Page | 1

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

● For obese individuals, total body water should be

OUTLINE lowered to 10-20%
I. Review of Fluid and Electrolyte and Acid Base ● For malnourished individuals, total body water
Dynamics increases approx. 10% from the average young adult
A. Water Distribution and Fluid Compartments ● For newborns, total body water amounts to 80% of
B. Electrolytes their total body weight
1. Major Cations in the Body ○ It increases into 65% after year
a) Functions ● The average intake and output should be about
2. Major Anions in the Body 2500mL.
3. Normal Values for ELectrolytes ● The daily amount of urine output in adults is about
C. Fluid and Electrolyte Movement 1500mL.
1. Osmosis
2. Diffusion FLUID COMPARTMENTS
3. Filtration
4. Active Transport ● TWO CATEGORIES:
D. Acid and Bases ○ INTRACELLULAR FLUID (ICF)
II. Fluid Imbalances ○ EXTRACELLULAR FLUID (ECF)
A. Hypovolemia
B. Third Spacing INTRACELLULAR FLUID (ICF)
C. Hypervolemia
III. Electrolyte Imbalances ● located within the cells
A. Sodium Imbalance ● amounts to about 40% of the total body water
1. Hyponatremia
2. Hypernatremia EXTRACELLULAR FLUID (ICF)
B. Potassium Imbalance
1. Hypokalemia ● found outside of cells
2. Hyperkalemia ● classified by location:
C. Calcium Imbalance ○ Interstitial Fluid - 14% of body weight; spaces
1. Hypocalcemia between cells of the body
2. Hypercalcemia ○ Intravascular Fluid/Plasma - 5% of body
D. Magnesium Imbalances weight; arteries, veins, and capillaries
1. Hypomagnesemia ○ Transcellular Fluid - 1% of body weight;
2. Hypermagnesemia urine, digestive secretions, perspiration, and
IV. Acid-Base Imbalances
cerebrospinal, pleural, synovial, intraocular,
A. Respiratory Acidosis
B. Respiratory Alkalosis gonadal, and pericardial fluids
C. Metabolic Acidosis ● amounts to 20% of the total body water
D. Metabolic Alkalosis
V. CVP Insertion ELECTROLYTES
VI. Arterial Blood Gas (ABG) Test
VII. Parenteral Fluid Therapy MAJOR CATIONS IN THE BODY
A. Types of Intravenous Solutions
● Sodium - main extracellular cation
○ Functions:
REVIEW OF FLUID AND ELECTROLYTE AND ACID BASE ■ govern normal ECF osmolality
DYNAMICS ■ helps maintain acid-base balance
■ activates nerve and muscle cells
WATER DISTRIBUTION AND FLUID COMPARTMENTS ■ influences water distribution
● Potassium - main intracellular cation
WATER DISTRIBUTION
○ Functions
● Normal adult’s body weight consists of 50-60% of ■ regulates cell excitability
water ■ permeates cell membranes (affects
● Young adult males: 60% of total weight is water cell’s electrical status)
● Young adult females: 50% of total weight is water ■ helps control ICF osmolality and
● Females have a higher percentage of adipose tissue, osmotic pressure
and lower percentage of muscle mass ● Calcium - major cation in teeth and bones
○ Functions:

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 2

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

■ helps cells adhere to one another ● Calcium - 8.6-10.2 mg’dL

and maintain their shape (in cell ● Potassium - 3.5-5.0 mEq/dL
membranes) ● Phosphorus (Phosphate) - 2.5-4.5 mg/dL
■ acts as an enzyme activator within ● Magnesium - 1.6-2.3 mg/dL
cells
■ aids coagulation
■ affects cell membrane permeability
● These chemicals mix in a variety of ways, so the
and firing level
electrolytes in the body is expressed in milliequivalents
● Magnesium - a leading ICF cation
(mEq) per liter, rather than mg
○ Functions:
● ICF differs from ECF in terms of electrolyte content
■ contributes to many enzymatic and
● Since ICF requires special procedures to assess
metabolic processes (protein
electrolyte concentrations, these are often measured in
synthesis)
the section of plasma
■ modifies nerve impulse transmission
● Sodium outweighs other cations in the ECF because it
and skeletal muscle response
influences the total concentration of ECF.
● Hydrogen Ions
○ It is vital for managing bodily fluid volume.
○ Functions:
○ Sodium retention is linked to fluid retention
■ aid in the regulation of pH during
○ Sodium loss is linked to bodily fluid content
digestion
reduction
■ necessary for stomach’s digestive
● The body expends a lot of energy to sustain the high
fluids to maintain a low pH, which
extracellular sodium concentration and the high
aids in digestion
intracellular potassium concentration. It does this by the
■ aids in cellular respiration
use of cell membrane pumps, which exchange sodium
and potassium ions.
MAJOR ANIONS IN THE BODY
● Hydrostatic Pressure - determines normal fluid
● Chloride - main ECF anion movement through the capillary wall into tissues
○ Functions: together with osmotic pressure
■ helps maintain normal ECF osmolality ● Osmotic Pressure - produced by plasma protein
■ affects body pH
■ aids in maintaining acid-base
balance; combines with hydrogen FLUID AND ELECTROLYTE MOVEMENT
ions to produce hydrochloric acid
● Bicarbonate - present in ECF OSMOSIS
○ Functions:
■ regulates acid-base balance ● water moves across a selectively permeable membrane
● Phosphate - main ICF anion from an area of lower solute concentration to an area to
higher solute concentration
○ Functions:
○ Osmolality
■ promotes energy storage and
carbohydrate, protein, and fat ■ concentration of a solution
metabolism ■ refers to the number of solutes per
■ acts as a hydrogen buffer kilogram of water (by weight)
● Sulfate ■ it is reported in milliosmoles per
kilogram (mOsm/kg)
○ Function:
○ Osmotic Pressure and Tonicity
■ for proper cell growth
■ the power of a solution to draw
● Proteinate Ions
water across a membrane
○ Function:
■ Oncotic Pressure - also known as
■ Aid in growth and maintenance of
colloid osmotic pressure that is
tissues
exerted by proteins, pulling fluid
NORMAL VALUES FOR ELECTROLYTES from the interstitial space into the
intravascular compartment
● Sodium - 135-145 mEq/L ■ Tonicity - refers to the effect a
● Chloride - 98-102 mEq/L solution’s osmotic pressure has on

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 3

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

water movement across the cell ● Bases bind with hydrogen

membrane within that solution ● normal pH is 7.0
■ Isotonic solutions have the same ● BLOOD HAS A NORMAL RANGE OF ABOUT 7.35-7.45
concentration of solutes as plasma
FLUID IMBALANCES
DIFFUSION
● when body’s water content is not balanced in either
● solute molecules move from an area of high solute volume or distribution
concentration to an area of low solute concentration
HYPOVOLEMIA
● Simple
● Facilitated Diffusion ● also known as Fluid Volume Deficit (FVD)
● it happens when the loss of ECF volume is greater than
FILTRATION the intake of fluid
● it happens when water and electrolytes are lost in same
● water and dissolved substances move from an area of
proportion
high hydrostatic pressure to an area of low hydrostatic
pressure
ASSESSMENT
● usually occurs across capillary membranes
● Identify the patient at risk to hypovolemia
ACTIVE TRANSPORT
● Assess the patient’s vital signs
● Observe for the signs and symptoms of hypovolemia
● allows molecules to move across cell membranes and
epithelial membranes against a concentration gradient ● Assess the patient’s mental state and level of
consciousness
● this movement requires energy (ATP) and a carrier
mechanism to maintain a higher concentration of
SIGNS AND SYMPTOMS
substance on one side of the membrane than on the
other ● Thirst
OSMORECEPTORS ● Low BP
● Elevated temp
● regulates fluid volume in the hypothalamus by the ● Rapid, weak, or thready pulse
excretion of water in the form of urine and the ● Warm, flushed, dry skin
promotion of thirst ● Weight loss
● sensitive to changes in blood volume and BP through ● Oliguria
information relayed by baroreceptor ● Orthostatic Hypotension
● triggers thirst
PATHOPHYSIOLOGY
BARORECEPTORS

● stretch receptors in the aortic arch and carotid sinus

● signal the brain to release ADH when blood volume
decreases by 10%, systolic BP falls below 90 mmHg, or
the right atrium is underfilled

RENIN ANGIOTENSIN ALDOSTERONE SYSTEM

● chains of chemicals released to increase both BP and

blood volume
● it is triggered by the juxtaglomerular apparatus

NATRIURETIC PEPTIDES
DIAGNOSTIC AND LABORATORY TESTING
● hormone-like substances that act in opposition to the
renin-angiotensin-aldosterone system CBC
ACID AND BASES • test the hematocrit and hemoglobin
● Acids release hydrogen into fluid

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 4

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

• hematocrit often is elevated due to loss of intravascular THIRD SPACING

volume and hemoconcentration
• Movement of fluid from the intravascular or intercellular
SERUM OSMOLALITY TEST space to tissue compartments, where it gets stuck and
ineffective
• Distinguishes isotonic fluid loss from water loss • linked to colloid loss, which can occur as a result of
hypoalbuminemia (low albumin levels in the blood) or
• Water loss = high osmolality
burns, as well as severe allergic responses that affect
• Isotonic fluid loss = may be within acceptable ranges capillary and cellular membrane permeability
• translocation depletes the intravascular fluid volume =
URINE SPECIFIC GRAVITY TEST hypotension, shock, and circulatory collapse

• As the kidneys conserve water, both the specific gravity ASSESSMENT

and osmolality of urine increase
• Identify the patient at risk to third spacing
CENTRAL VENOUS PRESSURE (CVP) • Assess the patient’s vital signs
• Measures the mean pressure in the superior vena cava or • Observe for the signs and symptoms of third spacing
right atrium • Assess the patient’s mental state and level of
• Provides accurate assessment of fluid volume status consciousness
• signs and symptoms are the same with hypovolemia but
BLOOD UREA NITROGEN (BUN) without the weight loss

• A volume-depleted patient has BUN elevated out of SIGNS AND SYMPTOMS

proportion to the serum creatinine
• Ratio > 20:1 • Thirst
• Low Blood pressure
SERUM CREATININE TEST • Elevated Temperature
• Pulse are either Rapid, weak, and thready
• Measures the amount of creatinine in the blood
• Skin are warm, flushed, dry
PHARMACEUTICAL MANAGEMENT • Enlargement of organ cavities
• Generalized edema
● Oral feeding is suggested if deficiency is not severe
● IV route is required it fluid losses are severe PATHOPHYSIOLOGY
● Isotonic solutions are the first line treatment for
hypotensive patient with FVD because they expand
plasma volume
● Normotensive patient = hypotonic electrolyte solution
○ E.g. 0.45% SODIUM CHLORIDE
○ Often used to provide both electrolytes and
water for renal excretion of metabolic wastes
○ To avoid volume overload
■ Accurate and regular evaluations of
I&O, weight, VS, central venous
pressure, degree of awareness, breath
sounds, and skin color are performed

NURSING MANAGEMENT

• Monitor the patients I&O hourly or every 8 hrs

• Assess the patient’s vital signs
• Monitor the patient’s skin and tongue turgor
• Administer IV fluids as prescribed by the physician
• Encourage the patient to consume at least 8-10 glasses
of water

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 5

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

• Administer IV fluids as prescribed by the physician

HYPERVOLEMIA

ASSESSMENT

• Look for swelling of extremities

o esp. Legs, ankles and feet
• Jugular veins in the neck
• Monitor accumulation of fluid in abdominal cavity
• Auscultate lungs
• Vital signs

SIGNS AND SYMPTOMS

• Fatigue and weakness

• SOB
• Edema
• Weight gain
• Confusion and altered mental status
• Pulmonary edema
• Abdominal distention
• Decrease urine output
• High BP
• Jugular venous distention

PATHOPHYSIOLOGY

DIAGNOSTIC AND LABORATORY TESTING

• Blood Test
• Urine Specific Gravity
• CVP

RESULTS

• Blood tests and urine specific gravity = borderline

normal or reveal evidence of hemoconcentration
• CVP = below normal, as are other hemodynamic
measurements

PHARMACEUTICAL MANAGEMENT
DIAGNOSTIC FINDINGS
• PRIORITY: Restore circulation volume and remove
• Blood cell count and hematocrit level are low as a result
retained fluid
of hemodilution – a reduced ratio of blood components
o Accomplished by delivering IV fluids at times at
to watery plasma
high rates and blood components such as
albumin to restore colloidal osmotic pressure • Urine Specific Gravity – low = reflecting the larger
proportion of water
• IV diuretic may be ordered
• CVP – elevated above its normal range of 2 to 9 mmHg
NURSING MANAGEMENT
ELECTROLYTE IMBALANCES
• Monitor the patients I&O hourly or every 8 hrs SODIUM IMBALANCE
• Assess the patient’s vital signs
• Monitor the patient’s skin and tongue turgor • Sodium

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 6

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

o Chief cation in ECF PHARMACOLOGIC AND MEDICAL CARE

o Essential for maintaining normal nerve and
muscle activity • AVP receptor antagonist
o Regulating osmotic pressure and preserving • IV conivaptan hydrochloride
acid-base balance • Tolvaptan
o Regulate and distribute fluid volume in the
body DIAGNOSIS
o Normal concentration: 135-145 mEq/L
o Lower = hyponatremia • Serum sodium and osmolality – decreased
o Higher = hypernatremia • 24-hour urine specimen – evaluate sodium excretion
o In conditions associated with normal or
HYPONATREMIA
increased extracellular volume (such as SIADH),
• Causes urinary sodium is increased
o Profuse diaphoresis o In conditions resulting from losses of isotonic
o Excessive ingestion of plain water or fluids (e.g., sweating, diarrhea, vomiting, and
administration of nonelectrolytes IV fluids third-space fluid accumulation), by contrast,
o Profuse diuresis urinary sodium is decreased.
o Loss of GI secretions HYPERNATREMIA
o Addison’s disease
• Excess sodium in the blood
ASSESSMENT
• CAUSES
o profuse watery diarrhea
• Monitor symptoms
o excessive salt intake without sufficient water
• Vital signs intake
• Edema o high fever
• Measure electrolyte levels o decreased water intake (e.g., in older adults,
• Monitor serum sodium levels debilitated, unconscious, or developmentally
• Assess kidney function delayed clients)
• Assess urinary sodium levels o excessive administration of solutions that
• Measure the concentration of solutes in blood contain sodium
o excessive water loss without an accompanying
PATHOPHYSIOLOGY loss of sodium
o severe burns

ASSESSMENT

• monitor serum sodium levels and serum osmolality

• Monitor urine specific gravity
• Vital signs
• Monitor electrolyte levels
• Test for diabetes insipidus
• Look for signs of dehydration

PATHOPHYSIOLOGY

MANAGEMENT

• Monitor I&O
• Monitor body weight
• Sodium Replacement
• Water restriction

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 7

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

o taken by the body by consuming food and

drinks rich in potassium
o NORMAL RANGE: 3.5-5 mEq/L
• Kidneys maintain normal potassium levels by excreting
excess amount through urine

SOURCE OF POTASSIUM

• fruits which include apricots, bananas, kiwi, oranges, and

pineapples
• vegetables, such as leafy greens, carrots, and potatoes
• lean meats
• whole grains
• beans and nuts
NURSING MANAGEMENT
HYPOKALEMIA
• Maintains accurate intake and output measurements
• It is the reduced serum potassium concentration which
• Assesses vital signs every 1 to 4 hours is below normal range. This is caused by:
• Monitors the infusion of IV fluids o inadequate potassium intake
• Implement dietary restrictions or supplements o excessive renal potassium excretion
• Monitors the patient closely for changes in behavior, o potassium loss in pathologic GI secretions,
such as restlessness, disorientation, and lethargy. such as diarrhea, fistulas, vomiting, or high
nasogastric output, or
DIAGNOSIS o intracellular shifts from metabolic alkalosis or
insulin therapy.
• Serum sodium levels are greater than 145 mEq/L in
hypernatremia. ASSESSMENT
• Serum osmolality is greater than 295 mOsm/kg in
hypernatremia • Identify patients at risk for hypokalemia
• Assess the patient’s diet for a lack of potassium
MEDICATION • Assess patient for signs and symptoms of hypokalemia
• Assess for abdominal pain, distention, GI bleeding
• PRIORITY: Oral or IV treatment
• Hypotonic IV fluids (0.45% NaCl solution or 5% dextrose
in water) – isotonic when administered but becomes
hypotonic which provides pure water when the glucose SIGNS AND SYMPTOMS
is metabolized
o Correct the water deficit • Potassium level under 3.5 mEq/L
• Diuretics – increase sodium excretion • Fatigue, muscle weakness, and paresthesia
• Prolonged cardiac repolarization, decreased strength of
POTASSIUM IMBALANCES myocardial contraction, orthostatic hypotension,
reduced sensitivity to digoxin, increased resistance to
POTASSIUM antiarrhythmics, and cardiac arrest
• Flat ST segment and Q wave on electrocardiogram
• Conduct electrical impulses throughout the body (ECG)
• Supports several vital bodily processes • Decreased bowel motility
o Blood Pressure • Suppressed insulin release and aldosterone secretion
o Water balance
• Inability to concentrate urine and increased renal
o Muscle contractions
phosphate excretion
o Nerve impulses
• Respiratory muscle weakness
o Digestion
o Heart rhythm • Metabolic alkalosis, low urine osmolality, slightly
o pH balance elevated glucose level, and myoglobinuria
• not naturally produced mineral in the body PATHOPHYSIOLOGY

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA

PLM BS
NURSING MEDICAL-SURGICAL NURSING I
1ST SEMESTER
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report
• When human blood has too little potassium, hypokalemia
develops. This could occur for a number of reasons: a.
Not Enough in Food: Low levels might result from not
consuming enough potassium in our diets. b. Our
kidneys occasionally eliminate too much potassium from
our bodies, which can cause renal problems. c. Certain
Drugs: Some drugs might increase the amount of
potassium we lose through urine. d. Digestive Issues:
Issues like vomiting or diarrhea can lead to potassium
loss. Muscle weakness, irregular heartbeats, and
potentially serious cardiac problems can result from low
potassium levels. In an effort to compensate, our body
attempts to deal with this by transferring potassium from
cells into the bloodstream, but this may not be sufficient.
DIAGNOSTIC AND LABORATORY
• Patients who are at risk for hypokalemia or who are
receiving treatment for it can have their potassium
levels checked using serum potassium (K+).
• ABGs, or arterial blood gases, are measured to
ascertain acid-base balance. Hypokalemia frequently
coexists with an elevated pH (alkalosis).
• Blood tests for renal function as those for serum
creatinine and BUN testing may be prescribed to look
for potential causes or symptoms of hypokalemia.
• To assess the effects of hypokalemia on the cardiac
conduction system, ECG recordings are acquired.
PHARMACOLOGIC AND MEDICAL CARE
• Potassium supplements such as Potassium chloride is
taken through IV fluids
L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
Page | 8
Course Code:
NRS 3113
LECTURE
CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano
• Diet rich in potassium is recommended such as
bananas, oranges, avocados, spinach, potatoes,
tomatoes, meat, seafood, milk, and yogurt
NURSING MANAGEMENT
• Taking potassium supplements along with potassium-
sparing diuretics is not recommended
• If taking of parenteral potassium has ended, consume
potassium-rich diet
• Take potassium supplements with meals
• Never use salt-substitutes when consuming potassium
since the former is potassium-based
• Monitor patient for complications
• Inform the patient's family on how to prevent, spot, and
handle hypokalemia
HYPERKALEMIA
• Serum potassium concentration above normal range of
3.5 to 5.0 mEq/L which is caused by
o Excessive intake of potassium
o Increased release of potassium from within the
.cells, or
o impaired potassium excretion by the kidneys.
o Excessive intake can be from oral or IV
supplementation, or from red blood cell lysis.
o Disruption of cell membranes and release of
intracellular potassium into ECF is caused by
hemolysis, rhabdomyolysis, and crush injuries.
ASSESSMENT
• Identify patients at risk for hyperkalemia.
• Assess patient’s diet for excess use of salt substitutes.
• Assess patient for signs and symptoms of hyperkalemia.
• Assess arterial blood gas studies for metabolic
alkalosis.
SIGNS AND SYMPTOMS
• Potassium level above 5 mEq/L
• Cardiac conduction disturbances, ventricular
arrhythmias, prolonged depolarization, decreased
strength of contraction, and cardiac arrest
• Tall, tented T wave; widened QRS complex; and
prolonged PR interval on ECG
• Muscle weakness and paralysis
• Nausea, vomiting, diarrhea, intestinal colic, uremic
enteritis, decreased bowel sounds, abdominal
distention, and paralytic ileus
PATHOPHYSIOLOGY

PLM BS
NURSING MEDICAL-SURGICAL NURSING I
1ST SEMESTER
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report
• When there is too much potassium in the blood, it is
called hyperkalemia and is frequently caused by: a. issues
with the kidneys that impact potassium regulation. b.
excessive potassium intake from food or supplements. c.
potassium is released into the blood due to cell
destruction. d. Some drugs affect how potassium is
handled. Heart rhythm problems and muscle weakness
might result from high potassium levels. By putting
potassium into cells and removing it through the kidneys.
DIAGNOSTIC AND LABORATORY
• Blood test: renal failure is one of the common causes of
hyperkalemia. Impaired kidneys cannot excrete
potassium properly leading to increased serum
potassium level.
• Potassium levels can provide a false positive result called
pseudo hyperkalemia. This is due to the tourniquet being
too tight or too long can cause red blood cells to burst
releasing the potassium within the cell.
• During venipuncture, repeated clenching of fist can cause
potassium to leak increasing the lab result by 1 to 2
mEq/L
• Urine tests: this test provides information about the
blood, glucose, protein, or infection in the urine. It could
indicate glomerulonephritis, inflammation of the kidney,
or glomerulonephrosis, a non-inflammatory condition
where kidney releases protein.
• Cardiac tests: having a high serum potassium level can
cause life-endangering arrythmias. Electrocardiograms
help detect hyperkalemia and identify the kind of
arrythmia present.
• A serum potassium level more than 5.0 mEq/L is
indicated by serum electrolytes. The symptoms of
hyperkalemia may be exacerbated by low calcium and
sodium levels, so these electrolytes are typically
evaluated as well.
L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
Page | 9
Course Code:
NRS 3113
LECTURE
CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano
• To find out if there is acidosis, ABGs are assessed.
• To assess the impact of hyperkalemia on cardiac
conduction and rhythm, an ECG is acquired and ongoing
ECG monitoring is implemented.
PHARMACOLOGIC AND MEDICAL CARE
• Hemodialysis or peritoneal dialysis both removes waste
products from our blood by filtering it with a machine.
• Cation-exchange resin (Kayexalate) binds potassium in
exchange for sodium where it can be administered orally
or rectally.
• Calcium gluconate counters the effects of hyperkalemia
on cardiac conduction system.
• Potassium leaves the ECF by being taken up by the cells
through the actions of insulin and glucose.
• Albuterol may be given through a nebulizer to push
potassium into the cells temporarily
• If acidosis is present, sodium bicarbonate allows the
blood pH level to return to normal promoting the
collection of the released potassium back into the cell.
• If renal function is normal, furosemide may be given to
promote excretion of potassium.
NURSING MANAGEMENT
• Take precautions when drawing blood
• Always have emergency equipment ready
• Teach the patient and family how to prevent, recognize,
and treat hyperkalemia
• Restrict intake of foods rich in potassium and remove
potassium supplementation in IV fluids and enteral and
parenteral solutions
• Monitor intake and output
• Monitor serum potassium levels, BUN, creatinine,
glucose, and arterial blood gas values
CALCIUM IMBALANCES
• The bones and teeth contain the majority of the body's
calcium. A modest proportion (approximately 1%) is
present in the blood. The parathyroid glands regulate
blood calcium levels. Calcium is required for blood
coagulation, smooth, skeletal, and cardiac muscle
function, as well as nerve impulse transmission. Vitamin
D is required for calcium absorption in the intestines.
Hypocalcemia occurs when the blood calcium level is
lower than normal; hypercalcemia happens when the
level is greater than usual.
HYPOCALCEMIA
• It happens when the calcium levels in the blood are too
low.
 Page | 10

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

• Hypocalcemia can be caused by a variety of medical
disorders, but it is frequently caused by low amounts of
parathyroid hormone (PTH) or vitamin D in your body.
• It can be mild or severe, temporary or chronic
POSSIBLE CAUSES
• Hypoparathyroidism, infusion of citrated blood, acute
pancreatitis, hyperphosphatemia, inadequate dietary
intake of vitamin D, or continuous or long term use of
laxatives
• Magnesium deficiency, medullary thyroid carcinoma, low
serum albumin levels, or alkalosis
• Use of aminoglycosides, caffeine, calcitonin,
corticosteroids, loop diuretics, nicotine, phosphates,
radiographic contrast media, or aluminum-containing
antacids
• Extracellular calcium serves to stabilize neuromuscular
cell membranes. This action is diminished in
hypocalcemia, increasing neuromuscular irritability. The
threshold of activation of sensory nerve fibers is also
decreased, resulting in paresthesias (alternate
sensations). The neurological system becomes more
excitable, and muscular spasms ensue. This shift in cell
membranes in the heart can result in dysrhythmias such
as ventricular tachycardia and cardiac arrest.
Hypocalcemia reduces the contractility of cardiac muscle
fibers, resulting in a reduction in cardiac output.

ASSESSMENT

• Identify the patient at risk for hypercalcemia

• Assess if the patient has a condition such as pancreatitis,
liver disease.
• Assess if the patient is currently taking a medication
• Assess the patient for signs and symptoms of
hypocalcemia, especially changes in cardiovascular and
neurologic status and in vital signs
• Check the patient’s vital signs and apical pulse
• Assess the patient for tingling in the extremities and the
are around the mouth DIAGNOSTIC AND LABORATORY
• Assess for muscle and abdominal cramps
• Calcium Blood Test
• Positive Chvostek’s Sign ( spasms of the facial muscles o To measure the level of calcium in the blood
when the facial nerves are tapped.
• Basic Metabolic Panel (BMP)
• Trousseau's Sign- : a carpopedal spasm induced by o To check the level of different compounds in the
inflating a blood pressure cuff above systolic blood blood such as the calcium, glucose, sodium,
pressure. potassium, bicarbonate, chloride, blood urea
• Assess for Tetany ( muscle twitching) nitrogen, creatinine
• Complete Metabolic Panel ( CMP)
SIGNS AND SYMPTOMS
o Covers all of a BMP's measures as well as extra
proteins and chemicals associated with liver
• Total serum calcium level lower than 8.6mg/dL ( normal
function
range 8.6 to 10.2 mg/dL)
• Parathyroid Hormone Test (PTH)
• Tingling around the mouth and in the fingertips and feet,
o To identify the possible diagnosis of
numbness, painful muscle spasms, and tetany
hyperparathyroidism.
• Bronchospasm, laryngospasm, and airway obstruction
• ECG
• Seizures o To evaluate the effects of hypocalcemia on the
• Changes in cardiac conduction heart, such as a prolonged ST segment
• Depression, impaired memory, confusion, and
hallucinations PHARMACOLOGIC AND MEDICAL CARE
• Dry or scaling skin, brittle nails, dry hair, and cataracts
• Skeletal fractures resulting from osteoporosi • Treatment of Hypocalcemia can be treated using Oral or
IV Calcium
PATHOPHYSIOLOGY

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 11

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

• IV calcium is used in patients with severe hypocalcemia CALCIUM CONTAINING FOODS

to prevent life-threatening problems such as airway
obstruction. • Milk Products
• Calcium Supplements may be combined with vitamin D • Green Leafy Vegetables
or it can be given alone to increase GI Absorption of • Canned Salmon
Calcium • Canned Sardines
• Fresh Oysters
IV Calcium
NURSING MANAGEMENT
• Calcium Chloride
• Calcium Gluconate • Identify patients at risk for hypocalcemia.
Calcium Salts • Assess the patient for signs and symptoms of
hypocalcemia, especially changes in cardiovascular and
• Calcium Carbonate neurologic status and in vital signs
• Calcium Chloride • Administer I.V. calcium as prescribed.
• Calcium Citrate • Review the procedure for eliciting Trousseau’s and
• Calcium Glubionate Chvostek’s signs
• Calcium Gluceptate • Take seizure or emergency precautions as needed.
• Calcium Lactate • Encourage a patient with osteoporosis to perform
weight-bearing exercise regularly.
MEDICATION ADMINISTRATION • Encourage the patient to increase his intake of foods that
are rich in calcium and vitamin D.
• For Oral Calcium Salts • Teach the patient and his family how to prevent,
o Administer 1 to 1.5 hours after meals and at recognize, and treat hypocalcemia
bedtime.
o Give calcium tablets with a full glass of water HYPERCALCEMIA
• For IV Calcium Salts
• Too much calcium level in the blood.
o Assess IV site for patency. Do not administer
• The most common causes
calcium if there is a risk of leakage into the
o Hyperparathyroidism
tissues.
o May be given by slow IV push (dilute with o Malignancies
sterile normal saline for injection prior to • Hypercalcemia symptoms can range from non-existent to
administering) or added to compatible severe.
parenteral fluids such as NS, lactated Ringer’s • The treatment is determined on the cause.
solution, or D5W.
OTHER POSSIBLE CAUSES
o Administer into the largest available vein; use a
central line if available.
• Malignant neoplasms
o Do not administer bicarbonate or phosphate.
• Metastatic bone cancer
o Continuously monitor ECG when administering
IV calcium to patients taking digitalis due to • Hyperparathyroidism
increased risk of digitalis toxicity. • immobilization and loss of bone mineral
o Frequently monitor serum calcium levels and • Thiazide diuretic use
response to therapy. • High calcium intake
• Hyperthyroidism or hypothyroidism
NUTRITION THERAPY
ASSESSMENT
• To improve calcium absorption from the GI tract, vitamin
D treatment may be used. • Identify the patient at risk of hypercalcemia.
• Aluminum hydroxide, calcium acetate, or calcium • Assess if the patient has a condition such as
carbonate antacids may be prescribed to decrease hyperparathyroidism, malignancies, renal failure.
elevated phosphorus levels before treating hypocalcemia
• Assess the patient’s vital signs including the apical pulse.
in the patient with chronic kidney disease.
• Assess the patient’s mental status and level of
• Calcium supplements must be given in divided doses of
consciousness.
no higher than 500 mg to promote calcium absorption
• Assess the deep tendon reflexes.

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 12

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

SIGNS AND SYMPTOMS • Notably, hypercalcemia exacerbates digitalis toxicity by

enhancing the inotropic effect of digitalis.
• Total serum calcium level greater than 10.2 mg/Dl.
• Muscle weakness and lack of coordination. DIAGNOSTIC AND LABORATORY TEST
• Anorexia
• Calcium Blood Test
• Constipation
o To measure the levels of calcium in the blood
• Abdominal Pain
• Parathyroid Hormone Test (PTH)
• Nausea and Vomiting
o To measure the levels of parathyroid hormone
• Polyuria and Renal Colic in the blood
• Confusion, impaired memory, slurred speech. • ECG
o Changes in hypercalcemia include a shortened
PATHOPHYSIOLOGY
QT interval, shortened and depressed ST
segment, and widened T wave. Bradycardia or
heart block may be identified on the ECG.
• Bone Density Scan
o Monitor bone resorption and the effects of
treatment measures on mineralization of bone.
• X-ray
o It may reveal bone changes if the patient has
hypercalcemia secondary to a malignancy, bone
cavitations, or urinary calculi.

PHARMACEUTICAL MANAGEMENT

• Mild hypercalcemia is treated by increasing oral fluid

• Hypercalcemia, or increased calcium levels in the blood,
can result from a variety of factors.
o Cancer and hyperparathyroidism are frequent
causes.
o Malignant tumors cause hypercalcemia by a
variety of processes, whereas
hyperparathyroidism causes excessive
parathyroid hormone (PTH) production, which
causes increased calcium release from bones
and increased absorption in the intestines and
kidneys.
• Immobilization-related hypercalcemia is uncommon;
however, it can occur in people with high calcium
turnover rates, which is frequently associated with severe
fractures or spinal cord injuries.
• Thiazide diuretics can marginally enhance blood calcium
levels by potentiating PTH effect on the kidneys.
• Calcium overload can also be caused by vitamin A and D
deficiency, persistent lithium usage, and theophylline
toxicity.
• Calcium levels are inversely related to phosphorus levels.
• Hypercalcemia symptoms include decreased
neuromuscular excitability, which causes muscle
weakness, incoordination, anorexia, and constipation.
• Severe instances might induce cardiac arrest, especially
if blood calcium levels exceed around 18 mg/dL (4.5
mmol/L).
intake and reducing calcium ingestion until laboratory
results return to normal.
• Acute hypercalcemia is treated by administering one or
more of the following: IV sodium chloride solution
(0.45% or 0.9%) and a diuretic such as furosemide
(Lasix) to increase calcium excretion in the urine.
• Calcitonin can be used to reduce blood calcium levels
and is especially beneficial for individuals with heart
disease or renal damage who cannot tolerate high salt
loads. Calcitonin decreases bone resorption, increases
calcium and phosphorus deposition in the bones, and
increases calcium and phosphorus excretion in the urine.
• Corticosteroids or the antineoplastic drug plicamycin
(Mithracin) may also be used to treat hypercalcemia
caused by malignant illnesses that has not responded to
other kinds of therapy.
• Bisphosphonates (pamidronate and etidronate) are
commonly used to treat hypercalcemia associated with
malignancies. These drugs also are used to prevent and
treat osteoporosis.
SURGICAL PROCEDURE
• Parathyroidectomy
o Surgical procedure used to remove one or more
parathyroid glands or a tumor affecting a
parathyroid gland.

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 13

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

o Frequently performed to treat hyperactive o weakness

parathyroid glands, also known as o irregular heart rhythms
hyperparathyroidism. o In severe cases, seizures or cardiac issues.

NURSING MANAGEMENT POSSIBLE CAUSE

• Identify patient at risk for hypercalcemia. • Chronic alcoholism

• Assess the patient for the signs and symptoms of
hypercalcemia.
• Encourage Ambulation
• Move the patient carefully to prevent fractures.
• Take safety or seizure precautions as needed.
• Administer the prescribed medications.
• Monitor the patients I&O hourly or every 8 hrs.
• Encourage patients at risk to limit their intake of milk and
milk products, as well as calcium-containing antacids and
supplements.
• Patients with prolonged immobility or hypercalcemia are
encouraged to consume fluids that increase the acidity
of urine (which inhibits calcium stone formation).
MAGNESIUM IMBALANCES
• Magnesium is found in bone cells and specialized cells of
the heart, liver, and skeletal muscles.
• Only a small percentage of the total magnesium in the
body is found in extracellular fluid.
• Magnesium is an essential mineral that plays a crucial
role in various bodily functions:
o muscle contraction
o nerve function
o maintenance of a normal heartbeat
o transmission of nerve impulses
o muscle excitability
o activates several enzymes systems:
▪ functioning of B vitamins
▪ use of potassium and calcium.
• Magnesium Imbalances are abnormal levels of
magnesium in the body.
o too high (hypermagnesemia)
o too low (hypomagnesemia)
HYPOMAGNESEMIA
• refers to a below-normal serum magnesium
concentration (1.3 mg/dL) and is frequently associated
with hypokalemia and hypocalcemia.
• may be caused by deficient magnesium intake, excessive
losses, or a shift between the intracellular and
extracellular compartments.
• When magnesium levels drop below the normal range, it
can lead to a range of symptoms and potential
complications.
o muscle cramps
o tremors
• Malnutrition
• I.V. therapy without magnesium replacement
• Laxative abuse
• Anorexia
• Use of osmotic diuretics or antibiotics, such as
gentamicin
• Pancreatitis
• Hyperaldosteronism or renal disease that impairs
magnesium reabsorption.
ASSESSMENT
• Identify patients at risk for hypomagnesemia.
• Assess the patient for signs and symptoms of
hypomagnesemia.
• Check the client's vital signs, including blood pressure,
heart rate, and respiratory rate.
• Assess for physical signs of hypomagnesemia, such as
muscle weakness, muscle fasciculations (twitching), and
neurological symptoms.
• Monitor diagnostic studies such as serum electrolytes,
serum albumin levels, and the ECG.
• If the patient is confused or agitated, take safety
precautions.
• Take seizure precautions as needed.
Note: When the serum magnesium level reaches 10 to 15 mEq/L,
respiratory paralysis may occur.
SIGNS AND SYMPTOMS
• Magnesium level under 1.3 mEq/L
• Decreased blood pressure, ventricular fibrillation,
tachyarrhythmias, and increased susceptibility to digoxin
toxicity
• Nausea, vomiting, and anorexia
• Apathy, depression, agitation, confusion, delirium, and
hallucinations
• Positive Babinski, Chvostek, and Trousseau signs
• Cardiac dysrhythmias.
PATHOPHYSIOLOGY

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 14

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

o Magnesium Chloride
o Magnesium Lactate

NURSING MANAGEMENT

• Close monitoring for ECG changes and dysrhythmias.

DIAGNOSTIC AND LABORATORY EXAMINATION
• Urinary magnesium test
o may help identify the cause of magnesium
depletion, and levels are measured after a
loading dose of magnesium sulfate is given.
• Serum Magnesium Test
o It measures the concentration of magnesium in
the blood. Levels below 1.46 mg/dL indicate
hypomagnesemia.
• Electrolyte Panel
o An electrolyte panel measures various
electrolytes in the blood, including magnesium,
sodium, potassium, and calcium.
o Comparing magnesium levels with other
electrolytes can help identify imbalances.
PHARMACEUTICAL MANAGEMENT
• IV magnesium sulfate must be given by an infusion pump
and at a rate not to exceed 150 mg/min, or 67 mEq over
8 hours.
• Indications for IV Magnesium for Severe
hypomagnesemia with symptoms such as cardiac
arrhythmias or seizures, when rapid correction is needed,
such as in cases of acute alcohol withdrawal.
• Oral Magnesium Supplements
o Magnesium Oxide
o Magnesium Citrate
• In patients receiving digitalis, monitor for digitalis
toxicity.
o Low magnesium levels can precipitate
ventricular dysrhythmias, including lethal
dysrhythmias such as ventricular fibrillation.
• Monitor serum electrolytes, including magnesium,
potassium, and calcium.
o Magnesium deficiency often is accompanied by
deficiencies of potassium and calcium.
• Monitor GI function, including bowel sounds and
abdominal distention.
o Hypomagnesemia reduces GI motility.
• In cases of severe hypomagnesemia, precautionary
measures for seizures should be implemented.
• Patients with magnesium depletion should be screened
for dysphagia, as they may have trouble in swallowing.
• Assess deep tendon reflexes frequently during IV
magnesium infusions and prior to each IM dose.
o Depressed tendon reflexes indicate a high
serum magnesium level.
• Maintain a quiet, darkened environment. Institute seizure
precautions.
o Increased neuromuscular and CNS irritability
can lead to seizures.
o A quiet, dark environment reduces stimuli.
• Patient education plays a major role in treating
magnesium deficit.
o The patient is educated about the sources of
magnesium-rich foods.
o Mild magnesium deficiency can be corrected by
diet alone.
PRINCIPAL DIETARY SOURCES OF MAGNESIUM INCLUDE:
• Green Leafy Vegetables
• Nuts
• Seeds
• Legumes
• Whole Grains
• Seafood
• Peanut Butter
• Cocoa
• Banana
• Orange

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 15

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

HYPERMAGNESEMIA

• Serum magnesium level higher than 2.6 mg/dL

• Rare electrolyte abnormality
• Kidneys efficiently excrete magnesium
• Possible cause:
o Excessive magnesium intake
o Excessive use of antacids or laxatives
o Renal failure
o Uncontrolled diabetes (ketoacidosis)
o Addison’s disease
o Hyperparathyroidism

ASSESSMENT

• Identify patients at risk for hypermagnesemia

• Review all medications for a patient with renal failure.
• Assess the patient for signs and symptoms of
hypermagnesemia
• Ask about the patient's medication history, including
the use of magnesium-containing supplements,
laxatives, or antacids.
• Conduct a thorough physical examination to assess
vital signs, including heart rate and blood pressure.
• Evaluate the patient's clinical symptoms, which may
include muscle weakness, nausea, vomiting, lethargy,
confusion, irregular heartbeat, low blood pressure, and,
in severe cases, cardiac arrest
SIGNS AND SYMPTOMS
• Magnesium level above 2.6 mEq/L
• Loss of deep tendon reflexes, paresis, and paralysis
• Bradycardia
• Lethargy or drowsiness, apnea, and coma
• Peripheral vasodilation with decreased blood pressure,
facial flushing and sensations of warmth and thirst
• Difficulty breathing
PATHOPHYSIOLOGY
• Electrocardiogram (ECG or EKG)- may include a
prolonged PR interval, tall T waves, a widened QRS, and
a prolonged QT interval, as well as an atrioventricular
block (Grossman & Porth, 2014).
• Urinary magnesium tests-may help identify the cause of
magnesium depletion, and levels are measured.
• Comprehensive Metabolic Panel (CMP)-To assess a
range of electrolytes, including magnesium, calcium,
potassium, and sodium.
o Help identify other electrolyte imbalances that
may be occurring alongside
hypermagnesemia.
PHARMACEUTICAL MANAGEMENT
• IV calcium gluconate-antagonizes the cardiovascular
and neuromuscular effects of magnesium
• Hemodialysis with a magnesium-free dialysate-can
reduce the serum magnesium to a safe level within
hours
• Administration of loop diuretics (e.g., furosemide) and
sodium chloride or lactated Ringer IV solution-enhances
magnesium excretion in patients with adequate renal
function.

NURSING MANAGEMENT

• Identify patients at risk for hypermagnesemia.

DIAGNOSTIC AND LABORATORT EXAMINATION
• Serum Magnesium Levels-test the measurement of
serum magnesium levels in a blood sample.
• Review all medications for a patient with renal failure.
• Assess the patient for signs and symptoms of
hypermagnesemia.
• Assess reflexes; if absent, notify the practitioner.

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 16

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

• Administer calcium gluconate o Palpitations, tachycardia, and ventricular

• Have emergency equipment available fibrillation
• Prepare the patient for hemodialysis if prescribed. o Muscle twitching and seizures
• If the patient is taking an antacid, a laxative, or another o Warm, flushed skin, perspiration, and cyanosis
drug that contains magnesium, instruct him to stop. o pH below 7.35, PaCO2 above 50 mm Hg, and
normal or slightly elevated HCO
• Educate the patient and his family how to prevent,
recognize, and treat hypermagnesemia. CHRONIC RESPIRATORY ACIDOSIS
CLIENTS WITH ACID-BASE IMBALANCES
• closely related to chronic respiratory or neuromuscular
• 2 Categories: conditions
o Acidosis- occurs when Hydrogen ion o COPD
concentration increases above normal o Asthma
▪ pH below 7.35 o Cystic fibrosis
o Alkalosis-occurs when hydrogen ion o Multiple sclerosis
concentration falls below normal • Mentioned disorders affects alveolar ventilation due to
▪ pH above 7.45 airway obstructions, structural changes in the lungs, or
• Can be divided into: limited chest wall expansion
o Primary disorders-due to only 1 cause • Causes:
o Mixed disorders-combination of respiratory o Bronchial asthma
and metabolic disturbances o Emphysema
o Cystic fibrosis
RESPIRATORY ACIDOSIS o Advanced multiple sclerosis
o Bronchiectasis
• Disorder wherein pH is less than 7.35 and the PaCO2 is
• Signs and symptoms:
more than 45 mmHg o Weakness
o Roots from decreased oxygenation resulting
o Dull headache
from hypoventilation
o pH below 7.35, PaCO2 above 42 mm Hg, and
HCO3 − above 26 mEq/L
IMPORTANT NOTE: o Symptoms of underlying disease
▪ barrel chest and productive cough
pH normal range: 7.35 to 7.45 caused by chronic obstructive
PaCO2 normal range: 35 to 45 mmHg pulmonary disease

ACUTE RESPIRATORY ACIDOSIS ASSESSMENT

• Occurs as a result of: • Identify patients at risk

o sudden ventilation failure • Identify factors that increase risk of hypoventilation
o chest trauma which includes obesity, postoperative pain, tight
o aspiration of foreign object dressings, and abdominal distention
o acute pneumonia • Assess the patient for signs and symptoms of
o overdose of narcotic or sedative medications respiratory acidosis, mainly respiratory, pulse, and
• Causes: neurologic changes
o Pulmonary edema
o Aspiration PATHOPHYSIOLOGY
o Atelectasis
o Pneumothorax
o Sedative overdose
o Pneumonia
o Cardiac arrest
o Laryngospasm
o Improperly regulated
• Signs and Symptoms:
o Dulled sensorium, dizziness, feeling of fullness
in head, and unconsciousness

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
 Page | 17

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

RESPIRATORY ALKALOSIS

● pH of greater than 7.45 and a PaCO2 of less than 35

mmHg
● Always brought on by excessive breathing, which
results in a carbon dioxide deficiency

CAUSE

● Extreme anxiety (most common cause)

● Pulmonary emboli, pulmonary fibrosis, asthma,
pneumonia, or injury to the respiratory center
● Gram-negative bacteremia and sepsis
● High fever
● Hypoxemia
1. Reduced CO2 elimination causes respiratory acidosis
o Due to medications or lung conditions ASSESSMENT
2. Increased CO2 levels causes generation of carbonic acid
o Lowers blood pH ● Assess respiratory rate, depth, and ease
3. Causes acidemia ● Monitor VS and skin color
o Impact on metabolism, oxygen binding to ● Assess the patient’s signs of respiratory alkalosis which
hemoglobin, and enzyme activity includes neurologic, electrolyte, and ABG changes

DIAGNOSTIC AND LABORATORY SIGNS AND SYMPTOMS

• ABG- pH is less than 7.35 and PaCO2 is greater than ● Hyperventilation exceeding 40 breaths/ minute
45 mmHg ● Cardiac arrhythmias that fail to respond to conventional
o Bicarbonate level starts off normal but rises to treatment
more than 26 mEq/L ● Twitching (possibly progressing to tetany)
• Serum electrolytes may demonstrate hypochloremia ● pH above 7.45 and normal HCO3 − level (during an
(chloride level 98 mEq/L acute episode); normal pH and HCO3 − below 22
• Pulmonary function test mEq/L (during compensation in an acute episode); and
normal pH, HCO3 − below 22 mEq/L, and PaCO2
PHARMACOLOGIC AND MEDICAL CARE below 32 mm Hg (during a chronic episode)

• Bronchodilators- to clear airways PATHOPHYSIOLOGY

• Antibiotics- to treat respiratory infections
• Reversal medications- if an overdose of opioids or
anesthetics is the cause
• Oxygen- to precent carbon dioxide narcosis
o Gently supplied to individuals with persistent
respiratory acidosis
NURSING MANAGEMENT
• If the client has a chronic situation, be certain he
receives no more than without a prescription, 2 L of
oxygen
• Apply the prescription analgesic or teach the patient
relaxing techniques to reduce postoperative pain
• Encourage the postoperative patient to walk, breathe
deeply, and cough.
• Keep hydrated to keep secretions loose
• Food served should be appropriate for the patient’s
capability to chew and swallow
● pH decreases while pCO2 increases results to
compensatory mechanism and leads to kidneys
increases amount of HCO3 to lower pH level
● Respiratory alkalosis is brought on by high CO2 loss
brought on by hyperventilation, which is brought on by
conditions including anxiety, pain, fever, or drugs.
● Respiratory alkalosis causes the blood to become more
alkaline and reduce CO2 levels, which causes symptoms
including lightheadedness, tingling, disorientation, and
muscle spasms
DIAGNOSTIC AND LABORATORY
● ABGs typically have pH values higher than 7.45 and
PaCO2 values lower than 35 mmHg
PHARMACOLOGIC AND MEDICAL CARE

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA

PLM BS
NURSING MEDICAL-SURGICAL NURSING I
1ST SEMESTER
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report
● If anxiety is the cause, the patient is told to breathe
more slowly to let CO2 build up or to breathe into a
closed system (like a paper bag).
● In highly anxious people, an anti-anxiety medication
could be necessary to stop hyperventilation
● Provide oxygen when hypoxia is the cause of
hyperventilation
NURSING MANAGEMENT
● Teach the patient and family how to perform relaxation
techniques and prevent, recognize, and treat
hyperventilation.
● Teach the patient and family about safety precautions
for household medications.
METABOLIC ACIDOSIS
● A condition resulting from excess acid retention or
excess bicarbonate loss
● The lungs increase the rate and depth of ventilation to
exhale excess carbon dioxide, thereby reducing
carbonic acid levels.
● Characterized by a low pH (increased H+ concentration)
and a low plasma bicarbonate concentration. It can be
produced by a gain of hydrogen ion or a loss of
bicarbonate.
● Divided in two forms according to o the values of the
serum anion gap
○ High anion gap acidosis
○ Normal anion gap acidosis
● Anion gap refers to the difference between the sum of
all measured positively charged electrolytes (cations)
and the sum of all negatively charged electrolytes
(anions) in blood.
● The normal value for an anion gap is 8 to 12 mEq/L (8
to 12 mmol/L) without potassium in the equation. If
potassium is included in the equation, the normal value
for the anion gap is 12 to 16 mEq/L (12 to 16
mmol/L).
CAUSE
● Excessive alcohol consumption
● Excessive production of acids
● Loss of bicarbonate
● Renal failure
ASSESSMENT
● Obtain a detailed medical history, including information
about the onset and duration of symptoms, any
underlying medical conditions, recent illnesses or
infections, medication use, and any history of metabolic
disorders or kidney disease.
L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
Page | 18
Course Code:
NRS 3113
LECTURE
CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano
● Evaluate the patient for signs and symptoms of
metabolic acidosis, which may include rapid and
shallow breathing (tachypnea), confusion, lethargy,
weakness, fatigue, nausea, vomiting, and abdominal
pain.
● Assess vital signs, including blood pressure, heart rate,
respiratory rate, and body temperature.
SIGNS AND SYMPTOMS
● Rapid Breathing or shortness of breath
● Weakness and Fatigue
● Dehydration signs
● Hyperventilation (Kussmaul’s respirations)
● Nausea and Vomiting
PATHOPHYSIOLOGY
● Metabolic acidosis leads to decreased acid excretion
that can cause renal failure. It also increases the strong
acids in the body that may lead to keto acid in diabetic
keto-acidosis and also infusion of ammonium chloride
in the body. Lastly, it also causes loss of bicarbonate in
the kidney and the bowel.
DIAGNOSTIC AND LABORATORY
● Arterial Blood Gas (ABG) Analysis - measures the levels
of oxygen (O2) and carbon dioxide (CO2) in arterial
blood, along with the pH and bicarbonate (HCO3-)
levels. In metabolic acidosis, the pH is typically lower
than the normal range (<7.35), and the bicarbonate
level is decreased
● Urine pH and Urinalysis - Helps determine if the kidneys
are appropriately responding to acidosis. Low urine pH
(<5.3) suggests renal tubular acidosis (RTA).
● Anion Gap Calculation - Calculated by subtracting the
sum of measured cations (Na+ and K+) from the sum of
measured anions (Cl- and HCO3-). An elevated anion
gap (>12 mEq/L) suggests high anion gap metabolic
acidosis (HAGMA)
● Serum Lactate Level - Elevated lactate levels in the
blood can indicate lactic acidosis
● Toxicology Screen
PHARMACOLOGIC AND MEDICAL CARE
● Intravenous (IV) Fluids
● Alkali Therapy (Oral or Intravenous)
● Sodium Bicarbonate (NaHCO3)
○ Note: The use of sodium bicarbonate is
controversial and should be reserved for
specific situations, as it can have adverse
effects, including rebound acidosis.
NURSING MANAGEMENT

PLM BS
NURSING MEDICAL-SURGICAL NURSING I
1ST SEMESTER
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report
● Monitor vital signs regularly
● Assess respiratory status
● Monitor ABG results
● Administer intravenous (IV) fluids
● Monitor electrolyte levels
METABOLIC ALKALOSIS
● Results in increased plasma pH because of accumulated
base bicarbonate or decreased hydrogen ion
concentrations.
● Characterized by an elevated blood pH (above the
normal range of 7.35 to 7.45) and an excess of
bicarbonate (HCO3-) in the blood.
CAUSE
● Diuretic use such as loop diuretics (e.g., furosemide)
and thiazide diuretics (e.g., hydrochlorothiazide), can
cause excessive loss of chloride and potassium ions,
leading to metabolic alkalosis
● Excessive Antacid Use
● Excessive Alkali Ingestion
ASSESSMENT
● Obtain a detailed medical history
● Evaluate the patient for signs and symptoms a
● Assess the patient's hydration status
● Examine for muscle weakness or spasms
SIGNS AND SYMPTOMS
● Muscle Twitching or Cramps
● Weakness and Fatigue
● Nausea and Vomiting
● Tingling or Numbness
PATHOPHYSIOLOGY
● Increased in PCO2 by 0.7 mmhg per 1 meq/L increase
in HCO3- that result to decreased albumin, increase in
sodium and decreased chloride that results to vomiting
of stomach content can be treated by loop of diuretics
or thiazides
DIAGNOSTIC AND LABORATORY
● Arterial Blood Gas (ABG) - Analysis ABGs show a pH
greater than 7.45 and bicarbonate level greater than
26 mEq/L. With compensatory hypoventilation, carbon
dioxide is retained, and the PaCO2 is greater than 45
mmHg
● Urine pH and Urinalysis - May be low (pH 1 to 3) if
metabolic acidosis is caused by hypokalemia. The
kidneys selectively retain potassium and excrete
L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
Page | 19
Course Code:
NRS 3113
LECTURE
CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano
hydrogen ions to restore ECF potassium levels. Urinary
chloride levels may be normal or greater than 250
mEq/24 hours
● Serum electrolytes - often demonstrate decreased
serum potassium (< 3.5 mEq/L) and decreased chloride
(< 95 mEq/L) levels. The serum bicarbonate level is
high.
PHARMACOLOGIC AND MEDICAL CARE
● IV administration of normal saline (0.9% NaCl)
● In severe alkalosis, an acidifying solution such as dilute
hydrochloric acid or ammonium chloride may be
administered.
NURSING MANAGEMENT
● Monitor vital signs regularly
● Assess the patient's level of consciousness,
neuromuscular function, and any signs of
neuromuscular irritability
● Monitor the patient's respiratory status
● Monitor electrolyte levels, particularly potassium (K+),
sodium (Na+), and chloride (Cl-), as imbalances are
common with metabolic alkalosis.
● Watch for complications related to metabolic alkalosis,
such as cardiac arrhythmias, seizures, or muscle cramps,
and intervene promptly if they occur.
CUT DOWN / CVP INSERTION
• A medical procedure where a surgeon makes a small
incision (cut) in a patient's skin to directly access a blood
vessel, typically a vein or artery.
• Conducted when conventional techniques for gaining
vascular entry, like inserting a catheter through the skin
(percutaneous) or utilizing a needle, are difficult or
impractical.
o A minor surgical cut is created above the
selected blood vessel, typically in the arm or
leg.
o This enables the rapid delivery of fluids, blood
products, and necessary medications for the
urgent care and stabilization of critically unwell
patients.

PLM BS
NURSING MEDICAL-SURGICAL NURSING I
1ST SEMESTER
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report
CENTRAL VENOUS PRESSURE (CVP)
• A.K.A. central venous catheter
• Used to monitor the central venous pressure (pressure of
blood in the body's central venous system).
• Used when we need access to a vein over a long period
of time (anywhere from two weeks to several months).
• A central venous pressure (CVP) line is typically
introduced into either the subclavian or jugular vein and
carefully advanced until the catheter's tip is positioned in
close proximity to the point where the superior vena cava
(SVC) meets the right atrium.
o Normal CVP is 2 to 6 mm Hg.
▪ This measurement is used to detect
an excess or a deficit in venous blood
L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
Page | 20
Course Code:
NRS 3113
LECTURE
CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano
volume. The catheter’s proximal end is
connected to a three-way stopcock,
which controls the direction in which
IV fluid flows.
o The catheter is attached to a transducer that
connects to a computer used to analyze
hemodynamic data.
o Primarily used to monitor fluid volume status.
To measure venous and atrial pressures.
• When measuring CVP, transducer must be positioned at
the same level as the client's right atrium to obtain
accurate readings.
• The client should be in a supine position or with a slightly
elevated head, maintaining consistency with previous
measurements.
• The head of the bed can be adjusted between CVP
measurements.
• The physician specifies how often CVP measurements
should be taken, but the nurse can perform
measurements whenever there is suspicion of a change
in the client's fluid status.
ARTERIAL BLOOD GAS (ABG) TEST
• Blood test that requires a sample from an artery in your
body to measure the levels of oxygen and carbon dioxide
in your blood.
• Used to identify the specific acid–base disturbance and
the degree of compensation that has occurred.
• The analysis is usually based on an arterial blood sample;
however, if an arterial sample cannot be obtained, a
mixed venous sample may be used.
• An arterial blood gas test usually includes the following
measurements:
o Oxygen content (O2CT): This measures the
amount of oxygen in your blood.

PLM BS
NURSING MEDICAL-SURGICAL NURSING I
1ST SEMESTER
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report
o Hemoglobin: This measures the amount of
hemoglobin, the protein responsible for
carrying oxygen to your cells, in your blood.
o Oxygen saturation (O2Sat): This measures how
much hemoglobin in your blood is carrying
oxygen. Hemoglobin is a protein in your red
blood cells that carries oxygen from your lungs
to the rest of your body.
o Partial pressure of oxygen (PaO2): This
measures the pressure of oxygen dissolved in
your blood. It helps show how well oxygen
moves from your lungs to your bloodstream.
o Partial pressure of carbon dioxide (PaCO2): This
measures the amount of carbon dioxide in your
blood and how well carbon dioxide can move
out of your body.
o pH: This measures the balance of acids and
bases in your blood, known as your blood pH
level. The pH of blood is usually between 7.35
and 7.45. If it’s lower than that, your blood is
considered too acidic. If it’s higher than that
range, your blood is considered too basic
(alkaline).
o Bicarbonate (HCO3): This is calculated using
the measured values of pH and PaCO2 to
determine the amount of the basic compound
made from carbon dioxide (CO2.)
ASSESSING ABG
The following steps are recommended to evaluate arterial blood
gas values. They are based on the assumption that the average
values are:
pH = 7.35–7.45
PaCO2 = 35–45 mm Hg
HCO3− = 24 to 27 mEq/L
1. First, note the pH. It can be high, low, or normal, as follows:
A normal pH may indicate perfectly normal blood gases, or it
may indicate a compensated imbalance. A compensated
imbalance is one in which the body has been able to correct
the pH by either respiratory or metabolic changes (depending
on the primary problem).
For example, a patient with primary metabolic acidosis starts
out with a low bicarbonate level but a normal CO2 level. Soon
afterward, the lungs try to compensate for the imbalance by
exhaling large amounts of CO2 (hyperventilation).
As another example, a patient with primary respiratory
acidosis starts out with a high CO2 level; soon afterward, the
kidneys attempt to compensate by retaining bicarbonate. If
the compensatory mechanism is able to restore the
L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
Page | 21
Course Code:
NRS 3113
LECTURE
CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano
bicarbonate to carbonic acid ratio back to 20:1, full
compensation (and thus normal pH) will be achieved.
pH > 7.45 (alkalosis)
pH < 7.35 (acidosis)
pH = 7.4 (normal)
2. The next step is to determine the primary cause of the
disturbance. This is done by evaluating the PaCO2 and
HCO3− in relation to the pH.
Example: pH > 7.45 (alkalosis)
a. If the PaCO2 is less than 35 mm Hg, the primary disturbance is
respiratory alkalosis. (This situation occurs when a patient
hyperventilates and “blows off” too much CO2. Recall that CO2
dissolved in water becomes carbonic acid, the acid side of the
“carbonic acid–bicarbonate buffer system.”)
b. If the HCO3− is greater than 27 mEq/L, the primary disturbance
is metabolic alkalosis. (This situation occurs when the body gains
too much bicarbonate, an alkaline substance. Bicarbonate is the
basic or alkaline side of the “carbonic acid–bicarbonate buffer
system.”)
Example: pH < 7.35 (acidosis)
c. If the PaCO2 is greater than 40 mm Hg, the primary disturbance
is respiratory acidosis. (This situation occurs when a patient
hypoventilates and thus retains too much CO2, an acidic
substance.)
d. If the HCO3− is less than 24 mEq/L, the primary disturbance is
metabolic acidosis. (This situation occurs when the body’s
bicarbonate level drops, either because of direct bicarbonate loss
or because of gains of acids such as lactic acid or ketones.)
3. The next step involves determining if compensation has begun.
This is done by looking at the value other than the primary
disorder. If it is moving in the same direction as the primary value,
compensation is under way. Consider the following gases:
The first set (1) indicates acute respiratory acidosis without
compensation (the PaCO2 is high, the HCO3− is normal). The
second set (2) indicates chronic respiratory acidosis. Note that
compensation has taken place—that is, the HCO3− has elevated
to an appropriate level to balance the high PaCO2 and produce a
normal pH.
pH PaCO2 HCO3−
(1) 7.2 60 mm Hg 24 mEq/L
(2) 7.4 60 mm Hg 37 mEq/L
4. Two distinct acid–base disturbances may occur simultaneously.
These can be identified when the pH does not explain one of the

PLM BS
NURSING MEDICAL-SURGICAL NURSING I
1ST SEMESTER
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report
changes. When the PaCO2 is ↑ and the HCO3 is ↓, respiratory
acidosis and metabolic acidosis coexist. When the PaCO2 is ↓ and
the HCO3 is ↑, respiratory alkalosis and metabolic alkalosis
coexist.
Example: Metabolic and respiratory acidosis
a. pH 7.2 decreased pH (indicates acidosis)
b. PaCO2 52 increased pH (indicates respiratory acidosis)
c. HCO3 13 decreased HCO3 (indicates metabolic acidosis)
5. If metabolic acidosis exists, then calculate the anion gap (AG) to
determine the cause of the metabolic acidosis (AG vs. non-AG):
AG = Na − (Cl- + HCO3-)
Normal AG = 10−14 mmol/L
6. Evaluate the patient to determine if the clinical signs and
symptoms are compatible with the acid–base analysis.
PARENTERAL FLUID THERAPY
• In patients who are NPO, parenteral fluid therapy, also
termed IV fluid therapy, is used to administer fluids.
• The choice of an IV solution depends on the purpose of
its administration. Generally, IV fluids are given to
achieve one or more of the following goals:
o To provide water, electrolytes, and nutrients to
meet daily requirements
o To replace water and correct electrolyte deficits
o To administer medications and blood products
FLUID REPLACEMENT
• The balance of fluids and electrolytes in the intracellular
and extracellular areas must be generally consistent to
ensure health. I.V. is used if a person has a disease or a
condition that inhibits regular fluid intake or causes
excessive fluid loss. Fluid replenishment may be
required.
• I.V. Therapy that supplies the patient with life-sustaining
fluids, electrolytes, and drugs has the benefit of
delivering quick and predictable therapeutic results.
• When a patient suffers GI malabsorption, this method
also allows for fluid intake. I.V. Therapy allows for precise
dose titration of analgesics and other drugs.
TYPES OF INTRAVENOUS SOLUTIONS
ISOTONIC FLUIDS
• Isotonic solutions, such as D5W, have an osmolality (or
concentration) of 275 to 295 mOsm/kg. The dextrose
metabolizes quickly, however, acting like a hypotonic
solution and leaving water behind.
• Large amounts of the solution may cause hyperglycemia.
L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA
Page | 22
Course Code:
NRS 3113
LECTURE
CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano
• Another isotonic solution is normal saline solution, which
includes solely the electrolytes sodium and chloride.
Other isotonic fluids resemble ECF more.
• Ringer's solution, for example, comprises sodium,
potassium, calcium, and chloride. Lactated Ringer's
solution contains these electrolytes as well as lactate,
which is converted to bicarbonate by the liver.
HYPOTONIC FLUIDS
• Because fluid flows from the extracellular space into cells,
causing them to swell, hypotonic solutions should be
used with caution. Because of vascular fluid loss, this
fluid transfer might trigger cardiovascular collapse. Fluid
moving into brain cells can potentially produce increased
intracranial pressure (ICP).
• Hypotonic solutions shouldn’t be given to a patient at
risk for increased ICP for example, those who have had a
stroke, head trauma, or neurosurgery. Signs of increased
ICP include a change in the patient’s level of
consciousness, motor or sensory deficits, and changes in
the size, shape, or response to light in the pupils.
• Hypotonic solutions also shouldn’t be used for patients
who suffer from abnormal fluid shifts into the interstitial
space or the body cavities for example, as a result of liver
disease, a burn, or trauma
• Have an osmolality less than 275 mOsm/kg.
• Examples:
o half-normal saline solution
o 0.33% sodium chloride solution
o dextrose 2.5% in water
HYPERTONIC FLUIDS
• Hypertonic fluids include 3% NaCl and IV mannitol.
• If a patient is sodium depleted, a hypertonic sodium IV
solution might be used.
• If a patient is experiencing acute cerebral edema, IV
mannitol is often used.
• Hypertonic solutions pull water from the interstitial and
intracellular compartments into the bloodstream.
• These solutions draw water out of intracellular
compartments causing cellular dehydration.
• Examples:
o dextrose 5% in half-normal saline solution
o dextrose 5% in normal saline solution
o dextrose 5% in lactated Ringer’s solution
o dextrose 10% in water
COLLOIDS
• Colloids attract fluid to the circulation. If the capillary
lining is normal, the effects of colloids linger for several
days. During a colloid infusion, the patient should be
continuously watched for symptoms of hypervolemia
 Page | 23

PLM BS
NURSING MEDICAL-SURGICAL NURSING I Course Code:
NRS 3113
1ST SEMESTER LECTURE
(AY. 2023-2024)
TOPIC: FLUID & ELECTROLYTES AND ACID-BASE BALANCE
REFERENCE: BSN 3-9 Grp. 3 Written Report CLINICAL INSTRUCTOR: Prof. Joshua Nathaniel V. Ellano

such as elevated blood pressure, dyspnea, and bounding

pulse.
• If neither crystalloids or colloids are effective in treating
the imbalance, the patient may require a blood
transfusion or other treatment.

DELIVERY METHODS

PERIPHERAL LINES

• Peripheral I.V. Short-term or intermittent treatment is

supplied by a vein in the arm, hand, leg, or, in rare cases,
foot. Possible I.V. The metacarpal, cephalic, basilic,
median cubital, and greater saphenous veins are among
the locations. Because of the danger of thrombophlebitis,
using veins in the leg or foot is infrequent. Also, due of
the danger of vein irritation, dextrose concentrations
larger than 10% should not be administered
peripherally.

CENTRAL LINES

• Central venous therapy involves administering solutions

through a catheter placed in a central vein, typically the
subclavian or internal jugular vein, less commonly the
femoral vein.

CENTRAL VENOUS THERAPY IS USED FOR PATIENTS WHO:

✓ have inadequate peripheral veins

✓ need access for blood sampling
✓ require a large volume of fluid
✓ need a hypertonic solution to be diluted by rapid blood
flow in a larger vein
✓ need to receive vessel-irritating drugs
✓ need a high-calorie nutritional supplement.

COMPLICATIONS OF IV THERAPY

• Infiltration
• Infection
• Phlebitis and Thrombophlebitis
• Extravasation
• Air Embolism

L.M. ALEJAGA | G.A.A. GARCIA | K.C. PEREZ | J.C. RACHO | K.A.E. TABUZO | K.G.L. TAN | A.B. VALDEHUESA