FLUIDS AND

ELECTROLYTES:
BALANCE AND DISTURBANCE

PREPARED BY : CARLO P. TOLENTINO,RN

FLUID AND ELECTROLYTES

 IS A DYNAMIC PROCESS THAT IS CRUCIAL FOR LIFE AND

HOMEOSTASIS.POTENTIAL AND ACTUAL DISORDERS OF FLUID AND
ELECTROLYTE BALANCE OCCUR IN EVERY SETTING, WITH EVERY
DISORDER, AND WITH A VARIETY OF CHANGES THAT AFFECTS HEALTHY
PEOPLE EX. INCREASED FLUID AND SODIUM LOSS WITH STRENOUS
EXERCISE AND HIGH ENVIRONMENTAL TEMPERATURE, INADEQUATE
INTAKE OF FLUIDS AND ELECTROLYTES.
AMOUNTS AND COMPOSITION OF BODY FLUIDS

 APPROXIMATELY 60 – 70% OF THE WEIGHT OF A TYPICAL ADULT CONSIST

OF FLUIDS
 FACTORS THAT INFLUENCE THE AMOUNT OF BODY FLUIDS ARE AGE,
GENDER, AND BODY FAT.
 IN GENERAL YOUNGER PEOPLE HAVE A HIGHER PERCENTAGE OF BODY
FLUID THAN OLDER PEOPLE.
 MEN HAVE PROPORTIONATELY MORE BODY FLUIDS THAN WOMEN
 PEOPLE WHO ARE OBESED HAVE LESS FLUID THAN THOSE WHO ARE
THIN, BECAUSE FAT CELLS CONTAIN LITTLE WATER.
 THE SKELETON ALSO HAS A LOWER WATER CONTENT. MUSCLES ,SKIN
AND BLOOD HAVE THE HIGHEST AMOUNT OF WATER.
FLUID COMPARTMENTS:

 BODY FLUID IS LOCATED IN TWO FLUID COMPARTMENTS: THE ICF AND

THE ECF
 APPROXIMATELY 2/3 OF BODY FLUIDS IS IN THE INTRACELLULAR
COMPARTMENT AND IS LOCATED PRIMARILY IN THE SKELETAL MUSCLE
MASS.
 APPROXIMATELY 1/3 IS IN THE EXTRACELLULAR COMPARTMENT
 THE ECF FURTHER SUBDIVIDED
 INTRAVASCULAR – FLUID INSIDE THE VASCULAR SYSTEM, CONTAIN
PLASMA, THE EFFECTIVE CIRCULATING VOLUME, APPROXIMATELY 3L OF
THE AVERAGE 6L OF BLOOD VOLUME IS MADE UP OF PLASMA
 THE REMAINING 3L IS MADE UP OF ERYTHROCYTES, LEUKOCYTES AND
THROMBOCYTES
 INTERSTITIAL – CONTAINS THE FLUID THAT SURROUNDS THE CELLS AND
TOTAL OF ABOUT 11-12 L IN ADULTS. LYMPH IS AN INTERSTITIAL FLUID
 TRANCELLULAR – SMALLEST DIVISION OF ECF, CONTAINS APPROXIMNATELY
1L ( EX: CSF, PERICARDIAL FLUID, SYNOVIAL, INTRAOCULAR AND PLEURAL
FLUIDS, SEAT AND DIGESTIVE SECRETONS.

 BODY FLUID NORMALLY MOVES BETWEEN THE 2 MAJOR COMPARTMENT OR

SPACES IN AN EFFORT TO MAINTAIN AN EQUILIBRIUM BETWEEN THE SPACES
OR HOMEOSTASIS. LOSS OF FLUID FROM THE BODY CAN DISRUPT THIS
EQUILIBRIUM.
 LOSS OF ECF INTO A SPACE THAT DOES NOT CONTRIBUTE TO HOMEOSTASIS
BETWEEN THE ICF AND ECF IS REFERED TO AS “THIRD SPACE FLUID SHIFT OR
“THIRD SPACING” EXAMPLE : DECREASE IN URINE OUTPUT DESPITE
ADEQUATE FLUID INTAKE.
 URINE OUTPUT DECREASES BECAUSE FLUID SHIFTS OUT OF THE
INTRAVASCULAR SPACE: THE KIDNEY THEN RECEIVES LESS BLOOD AND
ATTEMPT TO COMPENSATE BY DECREASING URINE OUTPUT.
 OTHER SIGNS AND SYMPTOMS OF THIRD SPACING THAT INDICXATE AN
INTRAVASCULAR FLUID VOLUME DEFICIT INCLUDE INCREASED HEART
RATE, DECREASE BLOOD PRESSURE, , DECREASED CENTRAL VENOUS
PRESSURE, EDEMA INCREASED BODY WEIGHT.
COMPOSITION OF BODY FLUI ASNDS
 NON ELECTROLYTES – INCLUDE MOST ORGANIC MOLECULES, DO NOT
DISSOCIATE IN WATER AND CARRY NO NET ELECTRIC CHARGES.
 ELECTROLYTES – DISSOCIATE IN WATER TO IONS AND INCLUDE
INORGANIC SALTS, ACID AND BASES AND SOME PROTEINS.
 THE MAJOR CATIONS IN ECF IS SODIUM AND THE MAJOR ANION IS
CHLORIDE; IN ICF THE MAJOR CATION IS POTASSIUM AND THE MAJOR
ANION ID PHOSPHATE.
 ELECTROLYTES ARE THE MOST ABUNDANT SOLUTES IN BODY FLUIDS, BUT
PROTEINS AND SOME NONELECGTROLYTES ACCOUNT FOR 60 – 97 % OF
DISSOLVED SOLUTE.
PRINCIPLES OF BODY WATER DISTURBANCES
 BODY CONTROL SYSTEMS REGULATE INGESTION AND EXCRETION
- CONSTANT TOTAL BODY WATER
- TOTAL CONSTANT BODY OSMOLALITY
- HOMEOSTATIC MECHANISM RESPOND TO CHANGES IN ECF
- NO RECEPTORS DIRECTLY MONITOR FLUID OR ELECTROLYTES BALANCE.
- RESPOND TO CHANGES IN PLASMA VOLUME OR OSMOTIC
CONCENTRATION.
FLUID MOVEMENTS
 MOVEMENT OF FLUID IS DUE TO :

- HYDROSTATIC PRESSURE DIFFERENTIAL

- OSMOTIC PRESSURE DIFFERENTIAL
MOVEMENT OF BODY FLUIDS
 DIFFUSION – PROCESS BY WHICH SOLUTES MOVES FROM AN AREA OF
HIGHER TO LOWER CONCENTRATION, DOES NOT REQUIRE EXPENDITURE
OF ENERGY.
 OSMOSIS – PROCESS BY WHICH FLUIDS MOVES ACROSS A
SEMIPERMEABLE MEMBRANE FROM AN AREA OF LOWER TO HIGHER
CONCENTRATION.
 ACTIVE TRANSPORT – PHYSIOLOGIC PUMP THAT MOVES FLUIDS FROM AN
AREA OF LOWER TO HIGHER CONCENTRATION. ACTIVE TRANSPORT
REQUIRES ATP FOR ENERGY.
WATER
 2 LITERS OF WATER PER DAY ARE GENERALLY SUFFICIENT FOR ADULTS.
 MOST OF THIS MINIMUM INTAKE IS USUALLY DERIVED FROM THE WATER
CONTENT OF FOOD AND THE WATER OF OXIDATION ,THEREFORE IT HAS
BEEN ESTIMATED THAT ONLY 500 ML OF WATER NEEDS NE IMBIBED GIVEN
NORMAL DIET AND NO INCREASED LOSSES
 THESE SOURCE OF WATER ARE MARKEDLY REDUCED IN PATIENTS WHO
ARE NOT EATING AND MUST BE REPLACED BY MAINTENBANCE FLUIDS.
 WATER REQUIREMENTS INCREASE WITH:
- FEVER, SWEATING,BURNS, TACHYPNEA, SURGICAL DRAINS, POLYURIA, OR
ONGOING SIGNIFICANT GASTROINTESTINAL LOSSES.
AVERAGE DAILY INTAKE AND OUTPUT IN AN ADULT
INTAKE (ML) OUTPUT (ML)
ORAL FLUIDS 1300 URINE 1500
WATER IN FOOD 1000 STOOL 200
WATER PRODUCED 300 INSENSIBLE : LUNGS 300
BY METABOLISM SKIN 600

TOTAL GAIN 2,600 TOTAL LOSS 2,600

FLUID BALANCE
 THE BODY TRIES TO MAINTAIN HOMEOSTASIS OF FLUID AND
ELECTROLYTES BY REGULATING VOLUMES, SOLUTE CHARGES AND
OSMOTIC LOAD.
 NORMALLY, THERE IS A BALANCE ACHIEVED BETWEEN OUR TOTAL DAILY
INTAKE AND OUTPUT OF WATER.
 TOTAL FLUID INTAKE IS MODIFIED BY THE INDUCTION OF THE SENSATION
OF THIRST.
 THIS IS PRODUCED BY A REACTION OF CELLS IN HYPOTHALAMUS TO THE
INCREASED OSMOTIC PRESSURE OF THE BLOOD PASSING THROUGH THIS
REGION.
 ANOTHER STIMULUS OF THIRST WOULD BE THE DEGREE OF DRYNESS OF
THE ORAL MUCOSA.
REGULATION OF BODY WATER
 ANY OF THE FOLLOWING:
DECREASED AMOUNT OF WATER IN BODY
INCREASED AMOUNT OF SODIUM IN THE BODY
INCREASED BLOOD OSMOLALITY
RESULTS IN :…………….STIMULATION OF OSMORECEPTOR IN
HYPOTHALAMUS…………….RELEASE OF ANTIDIURETIC HORMONE………………
INCREASED THIRST.
REGULATION OF WATER INTAKE
 THE THIRST MECHANISM IS TRIGERRED BY A DECREASE IN PLASMA
OSMOLARITY, WHICH RESULTS IN DRY MOUTH AND EXCITES THE
HYPOTHALAMIC THIRST CENTER.

 THIRST IS QUENCHED AS THE MUCOSA OF THE MOUTH IS MOISTENED,

AND CONTINUES WITH DISTENTION OF THE STOMACH AND INTESTINES,
RESULTING IN INHIBITION OF THE HYPOTHALAMIC THIRST CENTER.
Regulation of Water Output

 Drinking is necessary since there is obligatory water loss due to the

insensible water losses.
 Beyond obligatory water losses, solute concentration and volume of urine
depend on fluid intake.
Influence of ADH

 The amount of water reabsorbed in the renal collecting ducts is

proportional to ADH release.
 When ADH levels are low, most water in the collecting ducts is not
reabsorbed, resulting in large quantities of dilute urine.
 When ADH levels are high, filtered water is reabsorbed, resulting in a lower
volume of concentrated urine.
 ADH secretion is promoted or inhibited by the hypothalamus in response
to changes in solute concentration of extracellular fluid, large changes in
blood volume or pressure, or vascular baroreceptors.
Problems of Fluid Balance

 Deficient fluid volume

 Hypovolemia
 Dehydration
 Excess fluid volume
 Hypovolemia
 Water intoxication
 Electrolyte Imbalance
 Deficit or excess of one or more electrolytes
 Acid-base imbalance
Factors Affecting Fluid Balance

 Lifestyle factors
 Nutrition
 Exercise
 Stress
 Physiological factors
 Cardiovascular
 Respiratory
 Gastrointestinal
 Renal
 Integumentary
 Trauma
Factors Affecting Fluid Balance

 Developmental factors
 Infants and children
 Adolescents and middle-aged adults
 Older Adults
 Physiological factors
 Surgery
 Chemotherapy
 Medications
 Gastrointestinal intubation
 Intravenous therapy
Regulation of Fluid compartments
 Osmosis and Osmolality

- when 2 different solutions are separated by a

membrane that is impermeable to the dissolved
substance, fluid shifts through the membrane from the
region of low solute concentration to the region of
high solute concentration. This diffusion of water
caused by a fluid concentration gradient known as
OSMOSIS.
TONICITY
- is the ability of all solutes to cause an
osmotic driving force that promotes water
movement from one compartment to another .
The control of tonicity determines the normal
state of cellular dehydration and cell size. Ex:
sodium , mannitol, glucose and sorbitol are
effective osmoles ( capable of affecting water
movement).
3 other terms are associated with
osmosis.
 OSMOTIC PRESSURE – amount of hydrostatic
pressure needed to stop the flow of water by osmosis
 ONCOTIC PRESSURE – osmotic pressure exerted by
proteins (ex. albumin )
 OSMOTIC DIURESIS – increase in urine output caused
by the excretion of substance such as glucose,
mannitol and contrast agent in urine.
Diffusion
 Tendency of the substance to move from an area
of higher concentration to lower concentration.
Ex: exchange of oxygen and carbon dioxide
between the pulmonary capillaries and alveoli and
the tendency of sodium to move from the ECF
where the sodium concentration is high, to the ICF
where its concentration is low.
Filtration
Is the capillaries tends to filter fluid out of the
intravascular compartments into the interstitial fluid.
Movement of water and solutes occurs from an area of
high hydrostatic pressure to an area of low hydrostatic
pressure. The kidneys filter approximately 180L of
plasma per day …..another ex: passage of fluids and
electrolytes fro the arterial capillary bed to the
interstitial fluid; in this instance the hydrostatic pressure
results from the pumping action of the heart.
Sodium – Potassium Pump
- Sodium tends to enter the cell by diffusion. This
tendency is offset by the sodium potassium pump that
is maintained by the cell membrane and actively moves
sodium from the cell into the ECF: Conversely the high
intracellular potassium is maintained by potassium
pump into the cell. By definition ACTIVE TRANSPORT
implies that energy must be expended for the
movement to occur against a concentration gradient.
 HOMEOSTATIC MECHANISM
 KIDNEY FUNCTION – vital to the regulation of fluid and electrolytes
balance, the kidney normally filter 180L of plasma everyday in the adult
and excrete 1 - 2 L of urine
 Major function of kidney
- Regulation of ECF volume by selective retention and excretion of fluids.
- Regulation of normal electrolytes level in the ECF by selective electrolyte
retention and excretion of fluids.
- Regulation of Ph of the ECF by retention of hydrogen ions
- Excretion of metabolic waste and toxic substance.
Heart and Blood vessels function
- Pumping action of the heart circulates blood through the kidneys under
sufficient pressure to allow for urine formation, failure of this functions
interferes with renal perfusion and thus with water and electrolyte
regulation.
Lung Functions
- Through exhalation the lungs remove approximately 300mL OF WATER
daily. Abnormal condition like hyperpnea or continuous coughing, increase
this loss, mechanical ventilation with excessive moisture decreases it. It also
play a major role in maintaining acid -base balance.
 Pituitary Functions
- HYPOTHALAMUS manufactures ADH which is stored in the posterior
pituitary gland and release as needed to conserve water. It also maintain
the osmotic pressure of the cells by controlling the retention or excretion
of water by the kidneys and regulating blood volume.
Adrenal Function
- ALDOSTERONE has a profound effect on fluid balance. Increased secretion
of aldosterone causes sodium retention and thus water retention and
potassium loss, Conversely ,decrease secretion causes sodium and water loss
and potassium retention.
Parathyroid Hormone
- Embedded in the thyroid gland, regulate calcium and phosphate balance by
means of parathyroid hormone PTH- it influence bone resorption, calcium
absorption from the instestine and calcium reabsorption from the renal
tubules.
Other Mechanism
 BARORECEPETORS – located in the right atrium, carotid and aortic arches.
These receptors respond to changes in the circulating blood volume and
regulate sympathetic and parasympathetic neural activity: as arterial
pressure decreases , it transmit impulses from the carotid to vasomotor
center,
 A decrease in impulses stimulate the sympathetic NS and inhibits PSNS.
The outcome is increase in cardiac rate, conduction and contractility
increase circulating blood volume. Sympathetic stimulation constrict renal
arterioles, this increase the release of ALDOSTERONE, DECREASE
GLOMERULAR FILTRATION AND INCREASE WATER AND SODIUM
RETENTION.
Renin Angiotensin Aldosterone System

 Renin is an enzyme that converts angiotensinogen, a substance form by

the liver, into angiotensin I. Renin is released by the juxtaglomerular cells
of the kidneys in response to decreased renal perfusion. Angiotensin
converting enzyme (ACE) converts angiotensin I to angiotensin II.
Angiotensin II, with its vasoconstrictor properties, increases arterial
perfusion pressure and stimulates thirst. As the sympathetic nervous
system is stimulated, aldosterone is released in response to an increased
released of renin. Aldosterone is a volume regulator and is also released as
serum potassium increases, serum sodium decreases, or
adrenocorticotropic hormone (ACTH) increases.
 Antidiuretic Hormone - the thirst mechanism have important
roles in maintaining sodium concentration and oral intakes of
fluids.as serum concentration increases and blood volume
decreases neurons in the hypothalamus are stimulated by the
intracellular dehydration; thirst then occur; person increases
intake of fluids.

 Osmoreceptors - located on the surface of hypothalamus , it

sense changes in sodium concentration, the neurons become
dehydrated and quickly release impulses to the posterior
pituitary gland which increase the release of ADH, CAUSING
REABSORPTION OF WATER AND DECREASE URINE OUTPUT.
 FLUID VOLUME DISTURBANCES

 FLUID VOLUME DEFICIT ( HYPOVOLEMIA )

- when fluid loss of ECF volume exceeds
the intake of fluid. It occurs when water
and electrolytes are lost in the same
proportion.
 Pathophysiology
 FVD results from loss of body fluids and occurs more rapidly when coupled with
decreased fluid intake.
 Prolonged period of inadequate fluid intake.
 Abnormal fluid losses resulting from VOMITING, DIARRHEA, GI SUCTIONING AND
SWEATING DECREASE INTAKE AS IN NAUSEA OR LACK OF ACCESS TO FLUIDS AND
THIRD SPACING movement of fluid from the vascular system to other spaces (
edema formation in burn, ascites, adrenal insufficiency, diabetes insipidus, osmotic
diuresis, haemorrhage and coma.

Clinical manifestation
Acute weight loss, decrease skin turgor, oliguria, concentrated urine, orthostatic
hypotension due to volume depletion, a weak rapid heart rate, flattened neck veins,
increased temperature, thirst, decrease or delayed capillary refill, decrease central
venous pressure, cool clammy, pale skin related to peripheral vasoconstriction,
anorexia, nausea, muscle weakness and cramps.
 Assessment and Diagnostic Findings
Laboratory data useful in evaluating fluid volume status include:
BUN because of dehydration or decrease renal perfusion or
function.
HEMATOCRIT because decreased if plasma volume
POTASSIUM occurs with GI and renal losses
SODIUM occurs with increased thirst and ADH
POTASSIUM occurs with adrenal insufficiency
SODIUM results from increase insensible losses.
URINE SPECIFIC GRAVITY relation to the kidney attempt to
conserve water.
 Medical Management
- Consider the maintenance of requirements ex, fever
- If the deficit not severe oral route is preferred, oral hydration
- Acute or severe deficit, IV route ISOTONIUC FLUIDS ( 0.9 NaCl )
- As patient become normotensive HYPOTONIC ELECTROLYTES
( 0.45 NaCl )
- Accurate I & O , weight, vital signs, central venous pressure, level of
consciousness, breath sounds, skin color – to determine when therapy
should be slowed to avoid fluid overload.
- - if the patient with sever FVD is not excreting enough urine and therefore
oliguric, the Doctor needs to determine whether the depressed renal
function is caused by decreased renal blood flow secondary to FVD Pre
renal azotemia more seriously by acute tubular necrosis from prolonged
FVD.
 NURSING MANAGEMENT
- Monitor and Measure I and O atleast q8 or hourly.
- Weight monitoring: acute loss of 0.5kg (1lb) represents fluid loss of approx.
500ml.
- Vital signs monitoring ( weak rapid pulse and orthostatic hypotension
- A decrease temp. often accompanies FVD unless there’s concurrent
infection.
- Skin and tongue turgor monitoring ( skin over the sternum, inner aspect of
thigh, forehead, (tongue turgor : normal person tongue has one
longitudinal furrow, in FVD tongue has additional furrow and smaller
because of fluid loss.
- Oral mucous membrane moisture is also assessed; a dry mouth may
indicate either FVD or mouth breathing.
- Urine concentration by measuring URINE SPECIFIC GRAVITY,
in a volume depleted patient the USG should be greater than
1.020 indicating healthy renal conservation of fluid.
- Mental function - eventually affected in severe FVD as a
results of decreasing cerebral perfusion.
- Decrease peripheral Perfusion can results in cold extremities
- Low central venous pressure is indicative of HYPOVOLEMIA
- HEMODYNAMIC MONITORING in patients with acute
cardiopulmonary decompensation to determine
HYPOVOLEMIA.
 PREVENTING HYPOVOLEMIA

 To prevent FVD Nurse identifies patient at risk and takes measure to minimize
fluid losses. Ex: if pt. has diarrhea, measure should be implemented to control
diarrhea and replacement fluids administered

CORRECTING HYPOVOLEMIA
Oral fluids are administered to help correct FVD, types of
fluids and electrolytes to administer
Oral hygiene
ORS ( Rehydralyte, Elete, Cytomax ) these provide fluid
,glucose and electrolytes in concentration that are easily
absorbed
Antiemetic if nauseated if before FLUID REPLACEMENT
 THANK YOU SO MUCH !

QUOTATION OF THE DAY

“ WE NEVER KNOW THE WORTH OF WATER TILL THE WELL IS

DRY”
 ELECTROLYTES
Are IONS that are founds in your
BODY FLUIDS. They help to conduct
ELECTRIC ENERGY, helps CONTROL
BODY FLUIDS, and maintain
HOMEOSTASIS in the body.
Electrolytes or “ electric lights “

 It lights up body with energy or the underwater

electric disco dance party of the body
 “Where fluid flow electrolytes Go”
 Helps body to SEND MESSAGE from cell to cell,
nerve to nerve and organ to organ, without these,
our body and brain and basically our life would cease
to function.
Goals of this Lecture
 1. What DISRUPTS electrolytes
FUNCTION
 2. Which FOODS have the MOST
electrolytes
 3. electrolytes VALUES and PRIORITIES
 LAB VALUES
 PRIORITY
-SIGNS AND SYMPTOMS
-NURSING ASSESSMENT
-NURSING INTERVENTION
The major CATIONS in the body fluids:

 SODIUM – (135 – 145 mEq/L)

 POTASSIUM – ( 3.5 – 5.0 mEq/L)
 CALCIUM – ( 8.6 – 10.2 mg/dL )
 MAGNESIUM – 1.3 – 3.2 mg/dL )
 HYDROGEN IONS
The major ANIONS

CHLORIDE – (97 – 107med/L)

BICARBONATE
PHOSPHATE
SULFATE
PROTEINATE IONS
 These chemicals unite in varying
combinations, therefore, electrolyte
concentration in the body expressed in terms of
MILLIEQUIVALENT (mEq) per liter, a measure of
chemical activity rather than in terms of
milligrams (mg) a unit of weight. More
specifically , a milliequivalent is defined as being
equivalent to the electrochemical activity of 1mg
of hydrogen ion. In a solution cations and anions
are equal in milliequivalent per liter.
PHYSIOLOGY OF ELECTROLYTES

 HEART
 DEEP TENDONS
 GI TRACTS
Electrolyte balance

 Predominant extracellular cation

 136-145 mEq / L
 Pairs with Cl, HCO; to neutralize charge
 Most important ion in water balance
 Important in nerve and muscle function
 Reabsorption in renal tubule regulated by:
 Aldosterone
 Renin/angiotensin
 Atrial Natriuretic Peptic (ANP)