Fluids and

Electrolytes
PATH 1016

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Learning Objectives
• Examine the etiology contributing to electrolyte
imbalances
• Differentiate between types of electrolyte
imbalances
• Sodium
• Potassium
• Calcium
• Correlate key manifestations of various types of
electrolyte imbalances to the underlying
pathophysiology
• Recognize significant potential complications
related to these conditions
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Review
Terms:
• ECF
• ICF
• Diffusion
• Edema
• ADH
• Osmolality

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Fluid Compartments ICF = intracellular
ECF = extracellular

ECF includes:
• Intravascular fluid
or blood
• Interstitial fluid or
intercellular fluids
• CSF –
cerebrospinal
fluids
• Transcellular fluids
present in various
secretions
(synovial cavities
of joints,
pericardial fluid

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Fluids

PATH1016_Fluids_Electrolytes 2022
Mechanism of Na+ & H2O retention
• Effective circulating volume
• Baroreceptors respond to stretch of vessel
walls
• Regulate renal sodium and water
elimination by modulating SNS outflow
and ADH

SNS – sympathetic nervous system

ADH – antidiuretic hormone

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 Maintained by:
• Thirst mechanism in
hypothalamus
• Antidiuretic hormone
Balance of (ADH) – controls amount
of fluid leaving the body
water and in the urine
electrolytes • Aldosterone –
reabsorption of Na &
H20
• Natriuretic peptide
hormones

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Fluid Excess: Edema
• Excess amount of fluid in the interstitial
compartment
• Causes swelling or enlargement of tissues
• Occurs in ECF: isotonic, hypotonic, hypertonic

• Causes of edema
• Increased capillary hydrostatic pressure
• Increased interstitial fluid osmotic pressure (from
increased capillary permeability
• Blocked lymphatic drainage
• Decreased capillary oncotic pressure (low albumin
proteins)
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 Causes of
Edema

VanMeter & Hubert, 2017, Gould’s

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 • Insufficient body fluids due to
inadequate intake or excessive loss of
fluids (or both)

• Affects ECF first then ICF

Fluid Deficit: • Fluid loss measured by change in

body weight*
Dehydration • Mild deficit: 2% decrease
• Moderate deficit: 5% weight loss
• Severe dehydration: 8% decrease
*adjust for age, body size & condition

• Infants & elderly at risk

• Hypovolemia, loss of electrolytes

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 Effects:
• Dry mucous membranes
• Decreased skin turgor or
Dehydration elasticity
Causes: • Low BP, weak pulse
• Fatigue
ü Vomiting, diarrhea • Increased hematocrit
ü Excess sweating (loss of • Decreased mental function,
Na & H20) confusion, LOC
ü DKA
ü Inadequate intake Body compensates by:
• Increased thirst
(elderly or unconscious) • Increased HR
ü Use of concentrated • Vasoconstriction – pale,
formula (infants) cool skin
• Decreased urine output

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 Sodium
• Most abundant cation in the ECF
• Functions at maintaining the ECF volume
• Sodium-water balance
• Na+/K+ pump
• Helps regulate the acid-base balance

• Absorbed in GI tract and eliminated by kidneys

Osmolality indicates the concentration of all the particles dissolved in body fluid.
• Disorders of Na+ concentration produce a
change in the osmolality of the ECF
• Hyponatremia = movement of water from ECF to ICF
• Hypernatremia = movement of water from ICF to ECF

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Hyponatremia
• Serum Na+ <135
mmol
• Na+ loss OR diluted
by water (dilatation
of ECF)
• Results from excess
Na loss or water
gain

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Causes of hyponatremia
Different causes of decreased GI losses, diuretic therapy,
concentration severe renal dysfunction,
• Hypertonic severe diaphoresis, DKA,
• hyperglycemia cerebral trauma, narcotic
use, lung cancer, some
• Hypotonic
drugs, hormonal imbalances,
• Water retention early chronic renal failure
• Hypovolemic
• Excess
sweating/exercise,
diarrhea
• Hypervolemic
• Accompanied by edema

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Manifestations
Early Mid-Late
• Fingerprint edema • CNS symptoms
• Muscle cramps, • Headache
weakness & twitching • Disorientation
• Hypotension, • Lethargy
tachycardia, weak, • Gross motor weakness
thready pulse • Seizures
• GI symptoms – N&V, • Depression of deep
abdo cramps tendon reflexes

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Diagnosis and treatment
• Dx
• ↓ serum Na+ and osmolality
• Assess volume status and predisposing conditions

• Tx
• Determined by the underlying cause and severity
• Restore Na levels: Saline solution/hypertonic
saline
• Loop diuretic (furosemide)

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Severe hyponatremia
• < 48 hrs
• Rapid treatment with 3% NS

• > 48 hrs
• Concern about how fast to correct serum Na+ levels
• May cause dramatic change in brain cell volume

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Hypernatremia
• Serum Na+ > 145 mmol
• ECF becomes hypertonic
• Leads to cellular dehydration

Common causes:
Water loss
• Decreased ECF volume through water loss

Sodium gain
• Increased ECF volume through sodium gain

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 Excess loss of body fluids
that have a lower than
normal concentration of
Na+ so that water is lost in
excess of Na+
• Loss from respiratory tract
Causes of = exercise, fever
• Watery diarrhea
hypernatremia • Hypertonic tube feeds
with inadequate amount
of water
• Excess Na intake
• Cardiac arrest
(medications)
• Deprivation of water
• Renal failure
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 Manifestations
• Thirst
• Decreased urine output
• Increased urine osmolality
• Skin warm, flushed, decreased turgor
• Increase serum osmolality
• Dry mucous membranes
• Decreased reflexes
• Headache, restlessness, agitation, decreased LOC
• due to altered cellular metabolism
• Late symptom: Na+ >155mEg/L = severed neuro changes
• Coma, seizures

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Diagnosis and treatment
• Dx
• Hx and physical – signs of dehydration
• Labs

• Tx
• Treat underlying cause
• Na+ restriction
• Replacement fluids via IV for severe dehydration

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 • Influenced by dietary intake and
Potassium urine output
• Elimination through kidney
• Most abundant • Absorbed in proximal tubule
cation in the ICF and loop of Henle
• Role in conducting • Secreted in distal and cortical
tubules for elimination
nerve impulses &
excitability of • Na/K pump
cardiac, skeletal & • Insulin increases cellular
uptake of K+
smooth muscles
• Content of ECF of • H+/K+ shift with metabolic
K+ = 3.5-5.0 mmol acidosis

• Exercise = muscle contraction

increases K+ in ECF
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Hypokalemia
• Serum K+ < 3.5 mmol
• Causes the resting membrane of the cell to become
more negative
• Needs more stimulus to reach threshold
potential and open the Na+ channels

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Causes of hypokalemia

Inadequate Transcellular
Excessive loss
intake shifts
• Dietary intake • GI (V/D) • ECF/ICF
<40 mmol/day • Renal • Insulin,
(diuretics, bronchodilators
aldosterone)
• Skin (trauma)

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Manifestations
• Increased urine output
• Thirst
• GI
üNausea
üVomiting
üAnorexia
üParalytic ileus

• Muscle weakness and cramps

• Metabolic alkalosis
• Confusion
• CVS = ECG changes, arrhythmias
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Treatment
• Foods high in K+
• Banana, orange juice
• Potassium supplements
• IV replacement when
needs to be rapid
• Rapid infusion of K+
can cause cardiac
arrest
• Cardiac monitoring

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Hyperkalemia
• Serum K+ >5.0 mmol
• Causes:
• Decreased renal elimination
üChronic kidney disease
üRenal failure
üAcidosis
üAldosterone
• Movement from ICF to ECF
üTrauma
üBurns
• Rapid IV administration
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2022 27
Manifestations of hyperkalemia
• GI
• Nausea Hyperkalemia is most
• Vomiting dangerous on the heart
when potassium levels
• Diarrhea rise rapidly = cardiac
arrhythmias
• Weakness, *Excess K+ affects
dizziness nerve impulse
conduction, results in
• Muscle cramps hyperactivity
• ECG changes:
peaked T waves
• Cardiac arrest
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Diagnosis and treatment
• Dx
• Hx and physical – muscle
weakness
• Labs
• ECG

• Tx – in emergency!!
• Calcium
Moves K+ into
• Sodium bicarbonate the cells!
• Beta-agonist
• Insulin and glucose

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Calcium
• Maintain body’s normal homeostasis
• Ca+ is stored in bone & excreted by kidney

• Regulated by Parathyroid hormone (PTH)

• absorption & elimination of Ca++ and phosphorus
• ↑Blood Ca++ by stimulating osteoclasts
• ↑GI absorption and renal retention

• Serum Ca++ = 2.1-2.6 mmol/L

• Protein bound calcium
• Combines with albumin
• Ionized calcium (ECF compartment)
• Participates in metabolic / enzyme reactions
• Contraction of skeletal muscle
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 • Serum Ca++ >2.75 mmol/L
Causes
• Hyperparathyroidism (bone
resorption)
• Renal disease
• Malignant tumors (multiple
myeloma)- hypercalcemia of
malignancy
• tumor products promote
Hypercalcemia bone breakdown
• tumor growth in bone
causes Ca++ release
• Prolonged immobilization
(bone resorption)
• Excess intake of Vitamin D
(increase uptake)

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Manifestations of hypercalcemia
Symptoms non-specific
• fatigue, weakness, lethargy
• increases formation of kidney stones & pancreatic
stones
• muscle cramps
• bradycardia, cardiac arrest
• pain
• GI activity also common
• Nausea, abdominal cramps
• Diarrhea / constipation
• Metastatic calcification

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 • Serum Ca++ <2.1
mmol/L
• Ionized Ca++ < 1.2
mmol/L

• Causes
• Abnormal losses from
kidney; renal failure
Hypocalcemia • Acute pancreatitis
• Lack of vitamin D
• Suppression of
parathyroid function
• Malabsorption states

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Manifestations of hypocalcemia
• Paresthesias, numbness and tingling
• Skeletal muscle cramps
• Hyperactive reflexes
• Tetany, carpopedal spasm
• Hypotension, cardiac insufficiency
• Arrhythmias
• Bone pain
• Severe – laryngeal spasm, seizures

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Diagnosis and treatment
• Dx
• Trousseau’s sign
• Chvostek sign
• Labs

• Tx
• IV infusion of calcium gluconate or calcium
chloride used when tetany present
• Oral intake when chronic hypocalcemia

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Trousseau’s sign = hypocalcemia

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Chvostek’s sign = hypocalcemia

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