Fluids and

Electrolytes
CANDICE RACHEL U. CANLAS, LPT-MD

SCHOOL OF NURSING

EMILIO AGUINALDO COLLEGE - CAVITE

Fluid and
Electrolyte
Management
✓ One of the cornerstones of
patient care
✓ Body fluids provide
transportation of nutrients to
cells and carry waste
products away from the cells
✓ Approximately 60% of adult
human body weight is
composed of water
✓ Percent BW is higher in infants
and lower in older adults
Fluid and Electrolyte Management

Functions of Water
✓Acts as a solvent to dissolve solutes
✓Acts as a medium for metabolic reactions
Internal Control Mechanisms for Fluid Balance
✓Thirst
✓Antidiuretic hormone (ADH)
✓Aldosterone
Goal: Maintain homeostasis
Homeostasis
✓Fluid intake is equal to fluid output
✓Fluid intake: liquids, solid foods, IV fluids, or parenteral fluids
✓Fluid output: urine, emesis, or feces
✓Insensible losses: skin, lungs, GI tract
✓Measurable losses: fistulas, drains, or GI suction
✓Overhydration: sudden weight gain is strong indicator
✓Edema: Fluid excesses that accumulate in interstitial spaces, such as the
pericardial sac, joint capsules, and lower extremities
✓Dehydration: Quantity of water lost exceeds water gained; water deficit;
Death occurs when 20-25% of TBW is lost
✓Sodium is the principal extracellular electrolyte that plays primary role in
water concentration
Types of Dehydration
Conditions Leading to Dehydration
 Tonicity and
Osmolality
Osmolality
✓ Used in reference to body fluids and is the concentration of
the particles in a solution
✓ Normal osmolality of body fluids: 290-310 mOsm/kg
Tonicity
✓ Used in reference to IV fluids and is the measurement of the
concentration of the IV fluids as compared with the
osmolality of body fluids
✓ Measure of osmotic pressure
❖ Isotonic – osmotic pressure inside and outside the cell is
equal; normal saline (0.9% NaCl) or lactated Ringers
solution; no net fluid movement
❖ Hypotonic – solution outside the cell has lower osmotic
pressure than inside the cell; 0.45% NaCl solution; causes
fluid to move out of the vein and into the tissues and cells
❖ Hypertonic – solution outside the cell has higher osmotic
pressure than inside the cell; 3% NaCl injection; causes fluid
to move from ISF into the veins
Solutions
Acid-Base Balance
✓ Regulated by the respiratory system and
kidneys
✓ Acid – substance that can donate or
release H+
✓ Base – substance that can accept H+,
such as bicarbonate
✓ pH – measure of the degree of acidity
and alkalinity; inversely related to
hydrogen ion concentration
✓ Normal pH range – 7.35 to 7.45; Acidosis
pH below 7.35 and alkalosis pH above
7.45
Regulation of Acid-Base Balance
✓Respiratory system compensates for metabolic problems and
pH imbalances by regulation of carbon dioxide (CO2)
✓Kidney compensates for metabolic problems by regulating of
reabsorption of bicarbonate (HCO3-) and excretion of
hydrogen ion (H+)
Laboratory Tests
✓Arterial Blood Gas (ABG) – influence of the respiratory system
✓Blood Test to determine Acid-Base balance – measures total
body CO2 and is usually represented as HCO3
 Acid-Base
Imbalance
Causes of
Acid-Base
Imbalance
Acid-Base Disorders and
Compensation
 Crystalloids
Colloids
Blood Products
Electrolytes
DIFFERENT FLUID &
ELECTROLYTE THERAPIES
Crystalloids
✓ Fluids given by IV injection that supply
water and sodium to maintain
osmotic gradient between the
extravascular and intravascular
compartments
✓ Short-term plasma volume –
expander (related to their sodium
concentration)
✓ Normal saline (0.9% NaCl) and
lactated Ringers solution
❖Serum is a term closely related to
plasma
 Mechanism of Action:
✓ Contain fluids and electrolytes that are normally found in
the body
✓ Do not contain proteins (colloids)
✓ Distributed faster into the interstitial and intracellular
compartments than colloids
✓ Better for treating dehydration than expanding plasma
volume alone
✓ Much less expensive than colloids and blood products
✓ No risk for viral transmission or anaphylaxis and no alteration
Crystalloids of coagulation profile associated with blood products
Indications:
✓ Maintenance fluids
✓ Compensate for insensible fluid losses, to replace fluids, and
to manage specific fluid and electrolyte disturbances
✓ Promote urinary flow
✓ Used for liver failure, burns, cardiopulmonary bypass surgery,
hypoproteinemia, renal dialysis, and shock
Contraindications:
✓ Drug allergy to a specific product, hypovolemia, and
electrolyte disturbance depending on the crystalloid used
 Adverse Effects:
✓ Do not stay within the blood vessels
and can leak out of the plasma into
the tissues and cells (because they
don’t have large particles like proteins)
→ peripheral edema and pulmonary
edema
Crystalloids ✓ Dilute proteins in the plasma →
reduces colloid oncotic pressure
✓ Prolonged use can cause fluid
overload
✓ Effects are relatively short-lived
Interactions:
✓ Rare
 Physiological electrolyte

No hypersensitivity reactions to it; safe

Sodium during pregnancy
Chloride
Contraindicated to patients with
hypernatremia and/ or hyperchloremia

Available in several concentrations in

solutions and available in 650 mg tablets
NaCl solutions

HYPERTONIC
ISOTONIC
- 3% and 5%
- 0.9% is the most
common - High-alert drug
HYPOTONIC
- Physiologically normal - Contraindicated in
- 0.45% and 0.25 increased, normal, or
concentration of
sodium chloride - Correcting to rapidly slightly decreased
can cause hemolysis of sodium concentrations
- Referred to normal
RBC - Correcting to rapidly
saline (NS)
can lead to osmotic
- Contains 154 mEq of
demyelination
sodium per liter
syndrome (fatal)
Colloids

✓ Substances that increase the colloid

oncotic pressure and move fluid from
interstitial compartment to plasma
compartment by pulling the fluid into
the blood vessels
✓ Three blood proteins responsible:
ALBUMIN, GLOBULIN, and
FIBRINOGEN
✓ Normal total body protein level: 7.4
g/dL; if it falls below 5.3 g/dL → fluid
shifts out of the blood vessels into the
tissues
✓ Colloid oncotic pressure decreases in
malnutrition and old age
✓ To reverse process: colloid
replacement therapy
Colloids
✓Commonly used colloids: ALBUMIN (naturally-occurring), DEXTRAN
(carbohydrates) , HETASTARCH (starch)
✓ Other types of colloids come from fats (lipid emulsion) and animal collagen (gelatin)
✓ With the exception of albumin, most colloids are combination of small and large
particles; small particles are eliminated quickly while the large particles maintain the
plasma volume
Mechanism of Action and Drug Effects:
✓PLASMA EXPANDERS - Colloids cannot pass into extravascular space and
has the ability to increase the colloid oncotic pressure → moves water
from extravascular space into the blood vessels in an attempt to make
blood isotonic → increase blood volume
✓Also make up part of the total plasma volume
✓Increase colloid oncotic pressure – move fluid from outside to inside the
blood vessels (can maintain this for several hours)
COLLOIDS
✓INDICATIONS: Shock and burns or whenever the patient
requires plasma volume expansion
✓Superior to crystalloids because it maintains plasma volume for
a longer time
✓More expensive and are more likely to promote bleeding
because they dilute the blood
✓CONTRAINDICATION: Drug allergy to specific product and
hypervolemia, and severe electrolyte imbalance
✓ADVERSE EFFECTS: Generally safe, Dilutional Effect = possible
bleeding; Dextran therapy can cause anaphylaxis and renal
failure (rare)
✓INTERACTIONS: None
Colloids
COLLOIDS
ALBUMIN
✓ Natural protein produced by liver
✓ Generates 70% of colloid pressure
✓ Human albumin is a sterile solution
albumin prepared from pooled blood,
plasma, serum, or placentas obtained
from healthy human donors; pasteurized
✓ Limited supply; expensive
✓ CI: hypersensitivity, heart failure, severe
anemia, or renal insufficiency
✓ Parenteral form only in 5% and 25%
DEXTRAN
✓ Solution of glucose
✓ Available as dextran 40 and has same
molecular weight as albumin
✓ Actions are similar to human albumin →
expands plasma volume
✓ CI: hypersensitivity, heart failure, renal
insufficiency, and extreme dehydration
✓ Available only in parenteral form mixed
in either 5% dextrose solution or 0.9%
NaCl solution
Dosing Guide for Crystalloids and Colloids
Blood Products
✓ Biologic drugs
✓ Augment the plasma volume
✓ RBC-containing products: Improve
tissue oxygenation
✓ More expensive than crystalloids
and colloids; less available because
they require human donors
✓ Indicated for patients who have lost
25% or more blood
Blood Products
Mechanism of Action and Drug Effects:
✓ Plasma Expanders - ability to increase
colloid oncotic pressure (pull water from
extravascular space to intravascular space)
✓ Ability to carry oxygen (RBC products)
✓ Administered when a person’s body is
deficient in these products
✓ CI: None
✓ Adverse Effects: Can be incompatible with
recipient's immune system → anaphylaxis
and rejection; transmit pathogens (hepatitis
and HIV)
✓ Interactions: Calcium and aspirin which
affect coagulation; Blood must NOT BE
administered with any solution other than
normal saline
Indications for Use of Blood Products
 Blood Products
Packed Red Blood Cells (PRBC)
✓ Obtained by centrifugation of whole
blood and separation of RBC’s from
plasma and other cellular elements
✓ Advantages: oxygen-carrying
capacity, less likely to cause cardiac
fluid overload
✓ Disadvantages: high cost, limited
shelf-life, fluctuating availability, as
well as their ability to transmit viruses,
trigger allergic reactions, and cause
bleeding abnormalities
Fresh Frozen Plasma (FFP)
✓ Obtained by centrifuging whole
blood and removing cellular
elements → resulting plasma is
frozen
✓ Used as adjunct to massive blood
transfusion in the treatment of
patients with underlying coagulation
disorders
✓ Plasma-expanding capability is
similar to dextran
✓ Disadvantage: Can transmit
pathogens
Guidelines for Use
of Blood Products
Electrolytes
Potassium
✓ Most abundant electrolyte inside the cells; 95% of
K+ in the body is intracellular
✓ Normal concentration = 150 mEq/L
✓ Ratio of intracellular to extracellular potassium is
important; changes in extracellular potassium can
lead to unwanted neuromuscular and
cardiovascular effects
✓ Obtained from diet
✓ Hypokalemia – serum potassium level less than 3.5
mEq/L; Result from decreased intake, shifting of K+
into cells, increased renal excretion and other losses
such as diarrhea, vomiting, or tube drainage
✓ Hyperkalemia – serum potassium level greater than
5.5 mEq/L; Result from increased intake, reduced
renal excretion, redistribution of potassium from
intracellular to extracellular compartment following
burns or rhabdomyolysis; Severe hyperkalemia
manifests as ventricular fibrillation and cardiac
arrest
Potassium
Mechanism of Action and Drug Effects:
✓ Involved in muscle contraction, transmission of nerve impulses, and regulation of
heartbeats (pacemaker function of the heart)
✓ Essential for the maintenance of acid-base balance, isotonicity, and
electrodynamic characteristics of the cell
✓ Plays a role in many enzymatic reactions; essential component in gastric
secretion, renal function, tissue synthesis, and carbohydrate metabolism
Indication: Treatment or prevention of potassium depletion
CI: Allergy to specific drug product, hyperkalemia from any cause, severe renal
disease, acute dehydration, untreated Addison disease, severe hemolytic disease,
conditions involving extensive tissue breakdown (multiple trauma, severe burns)
Adverse Effects: diarrhea, nausea, vomiting, GI bleeding and ulceration, pain at
injection site (parenteral administration)
❖IV potassium must not be given faster than 10 mEq/hr to patients who are not on
cardiac monitors; critically ill on cardiac monitors = 20 mEq/hr
 Toxicity and Management
✓ Result from hyperkalemia
✓ Symptoms: muscle weakness,
paresthesia, paralysis, cardiac rhythm
irregularities ➔ ventricular fibrillation and
cardiac arrest
✓ Severe hyperkalemia – dextrose IV +
insulin, sodium bicarbonate, and calcium
Potassium gluconate or chloride = reduces K+
concentration; followed by sodium
polystyrene sulfonate (Kayexalate) orally
or rectally or hemodialysis to eliminate
excess K+
Interactions: potassium sparing diuretics,
ACE inhibitors -= hyperkalemia; non-
potassium-sparing diuretics, amphotericin
B, and mineralocorticoids = hypokalemia
Dosage Guidelines for Potassium Infusion
 Potassium supplements
✓ Prevent or treat potassium depletion
✓ Oral (tablets, solutions, elixirs,
powders for solutions): acetate,
bicarbonate, chloride, citrate, and
gluconate salts
✓ IV parenteral salt forms: acetate,
chloride, phosphate (high-alert drugs
= cause toxicity)
Sodium polystyrene sulfonate
(Kayexalate)
✓ Cation exchange resin used to treat
hyperkalemia
✓ Administered orally via nasogastric
tube or as an enema
✓ Works in the intestine where K+ from
body are exchanged for Na+ in the
resin
✓ Electrolytes are monitored when this
is administered due to K+ losses
❖Should not be administered in
patients who do not have normal
bowel function; D/C if patients have
constipation
✓ Dosage: 15 to 30 g until desired
effect on serum potassium occurs
 Counterpart of potassium; principal cation outside the
cells

Normal concentration: 135 to 145 mEq/L

Sodium
Hyponatremia – sodium loss or deficiency than 135
mEq/L; manifested as lethargy, hypotension, stomach
cramps, vomiting, diarrhea, and seizures

Hypernatremia – sodium excess of 145 mEq/L: generally,

indicates deficit in total body water; manifested as
muscle cramps, headache, lethargy, seizures, coma, and
possible intracranial hemorrhage
 Type Total Body Total Sodium
Water (TBW)

Hypovolemic Decreased Decreased (to

hyponatremia a greater
extent)
Types of
Hyponatremia Euvolemic Increased Normal
hyponatremia

Hypervolemic Increased (to Increased

hyponatremia a greater
extent)
 Mechanism of Action and Drug Effects:
✓ Involved in control of water distribution,
fluid and electrolyte balance, and
osmotic pressure of body fluids
✓ Chloride complements physiologic
action of sodium
Indications: Treatment or prevention of
Sodium sodium depletion
CI: Drug allergy to specific product and
hypernatremia
AE: Oral administration can cause gastric
upset – nausea, vomiting, cramps: IV
administration can cause venous
phlebitis
Interactions: antibiotic called
quinupristin/dalfopristin (Synercid)
 Sodium Chloride
✓ Replacement electrolyte for
prevention or treatment of sodium
loss
✓ Diluent for infusion of compatible
drugs and in assessment of kidney
function after fluid challenge
✓ IV preparations and 650 mg tablets
Conivaptan
✓ Nonpeptide dual arginine vasopressin (AVP), V1A
and V2 receptor antagonist
✓ Inhibits the effects of ADH in the kidney
✓ Specifically indicated for treatment of hospitalized
patients with euvolemic hyponatremia, or low-
serum sodium levels at normal water volumes
✓ IV infusion
✓ AE: infusion site reactions, thirst, headache,
hypokalemia, vomiting, diarrhea, and polyuria
✓ Monitor serum sodium levels because can cause
osmotic demyelination syndrome
✓ Interactions: cytochrome P-450 enzyme inhibitors
- ketoconazole, itraconazole, clarithromycin,
ritonavir and indinavir → increase serum Na+
levels
Nursing
Process
FLUID & ELECTROLYTES