lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

Assessment
 Factors aecng uid, electrolyte, & acid-base balance
o Age
 Infants & elderly more  Elderly more prone to
suscepble to uid imbalances hypokalemia r/t wasng
 Infants have a higher metabolic potassium with diurecs
rate – creates more toxins, can’t  Elderly generally don’t drink
concentrate urine, water lost to enough water
evaporaon r/t high body  Subcutaneous ssue loss in
surface area elderly leads to increased
moisture loss
o Gender
 Hormonal uctuaons in  Men have a greater total body
women water percentage
o Stress – increased uid retenon from aldosterone producon, decreased renal excreon
o Weight – total body uid disproporonate weight in people that are obese
o Surgery – pre-op NPO, blood loss, stress, uid drainage, post-op voming
o Medical condions – cardiac, hepac, renal & respiratory
 Vital signs
o Pay close aenon to prolonged fever, tachycardia, changes in respiraons, & alteraons in BP
o Monitor q4
 Weight
o I&O record isn’t always an accurate reecon of changes in uid balance
o Daily weights are the more precise method
 Same gown/clothing, same scale, same me of day, before breakfast, aer voiding
o A change of 1kg (2.2lb) = 1L (1000mL) of uid
 Skin turgor & mucous membranes
o Skin turgor can provide an indicator of uid volume imbalance
o Decit
 Skin remains pulled upright  Furrows in the tongue (severe
(tented) aer release decit)
 Mucous membranes are dry &  Common to see dry, cracked lips
scky
 Neurologic assessment
o Deep tendon reexes o Confusion, agitaon, coma
o Tremors
 Cardiovascular assessment
o Irregular heart rate o Blood pressure
o Palpitaons o Peripheral pulses
o Grading of pulses
o Presence of edema
 Signicant & visible sign of uid volume excess
 Usually found in dependent areas of the body
 Late indicator of uid volume excess
 Ping edema – characterized by a lasng indentaon in the skin when pressure is applied
 Brawny edema – obvious swelling; ssue is too rm & hard to be indented
 Respiratory assessment
o Abnormal lung sounds (crackles) o Respiratory rate
o Diminished lung sounds
 Musculoskeletal assessment
o Muscle strength

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

 GI & GU assessment
o Intake (PO, IV uids) o Nausea & voming
o Frequency & characteriscs of stool – o Amount of urine output
conspaon or diarrhea

Nursing Intervenons
 Monitoring uid balance
o The nurse should evaluate the impact of disease or eect of treatment on an ongoing basis
 Fluid replacement – pt may need to increase uid intake to oset losses
 Electrolyte replacement
o 2 most commonly prescribed supplements are K+ and Ca+
 Intake & Output (I&Os)
o Oral intake includes all uids & foods that become liquid at room temperature
 Ice chips, ice cream, popsicles/water ice, soup, jello
o Output consists of any body uid that can be measured
o Nurse notes whether I&Os balance in a 24 hour period
 Nurse is responsible for conrming that ordered tests have been completed & results are communicated to the
HCP
o Labs oen ordered to monitor uid, electrolytes, & acid-base balance; also to assess eecveness of
prescribed meds
 Restricng electrolyte intake
o Sodium restricons are classied as mild, moderate, or severe
o Na+ restricons
 Mild – 3000-4000 mg/day
 “no added salt”
 Moderate – 2000 mg/day
 “low sodium”
 Severe – 500 mg/day
o Instruct pt on the dietary restricons & common foods to avoid
 Maintaining uid & electrolyte balance
o Restricng uid intake – use 50% of the o Amount of uid is divided further into
uid amount during the day when the uid with meals, between meals, & with
pt is most acve & consumes two meals med admin
 Restricng electrolyte intake
 Educaon
o Buy fresh or frozen, not canned o Salt substutes & herbs are okay
o No cured meats allowed o Some OTC meds have high sodium
contents

Mechanisms
 Body uid is either intracellular (ICF) or extracellular (ECF)
o Majority of uid is ICF – within the cell
o Extracellular uid – uid outside of the cell
 Intersal, intravascular, or transcellular
 Extracellular uid imbalances
o Correct the underlying cause & replace water & electrolytes – orally, with blood products, or through
balanced IV soluons
 Osmoc pressure

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

o Amount of pressure required to stop
osmoc ow of water
 Hypovolemia & BP decrease smulate the release of renin by the kidneys
o Converts angiotensinogen to
angiotensin I
o ACE (angiotensin converng enzyme)
form the lungs kidneys changes
angiotensin I to angiotensin II
 Homeostasis – maintenance of uid balance
o Monitored by the kidneys through
changes in blood pressure
o Renin-angiotensin-aldosterone
mechanism
o Controlled by several mechanisms:
renin-angiotensin regulates BP & uid
o Determined by the concentraon of
solutes in soluon
o Angiotensin II – vasoconstricon
through body to increase BP,
reabsorpon of water, smulate adrenal
cortex to produce aldosterone, secrete
ADH, smulates thirst mechanism
balance through vasoconstricon &
excreon or reabsorpon of Na+
o ADH (released by the pituitary gland) –
maintain serum osmolality by
controlling the amount of water
secreted in the urine

ECF & ICF

 ICF
o Prevalent caon is K+ o Prevalent anion is PO43-
 ECF
o Prevalent caon is Na+ o Prevalent anion is Cl-
 Hypovolemia (ECF volume decit) – abnormal loss of normal body uids, inadequate intake, or plasma to
intersal uid shi
o Clinical manifestaons r/t loss of vascular volume as well as CNS eects
o Treatment: replace water & electrolytes with balanced IV soluon
o Use of hypotonic IV uids
o Diagnoses used
 Decient uid imbalance  Acute confusion
 Electrolyte imbalance  Imbalanced nutrion: less than
 Decreased cardiac output body requirements
o Hypovolemic shock is a potenal complicaon
o Nursing diagnoses – decient uid imbalance, electrolyte imbalance, decreased cardiac output, acute
confusion, imbalanced nutrion
 Dehydraon – loss of water without corresponding loss of sodium
o Assessment
 Chvostek’s sign, Trousseau’s sign, deep tendon reexes, tremors, confusion, agitaon, coma,
jugular vein distension, ECG waveforms, pulses, BP, crackles, diminished lung sounds, respiratory
rate, frequency & characteriscs of stool, N/V, amt of urine output
 Hypervolemia (ECF volume excess)
o Excess intake of uids, abnormal retenon of uids, or intersal to plasma uid shi
o Clinical manifestaons r/t excess volume
 Weight gain is the most common
o Edema (see assessment)
o Care
 Remove uid without changing electrolyte composion or osmolality of ECF
 Diurecs, uid restricon, restricon of sodium intake, removal of uid to treat ascites
or pleural eusion
o Nursing diagnoses – excess uid volume, electrolyte imbalance, impaired gas exchange, impaired ssue
integrity, acvity intolerance

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

Fluid Tonicity
 Isotonic, hypotonic, hypertonic
 Eects of water on RBCs

o Hypotonic – water excess; solutes less o Hypertonic – water decit; solutes more
concentrated than in cells concentrated than in cells
 Results in cellular swelling  Results in cellular shrinking
o Isotonic – normal water level
 Regulaon of water balance
o Renal regulaon
 Primary organs for regulang uid & electrolyte balance
 Adjusng urine volume
 Selecve reabsorpon of water & electrolytes
 Renal tubules are site of acon of ADH & aldosterone
 Hydrostac pressure
o Force of uid in a compartment o BP generated by heart’s contracon
 Oncoc pressure
o Colloid osmoc pressure o Osmoc pressure caused by plasma
proteins
 Fluid movement in capillaries – amount & direcon of movement determined by

o Capillary hydrostac pressure o Intersal hydrostac pressure

o Plasma oncoc pressure o Intersal oncoc pressure
 Fluid spacing
o First spacing – normal distribuon o Third spacing – uid is trapped where
o Second spacing – abnormal it’s dicult or impossible for it to move
accumulaon of intersal uid back into cells or blood vessels
(edema)

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

Regulaon of Water Balance

 Hypothalamic-pituitary regulaon
o Osmoreceptors in hypothalamus sense o Decreased plasma osmolality (water
uid decit or increase excess) suppressed ADH release
o Decit smulates thirst & ADH release
 Renal regulaon
o Primary organs for regulang uid & electrolyte balance
o Adjusng urine volume
 Selecve reabsorpon of water  Renal tubules are sites of acon
& electrolytes of ADH & aldosterone
 Adrenal corcol regulaon
o Releases hormones to regulate water & o Glucorcoids (corsol)
electrolytes o Mineralcorcoids (aldosterone)
 Cardiac regulaon
o Natriurec pepdes are antagonists to o They suppress secreon of aldosterone,
the RAAS renin, & ADH to decrease blood volume
o Hormones made by cardiomyocytes in and pressure
response to increased atrial pressure
 GI regulaon
o Oral intake accounts for most water o Diarrhea & voming can lead to
o Small amounts of water are eliminated signicant uid & electrolyte loss
by the GI tract in feces

IV Fluids & Electrolyte Replacement

 Purpose
o Maintenance – when oral intake isn’t o Assist those with physical limitaons
adequate o Replacement – when losses have
o Assess ability to obtain adequate uid occurred
independently, express thirst & swallow
eciently
 Parenteral uid & electrolyte replacements
o Blood transfusions (regarding volume) o Allow for giving drugs that are
o Central venous access devices (CVAD) potenally vesicants
o Permit frequent, connuous, rapid, or o Used to admin blood/blood products &
intermient admin of uids & meds parenteral nutrion
 Types of uids categorized by tonicity

 Hypotonic – lower osmolality than plasma

o Dilutes ECF

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

o Water moves from ECF to ICF by o Usually maintenance uids
osmosis o Monitor for changes in mentaon
 Isotonic – osmolality similar to plasma
o Similar osmolality to ECF (only expands o Ideal to replace ECF volume decit
ECF); no net loss or gain from ICF o Fluids: D5W, NS, LR
 Hypertonic – higher osmolality when compared to plasma
o Draws water out of cells into ECF o Fluids: D5 ½ NS
o Requires frequent monitoring of BP,
lung sounds, & serum Na+ levels
 D5W (5% dextrose in water) – isotonic
o Dextrose metabolizes quickly, net result o Used to replace water loss, prevents
of free water ketosis
o Provides 170kcal/L
 D5 ½ NS (5.5% dextrose in normal saline) – hypertonic
o Common maintenance uid o KCl added for maintenance or
o Replaces uid loss replacement
 D10W (10% dextrose in water) – hypertonic
o Provides 340 kcal/L o Limits dextrose concentraon that may
o Provides free water but no electrolytes be infused peripherally
 NS (normal saline) – isotonic
o 0.9% saline, slightly more NaCl than ECF o Only soluon used with blood
o Used when both uid & sodium is lost
 Lactated Ringer’s – isotonic
o Contains Na+, K+, Cl-, Ca2+, & lactate o Contraindicated with liver dysfuncon,
o Expands ECF – treats burns & GI losses hyperkalemia, & severe hypovolemia
 Colloids – stay in vascular space & increase oncoc pressure
o Human plasma products [albumin, FFP o Semisynthecs (dextran, starches,
(fresh frozen plasma), blood] Hespan)

Sodium (Na)
 Responsible for
o ECF volume & concentraon o Muscle contraclity
o Generang & transming nerve o Regulang acid-base balance
impulses
 Imbalances typically associated with parallel changes in osmolality
Hypernatremia
Causes Inadequate water intake, excessive
water loss, sodium gain
S/S Thirst, AMS (drowsiness, restlessness,
confusion, lethargy), S/S uid volume
decit
Seizures & coma possible
Intervenons - treat the underlying cause
- replace uids orally or via IV with
isotonic uids or hypotonic uids
(water decit)
- dilute with Na-free IV uids & give
diurecs (excess sodium)
- monitor carefully
Hyponatremia
Loss of sodium-containing uids,
water excess
Headache, irritability, diculty
concentrang
Severe – confusion, voming,
seizures, coma
- uid restricon may be only
treatment (water excess)
- loop diurecs & demeclocycline
- small amounts of IV hypertonic
saline soluon 3% NaCl (for seizures)
- uid replacement with isotonic
sodium-containing soluon

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

-encourage oral intake (abnormal
uid loss)

Potassium (K)
 Responsible for
o Resng membrane potenal of nerve & o Maintenance of cardiac rhythms
muscle cells o Acid-base balance
o Cellular growth
 Dietary sources
o Protein-rich foods o Salt substutes
o Fruits & vegetables o Potassium meds (PO or IV)
 Regulated by the kidneys
 Hypokalemia can enhance the eect of digitalis & lead to digitalis toxicity & subsequent cardiac arrest
 Always dilute IV KCl (potassium chloride)
 Never give KCl via IV push or as a bolus
 Major ICF caon
Hyperkalemia Hypokalemia
Causes Impaired renal excreon, shi from Increase of K+ via the kidneys or GI
ICF to ECF, massive intake of K+, some tract, increased shi of K+ from ECF to
drugs, renal failure ICF, dietary K+ deciency, renal losses
from diuresis
S/S Dysrhythmias, fague, confusion, Cardiac issues, skeletal muscle
tetany, muscle cramps, weak or weakness, weakness of respiratory
paralyzed skeletal muscles, ABD muscles, decreased GI molity,
cramps hyperglycemia
Intervenons - stop K+ intake - KCl supplements PO or IV
+
- increase K excreon – diurecs, - should not exceed 10 mEq/hr
dialysis, Veltessa, Kayexalate - use an infusion pump
- force K+ from ECF to ICF by IV insulin
with dextrose (severe hyperkalemia)

Calcium (Ca)
 Responsible for
o Formaon of teeth & bones o Myocardial contracons
o Blood clong o Muscle contracons
o Transmission of nerve imoulses
 Obtained from dietary intake; need vitamin D to absorb
 Present in bones & plasma
o Ionized Ca2+ is biologically acve
 Changes in pH & serum albumin aects Ca 2+ levels
 Balance controlled by
o Parathyroid hormone (PTH) – increases o Calcitonin – increases Ca2+ deposion
bone resorpon, GI absorpon, 7 renal into bone, increases renal Ca2+
tubule reabsorpon of Ca2+ excreon, & decreases GI absorpon

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

Chvostek’s sign – contracon of face muscles  Trousseau’s sign – carpal spasm induced by
aer light tap over the facial nerve in front of inang a BP cu above the systolic pressure for
the ear a few minutes
Hypercalcemia Hypocalcemia
Causes Hyperparathyroidism, cancer Decreased producon of PTH,
mulple blood trnasfusions, alkalosis,
increased Ca2+ loss
S/S Fague, lethargy, weakness, Posive Trousseau’s or Chvostek’s
confusion, hallucinaons, seizures, sign, laryngeal stridor, dysphagia,
coma, dysrhythmias, bone pain, numbness & ngling around the
fractures, nephrolithiasis, polyuria, mouth or in the extremies,
dehydraon dysrhythmias
2+
Intervenons - low Ca diet - treat the cause
- increased weight-bearing acvity - Ca2+ & vitamin D supplements
- increase uid intake - IV Ca2+ gluconate
- hydraon with isotonic saline - rebreathe into paper bag
infusion - treat pain & anxiety to prevent
- calcitonin hypervenlaon-induced alkalosis

Phosphate (P)
 Responsible for
o
o Funcon of muscle o Nervous system
o RBCs
 Primary anion in ICF Serum levels controlled by parathyroid hormone

 Involved in acid-base balance buering system, (PTH)
ATP producon, cellular uptake of glucose, &  Maintenance requires adequate renal
metabolism of macros (carbs, proteins, fats) funconing
 Reciprocal relaonship with Ca2+
Hyperphosphatemia Hypophosphatemia
Causes AKI, chronic kidney disease, excess Malnourishment/malabsorpon,
intake of phosphate or vitamin D, diarrhea, use of phosphate-binding
hypoparathydroidism agents, inadequate replacement
during parenteral nutrion
S/S Tetany, muscle cramps, paresthesia, CNS depression, muscle weakness &
hypotension, dysrhythmias, seizures pain, respiratory failure, HF, rickets,
(hypocalcemia) osteomalacia
Intervenons - ID & treat underlying cause - oral supplements

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

- restrict food/uids containing - ingeson of high phosphorus foods
phosphorus IV admin Na+ or K+ phosphate
- hemodialysis
- volume expansion & forced diuresis
- correct any hypocalcemia

Magnesium (Mg)

 Cofactor in enzyme for metabolism of carbs  Required for DNA & protein synthesis
 Responsible for
o Blood glucose control o Needed for ATP producon
o BP regulaon
 Acts directly on myoneural juncon  50-60% contained in bone
 Important for normal cardiac funcon  Absorbed in GI tract, excreted by kidneys
Hypermagnesia Hypomagnesia
Causes Increased intake of products Prolonged fasng, chronic
containing Mg, renal insuciency, alcoholism, uid loss from GI tract,
excess IV Mg admin prolonged parenteral nutrion
without supplementaon, diurecs,
PPI drugs, hyperglycemia osmoc
diuresis
S/S Hypotension, facial ushing, lethargy, Resembles hypocalcemia**
N/V, impaired deep tendon reexes,
muscle paralysis, respiratory & Muscle crampls, tremors, hyperacve
cardiac arrest deep tendon reexes, Chvostek’s &
Trousseau’s signs, confusion, vergo,
seizures
Intervenons - prevenon rst!! - treat underlying cause
IV CaCl or calcium gluconate if - oral supplements
symptomac - increase dietary intake
Fluids & IV furosemide to promote - parenteral IV or IM MG when severe
urinary excreon
- dialysis

Acid-Base Regulaon
 pH level – measure of H+ (hydrogen) ion concentraon
o Normal range – 7.35 to 7.45
o Acidosis - < 7.35
 Increased H+ concentraon
o Alkalosis - > 7.45
 Decreased H+ concentraon
o Death results in a pH level under 6.8 or over 7.8
 3 mechanisms to regulate acid-base balance
o Respiratory regulaon

 The lungs control the amount of  Respiratory center in the
carbonic acid available by medulla controls breathing
retaining or exhaling CO2
 CO2 + H2O > H2CO3 > H+ + HCO3-

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

 Increased respiraons lead to decreased CO2 in blood
increased CO2 eliminaon &
o Renal regulaon
 The kidneys neutralize acid & base by excreng or retaining H + ions & excreng or forming
bicarbonate ions
 Conserves bicarbonate & excretes acid
 3 mechanisms for acid eliminaon
 Secrete free H+  Excrete weak acids
+
 Combine H with
ammonia (NH3)
o Buer system
 Act chemically to change strong  Shis H+ in & out of the cell
acids to weak acids or bind  Primary regulator of acid-
them balance
 Carbonic acid – bicarbonate,
phosphate, protein, hemoglobin
buers

CVAD (central venous access devices)

 Catheters placed in large blood vessels
o Subclavian, jugular
 3 main types
o Centrally inserted catheters (central
lines)
 Permits frequent, connuous, rapid, or
intermient admin of uids & meds
 Allows for giving drugs that are potenally
vesicants
 Used to admin blood or blood products &
parenteral nutrion
 Advantages
o Immediate access
o Reduced venipunctures
 Disadvantages
o Increased risk of systemic infecon
o Invasive procedure
o Clamped or kinked catheter
o Tip against wall of vessel
o Thrombosis
 Intervenons
o Inspect catheter & inseron site
o Change dressing & clear according to policy
 Transparent semipermeable dressing or gauze dressing
 Chlorhexidine preferred cleansing agent
o Change injecon caps
 Centrally inserted catheter
o Inserted into a vein in the chest or ABD
wall with the p resng in the distal end
of superior vena cava
o Peripherally inserted central catheters
(PICC line)
o Implanted ports
 Useful for paents with limited peripheral
vascular access or need for long-term vascular
access
 Hemodynamic monitoring
 Venous blood samples
 Injecon of radiopaque contract media
o Decreased risk of extravasaon
o Precipitate buildup in lumen
o Embolism
o Risk of infecon
o Pneumothorax
o Catheter migraon
o Assess for pain
o Flushing is IMPORTANT!
o Non-tunneled or tunneled
o Dacron cu anchors catheter &
decreases incidence of infecon

Downloaded by Alaa Omar (alaaomar3002@gmail.com)

 lOMoARcPSD|17042315

Class 16 (Chp. 16) – Fluids, Electrolytes, & Acid-Base Balance

o Single, double, or triple lumen
o Examples of long-term tunneled catheters
 Hickman
 Broviac
 Groshong
 PICC lines
o Central venous catheter inserted into a o For paents who need vascular access
vein in arm for 1 week to 6 months
o Single or mul lumen, non-tunneled o Can’t use arm for BP or blood draws
o Advantages
 Lower infecon rate  Decreased cost
 Fewer inseron-related
complicaons
o Disadvantages
 Deep vein thrombosis (DVT)  Phlebis
 Implanted port
o Central venous catheter connect to an implanted, single or double subcutaneous injecon port
o Port is tanium or plasc with self-sealing silicone septum
o Drugs are injected through skin into port
o Advantages
 Good for long-term therapy  Cosmec discreon
 Low risk of infecon
 Midline catheters
o Peripheral catheters
 3-8” long  Single or double lumen
o Use & care similar to PICC lines o May stay in place up to 4 weeks

Vocabulary
 Diusion – movement of molecules across a permeable membrane from high to low concentraon
o Facilitated diusion – uses carrier to help move molecules
 Acve transport – process in which molecules move against concentraon gradient
o External energy is needed for this process
o Sodium-potassium pump – as Na+ diuses into the cell & K+ diuses out of the cell, the acve transport
system supplied with energy delivers Na+ back to ECF & K+ back to ICF
 Osmosis – movement of water down a concentraon gradient from low solute concentraon to high solute
concentraon, across a semi-permeable membrane

Downloaded by Alaa Omar (alaaomar3002@gmail.com)