequate, hypoalbuminemia

results which cause decreased colloid osmotic pressure and edema results. Other
factors such as diet, exercise, and stress affect fluid, electrolyte, and acid- base
balance.

METABOLIC STATES: As the metabolic rate increases the need for fluid
increases.

PHYSICAL ACTIVITY: Body temperature and cellular metabolites are

increased by physical activity, with an increased fluid loss, so there is an
increase in fluid needs.

PREGNANCY: In pregnancy, there is increased aldosterone secretion and

increased vena cava pressure which increases fluid filtration, causing
hydrostatic edema. At the later stage of pregnancy, the woman has 6.5% Lt of
extra fluid and decreases rapidly after delivery.

The intake of fluids and electrolytes is affected by the diet. People

with anorexia nervosa or bulimia are at risk for severe fluid and electrolyte
imbalances because of inadequate intake or purging regimens (e.g. induced
vomiting, use of diuretics and laxatives). Seriously malnourished people have
decreased serum albumin levels, and may develop edema because the osmotic
draw of fluid into the vascular compartment is reduced. Regular weight-bearing

9
physical exercise such as walking, running, or bicycling has a beneficial effect
on calcium balance. The rate of bone loss that occurs in postmenopausal women
and older men is slowed with regular exercise, reducing the risk of osteoporosis.
Stress can increase cellular metabolism, blood glucose concentration, and
catecholamine levels. In addition, stress can increase production of ADH, which
in turn decreases urine production. The overall response of the body to stress is
to increase the blood volume. Other life style factors can also affect fluid,
electrolyte, and acid –base balance. Heavy alcohol consumption affects
electrolyte balance, increasing the risk of low calcium, magnesium, and
phosphate levels. The risk of acidosis associated with breakdown of fact tissue
also is greater in the person who drinks large amount of alcohol.

Regulations and Functions of Electrolytes:

Most electrolytes enter the body through dietary intake and are excreted in the
urine. Some electrolytes, such as sodium and chloride, are not stored by the
body and must be consumed daily to maintain normal levels. Potassium and
calcium, on the other hand are stored in cells and bones. When serum level drop,
ions can shift out of the storage “pool” into the blood to maintain adequate
serum levels for normal functioning.

Sodium (NA+)

Sodium is the most common abundant cation in ECF and a major contribute to
serum osmolality. Normal level is 135 to 145 mEq/l. It controls and regulates
water balance. When re-absorbed from the kidney tubules, chloride and water
are reabsorbed with it, maintain ECF volume. It is found in many foods such as
bacon, ham, processed cheese and table salt.

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Potassium (K+)

It is the major cation in ICF, with only a small amount found in plasma and
interstitial fluids. ICF levels of potassium are usually 125 – 140 mEq/l while
normal serum potassium is 3.5 – 5.0 mEq/l. The ratio of ICF to ECF must be
maintained for neuro muscular response to stimuli. It plays a vital electrolyte for
skeletal, cardiac, and smooth muscle activity. It is involved in maintaining acid
balance, and contributes to intra cellular enzyme reactions. It must be ingested
daily because the body can’t conserve it. Many fruits and vegetables, meat, fish,
and other foods contain it.

Calcium (Ca2+)

The vast majority, 99%, of calcium in the body is in the skeletal system with a
relatively small amount in ECF. Although this calcium outside the bones and
teeth amounts to only about one percent of total calcium in the body, it is vital in
regulating muscle contraction and relaxation, neuromuscular function, cardiac
function. ECF calcium is regulated by a complex interaction of parathyroid
harmone, calcitonin, and calcitrion, a metabolite of vitamin D. When calcium
levels in the ECF fall, parathyroid harmone and calcitrol cause calcium to be
released from bones into ECF and increase absorption of calcium in bone,
reducing the concentration of calcium ions in the blood.

With ageing the intestines absorb calcium less effectively and more calcium is
excreted via kidneys. Calcium shifts out of the bones to replace the ECF losses,
increasing the risk of osteoporosis and fractures of the wrists, vertebrae, and
hips.

Serum calcium levels are often reported in two ways, based on its circulation in
plasma. Approximately 50% of serum calcium circulates in a free, ionized, or
unbound form. Other 50% is plasma bound to either proteins or other non
protein ions. The normal total serum calcium levels, which range from 8.5-

11
10.5mg/dL, represent both bound and unbound calcium. The 4.0-5.0 mg/dL,
represents calcium circulating in the plasma in free, or unbound, forms.

Sources:

 Milk
 Milk products
 Dark green leafy vegetables
 Canned salmon

Calcium supplements are also advised.

Magnesium (Mg2+)

It is found in skeleton and in intramuscular fluid. It is the second most abundant

intracellular cation with normal serum levels of 1.5 to 2.5 mEq/L. It is important
for intracellular metabolism, being particularly involved in the production and
use of ATP. It is also necessary for protein and DNA synthesis within the cells.
Only about 1% of the body’s magnesium is in ECF; here it is involved in
regulating neuromuscular and cardiac function. Maintaining and ensuring
adequate levels is important part of care of clients with cardiac disorders. Cereal
grains, nuts, dried fruit, legumes and green leafy vegetables are good sources of
magnesium in the diet, as are dairy products, meat and fish.

Chloride (CI-)

Chloride is the major anion of ECF, and normal serum levels are 95 to 108
mEq/L. Chloride functions with sodium to regulate serum osmolality and blood
volume. The concentration of chloride in ECF is reabsorbed in the kidney
chloride usually follows. Chloride is a major component of gastric juice as
hydrochloric acid (HCI) and is involved in regulating acid-base balance. It also

12
acts as a buffer in the exchange of oxygen and carbon dioxide in RBCs.
Chloride is found in the same foods as sodium.

Phosphate (PO4-)

Phosphate is the major anion of intracellular fluids. It also is found in ECF,

bone, skeletal muscle, and nerve tissue. Normal serum levels of phosphate in
adults range from 2.5 to 4.5 mg/d L. Children have much higher phosphate
levels than adults, with that of a newborn nearly twice that of an adult. Higher
levels of growth hormone and a faster rate of skeletal growth probably account
for this difference. Phosphate is involved in many chemical actions of the cell;
it is essential for functioning of muscles, nerves, and red blood cells. It is also
involved in the metabolism of protein, fat and carbohydrate. Phosphate is
absorbed from the intestine and is found in many foods such as meat, fish,
poultry, milk products, and legumes.

Bicarbonate (HCO3)

Bicarbonate is present in both intracellular and extracellular fluids. Its primary

function is regulating acid-base balance as an essential component of the
carbonic acid-base balance as an essential component of the carbonic acid-
bicarbonate buffering system. Extracellular bicarbonate levels are regulated by
the kidneys: Bicarbonate is excreted when too much is present; if more is
needed, the kidneys both regenerate and reabsorb bicarbonate ions. Unlike other
electrolytes that must be consumed in the diet, adequate amounts of bicarbonate
are produced through metabolic processes to meet the body’s needs.

Dehydration

Occurs when water is lost from the body leaving the client with excess sodium

Increased sodium osmolality and serum sodium

13
Overhydration

Occurs when water is gained in excess of electrolytes, resulting in low sodium

osmolality and low serum sodium levels

Electrolyte imbalances

1. Hyponatremia
2. Hypernatremia
3. Hypokalemia
4. Hypokalemia
5. Hypocalcemia
6. Hypercalcemia
7. Hypomagnesemia
8. Hypermagnesemia
9. Hypophosphatemia
10.Hyperphosphatemia
11.Hypochloremia
12.Hyperchloremia

14
Laboratory values used in evaluating fluid and electrolyte status in adults

● Serum sodium 135 mEq/L

● Serum potassium 3.5-5.3 mEq/L
● Total serum calcium 8.6-10mg/dL
● Serum magnesium 1.3-2.5mEq/L
● Serum phosphorus 2.5-4.5 mg/dL
● Serum chloride 97-100mEq/L
● Carbon dioxide content 22-30 mEq/L
● Serum osmolality 280-300mOsm/kgH2O
● BUN 5-20mg/dL
● Serum creatinine
o Female 0.1-1.1mg/dL
o Male 0.6-1.2mg/dL
● BUN - creatinine ratio 10:1-15:1
● Hematocrit
o Female 35-47%
o Male 42-52%
● Urinary sodium 72-220 mEq/day
● Urinary potassium 25-123mEq/day
● Urinary chloride 110-250 mEq/day
● Urinary specific gravity 1.016-1.022
● Urine osmolality 250-900 mOsm/kgH2O
● Urinary PH
● Random 4.5-8
● Typical urine <5-6

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Hyoponatremia

A Sodium deficit or serum sodium level <135 mEq/L

Risk factors

● Loss of sodium- gastrointestinal fluid loss, sweating, use of diuretics

● Gain of water- hypertonic tube feedings, excessive water intake, excess
IV dextrose
● Syndrome of inappropriate ADH - head injury, AIDS, malignant tumors
Clinical manifestations

● Lethargy
● Confusion
● Apprehension
● Muscle twitching
● Abdominal cramps
● Anorexia
● Vomiting
● Nausea
● Headache
● Seizures, coma
Lab indicators

● Decreased serum and urine sodium

● Decreased urine specific gravity and Osmolality
● Dry skin, increased pulse, decreased blood pressure
Management

Sodium replacement, water restriction (800 ml per day)

Nursing management

● Assess clinical manifestations

● Monitor intake output
16
 ● Encourage food and fluids high in sodium
● Limit water intake as indicated

Hypernatremia

Excess sodium and extracellular fluid (or) a serum sodium >145 mEq/L

Risk factors

● Water deprivation
● Diarrhoea
● Insensible water loss
● Parenteral administration of saline solutions
● Hypertonic tube feedings without adequate water
● Excessive use of table salt
● Conditions like diabetes insipidus, heat stroke
Clinical manifestations

● Thirst
● Dry, sticky mucous membranes
● Tongue –red, dry, swollen
● Weakness
● Severe
○ Fatigue
○ Restlessness
○ Decreased loss of consciousness
○ Disorientation
○ Convulsions

17
Lab indicators

1. Increased serum sodium

2. Decreased urine sodium
3. Increased urine specific gravity and osmolality
Management

● Hypotonic sodium solution

● Diuretics
● Desmopressin acetate (in diabetes insipidus)
Nursing management

● Monitor intake output, behavior changes, lab findings and diet

● Encourage fluids as ordered

Hypokalemia

Potassium deficit <3.5mEq/L

Risk factors

● Vomiting
● Diarrhoea
● Gastric suction
● Heavy perspiration
● Use of potassium wasting drugs
● Poor intake of potassium
● Hypoaldosteronism
Clinical manifestations

● Muscle weakness
● Leg cramps
● Fatigue, lethargy
● Anorexia
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 ● Nausea, vomiting
● Decreased Bowel motility
● Cardiac dysrhythmias
● Depressed deep tendon reflexes
● Weak, irregular pulses
Lab indicators

● ECG
○ Flattened T waves, prominent U waves, ST depression, prolonged
PR interval
Management

● IV replacement therapy
● Dietary intake
Nursing management

● Monitor heart rate, rhythm

● Monitor clients receiving digitalis
● Teach about potassium rich foods and prevent excessive loss of
potassium

Hyperkalemia

Potassium excess>4.5mEq/L

Risk factors

● Renal failure
● Potassium conserving diuretics
● Rapid infusion of IV potassium
● Excessive use of potassium containing salt substitutes

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Clinical manifestations

● Gastrointestinal hyperactivity
● Diarrhoea
● Irritability, apathy, confusion
● Muscle weakness
● Decreased heart rate
● Irregular pulse
● Paresthesias
Lab indicators

ECG - tall tented T waves, prolonged PR interval and QRS duration, absent P
waves, ST depression

Management

● Dietary potassium restriction

● IV calcium gluconate
● IV sodium bicarbonate
● Regular insulin
● Beta 2 agonists
Nursing management

● Closely monitor cardiac status and ECG

● Hold potassium supplements and potassium conserving diuretics
● Monitor serum potassium levels carefully
● Teach patient to avoid potassium rich foods

20
Hypocalcemia

Calcium levels <8.5mg/dL

Risk factors

● Hypoparathyroidism
● Malabsorption
Clinical manifestations

● Gastrointestinal hyperactivity
● Diarrhoea
● Irritability, apathy, confusion
● Muscle weakness
● Decreased heart rate
● Irregular pulse
● Paresthesias
Lab indicators

ECG - tall tented T waves, prolonged PR interval and QRS duration, absent P
waves, ST depression

Management

● Dietary potassium restriction

● IV calcium gluconate
● IV sodium bicarbonate
● Regular insulin
● Beta 2 agonists
Nursing management

● Closely monitor cardiac status and ECG

● Hold potassium supplements and potassium conserving diuretics
● Monitor serum potassium levels carefully
● Teach patient to avoid potassium rich foods
21
Hypocalcemia
Calcium levels <8.5mg/dL

Risk factors

● Hypoparathyroidism
● Malabsorption
● Pancreatitis
● Alkalosis
● Sepsis
● Alcohol abuse
Clinical manifestations

● Numbness
● Tingling of extremities and around mouth
● Muscle tremors
● Cramps
● Confusion
● Anxiety
Lab indicators

● ECG prolonged QT interval, lengthened ST

Management

● IV calcium
● Vitamin D therapy
Nursing management

● Monitor cardiovascular status

● Dietary calcium
● Supplements
● Exercise

22
Hypercalcemia

>10.5mg/dL

Risk factors

● Prolonged immobilization
● Hyperparathyroidism
● Malignancy of bone
● Paget’s disease
Clinical manifestations

● Lethargy
● Weakness
● Bone pain
● Depressed deep tendon reflexes
● Dysrhythmias
Lab indicators

ECG - shortened QT interval, bradycardia, heart blocks

Management

● Fluid administration
● Calcitonin
Nursing management

● Increase movement and exercise

● Oral fluids
● Limit intake of calcium containing foods

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Hypomagnesemia

<1.8mg/dL

Risk factors

● Excessive loss from gastrointestinal tract

● Long term use of certain drugs (diuretics)
● Chronic alcoholism
● Pancreatitis
● Burns
Clinical manifestations

● Neuromuscular irritability
● Positive Chvostek and Trousseau sign
● Insomnia
● Mood changes
● Anorexia
● Vomiting
● Increase tendon reflexes
● Increase blood pressure
Laboratory indicators

ECG : PVC flat or inverted T waves, depressed ST segment

Management

● Mild diet
● Oral magnesium salts
● IV magnesium sulphate
● Calcium gluconate

24
Nursing management

● Asus clients receiving digitalis for toxicity

● Protective measures (seizures)
● Magnesium rich foods

Hypermagnesemia

>2.7mg/dL

Risk factors

● Abnormal retention of magnesium

● Renal failure
● Adrenal insufficiency
● Treatment with magnesium salts
Clinical manifestations

● Peripheral vasodilatation
● Flushing
● Nausea
● Vomiting
● Muscle weakness
● Paralysis
● Hypertension
● Bradycardia
● Drowsiness
● Respiratory depression
Lab indicators

● ECG : tachycardia to bradycardia

● Prolonged PR interval and QRS

25
Management

● IV calcium
● Hemodialysis
● Loop diuretics
● 0.45% NaCl
● IV calcium gluconate
Nursing management

● Monitor vitals
● Loss of consciousness
● Advice clients with renal disease to contact primary care
provider before taking over the counter medication

Hypophosphatemia

<2.5mg/dL

Risk factors

● Alcohol withdrawal
● Acid base imbalance
● Diabetic ketoacidosis
● Re-feeding after starvation
Clinical manifestations

● Paresthesia
● Muscle weakness and pain
● Mental changes
● Possible seizures
Management

● Aggressive IV Phosphorus correction (<1mg/dl)

26
Nursing management

● Monitor serum Phosphorus levels

● Encourage Phosphorus containing foods

Hyperphosphatemia

>4.5mg/dL

Risk factors

● Acute / chronic renal failure

● Excessive intake of phosphorus
● Vitamin D excess
● Respiratory acidosis
Clinical manifestations

● Numbness
● Tingling around mouth and fingertips
● Muscle spasm
● Tetany
Management

● Vitamin D preparations
Nursing management

● Monitor lab findings

● Low Phosphorus diet
● Avoid laxatives, enemas

27
Hypochloremia

<96mEq/L

Risk factors

● Addison's disease
● Reduced chloride intake
● Diabetic ketoacidosis
● Excess levels of chloride through gastrointestinal tract, kidneys or
sweating
Clinical manifestations

● Agitation
● Irritability
● Tremors
● Muscle cramps
● Hyperactive deep tendon reflexes
● Shallow respiration
● Seizures, coma
Laboratory indicators

● Decreased NaCl
● Decreased sodium
● Increase serum PH
● Increased sodium carbonate
● Normal anion gap
● Decreased urine chloride
Management

● 0.9 % or 0.45% NaCl

● Foods high in chloride

28
Nursing management

● Monitor intake output

● ABG values
● Serum electrolytes
● Loss of consciousness
● Muscle strength and movements
● Vital signs
Hyperchloremia

>108mEq/L

Risk factors

● Excessive NaCl infusions with water loss

● Head injury
● Renal failure
● Corticosteroid use
● Respiratory alkalosis
● Metabolic acidosis
Clinical manifestations

● Acidosis
● Weakness
● Lethargy
● Tachypnea
● Deep rapid respirations
● Decreased carbon dioxide
● Dyspnea
● Tachycardia
● Pitting edema
● Coma
Laboratory indicators

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 ● Increased NaCl
● Increased sodium
● Decreased serum PH
● Decrease sodium carbonate
● Increased urine chloride
Management

● Ringer lactate solution

● IV sodium bicarbonate
● Diuretics
● Sodium, fluids, chloride (restricted)
Nursing management

● Monitor vitals
● ABG
● Intake output
● Teach patient regarding diet
SUMMARY

Fluids and electrolytes need to be balanced for the optimal functioning of the
systems in our body. Electrolytes are ions that can have either a negative or a
positive charge. Electrolytes and fluids play roles that are essential to life.

Nurses evaluate the client's responses to interventions that are used to correct
fluid and electrolyte imbalances by comparing the client’s baseline data,
including diagnostic laboratory data and the client’s signs and symptoms to the
outcome data after treatment and interventions.

Careful fluid and electrolyte management is essential in limiting the

morbidity and mortality rates. Maintenance of systemic perfusion is a critical
strategy in avoiding shock and the late consequences in the multiple system
organ failure syndromes.

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CONCLUSION

Nurses need an in-depth understanding of fluid and electrolyte imbalances to

anticipate, identify and respond to any possible imbalances that occur.

The body needs to maintain the balance of fluid and electrolytes to work
properly. Fluid and electrolytes balance is one of the key issues in maintaining
homeostasis of the body and hence plays important role in protecting cellular
function, tissue perfusion and acid-base balance.

BIBLIOGRAPHY

● Barbara Kozier, Glenora Erb. Textbook of Fundamentals of Nursing.

India: Dorling kindersley Pvt Ltd; 2008.
● Suzanne C smelizer, Janice L Hinkle, Brunner and Suddarth’s textbook of
Medical Surgical Nursing. India: Lippincott Williams and Wilkins; 2004.
● Potter and Perry.(2013).Fundamentals of Nursing.M/S Elsiever
publishers.869-870
● www.google.com
● www.slideshare.com
● https://www.registerednursing.org
● https://study.com

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