Fluid and Electrolytes Nursing Review

We need a proper balance of fluids and electrolytes in our How does our body balance electrolytes?
body to maintain life (not too high or too low…just the
right amount).

We consume these electrolytes through our diet via the

In fact, our body consists of 70% water and below you can
see the function of water in our body. However, this water
in our body is not just plain water. It consists of so many
substances such as electrolytes.
__
What are electrolytes?
foods and drinks we consume. Our kidneys filter and
reabsorb what electrolytes we need and don’t need in our
body. The kidneys do this via the nephrons in the kidneys,
which are the functional parts of the kidney.
__
Therefore, if a patient is experiencing kidney failure these
electrolytes will become imbalanced (many times too high
and the patient will need dialysis to help correct the
imbalance).

These are substances that once they enter and dissolve in

water (hence our blood) they produce an electrical charge
(become ions), which helps with electrical signaling in the
body and other important processes.
___
Our body is really “electric” because a lot of the processes
it does requires electrical signaling.
Other ways electrolyte levels can become imbalanced is if
they are lost in the body via an exit route. Electrolytes at
present in the urine, sweat, emesis, blood, and stool
(really any type of body substance). Plus, certain
medications can affect electrolyte levels along with trauma
like burns or other disease processes.

So, let’s learn about the 6 major electrolytes that make up

our body.
For instance, we need a balanced amount of electrolytes
for the following functions:
Sodium:

What is Sodium?
Contraction of muscles

Sending nerve impulses

It’s a very important electrolyte that helps regulate water
Creating bones
inside and outside of the cell. And it helps with muscle
contraction and transmission of nerve impulses.
Balancing the fluids in our body like our cells (via osmosis)

Maintaining the blood’s acid-base balance

Normal levels: 135-145 mEq/L
When certain electrolyte imbalances occur some of the
functions above will present abnormally. For example with
“contraction of muscles”, if certain imbalances occur
muscle spasms can present. In addition, the heart (which is Sodium mainly hangs out in the OUTSIDE of the cell in fluid
a muscle) can cause an abnormal EKG (which is a test that and helps water move inside and outside the cell as
assesses the electrical activity in the heart). needed.
So for example, when blood levels of sodium drop in the Seizures & Stupor (decrease in consciousness…confusion)
blood it affects the cells because suddenly water starts to
rush into the cell. This causes the cell to swell. On the flip
side, when too much sodium is outside the cell, water
Abdominal cramping
from inside the cell starts to leave and the cell shrinks.

Lethargic
Hyponatremia

Tendon reflexes diminished, trouble concentrating

Low sodium in the blood (less than 135 mEq/L)

Loss of urine & appetite

Causes:

Orthostatic hypotension, overactive bowel sounds

Not consuming enough sodium

Diuretics “thiazides”
Shallow respirations (happens late due to skeletal muscle
Vomiting (GI suction…rich in sodium and potassium)
weakness)
Diarrhea

Sweating
Spasms of muscles
Low secretion of aldosterone (Addison’s Disease)

Aldosterone: regulates blood pressure and causes water

Hypernatremia
and sodium to be kept by the kidneys but in turn excretes
potassium

Low amount of aldosterone: would cause the kidneys to

High sodium in the blood (greater than 145 mEq/L)
not reabsorb much sodium and drop blood levels and in
turn would cause the kidneys to keep potassium (leading
to hyperkalemia)
Causes:
SIADH (Syndrome of Inappropriate Antidiuretic Hormone
Secretion): too much ADH is released causing the body to
retain water which dilutes the sodium level.
Cushing’s Syndrome (high cortisol can cause sodium
Overload of fluid (dilutes sodium) with congestive heart retention and low potassium)
failure, hypotonic fluids infusions, renal failure
Primary Hyperaldosteronism (Conn’s Syndrome)
Signs and Symptoms of Hyponatremia
too much production of aldosterone (retain sodium along
with fluid and excrete potassium)

Remember “SALT LOSS” hypertonic solutions

corticosteroids
Not drinking enough water or losing too much water
(vomiting, diarrhea, diabetes insipidus…urinating so much
fluid out, sweating, burns)
increased intake of sodium
Signs and Symptoms of Hypernatremia
Remember: “No FRIED foods for you!” (too much salt)
Fatigue
Restless, really agitated (confused….central nervous
system changes)
Increased reflexes (progress to seizures and coma)
Extreme thirst (*big sign)
Decreased urine output, dry mouth/skin
Chloride
What is Chloride?
Chloride plays a role with acid-base balance in the body
along with balancing the fluids in our body by working with
sodium to maintain osmotic pressure. Also, sodium and
chloride really go together, and if sodium is decreased,
chloride is likely to be decreased as well.
Furthermore, chloride is needed to make hydrochloric
acid, which plays a huge role in food digestion. The kidneys
help maintain chloride blood levels by taking what you
don’t need and excreting it in the urine. Chloride is also
excreted through sweating and gut juices.
Therefore, if chloride is imbalanced (especially high) it may
be a kidney problem because specific parts of the nephron
remove chloride from the blood and place it in the urine (if
the kidneys aren’t functioning right this can’t happen so
more stays in the blood).
Normal level: 95-105 mEq/L
Hypochloremia
Low chloride levels in the blood ( <95 mEq/L)
Causes:
Loss of Chloride: GI system (vomiting, gastric juice loss via
NG tube suction or ileostomy)
Diuretics (thiazides and loop diuretics affect how renal
tubules reabsorb sodium and chloride which causes more
loss of the ions in the urine)
Burns
Cystic fibrosis (high amounts of chloride in the sweat)
Metabolic alkalosis (increase in bicarbonate leads to low
levels of chloride…they have an opposite relationship due
to how each ion shifts in the red blood cells for proper gas
exchange)
Fluid overload (diluting extracellular fluid: CHF, SIADH
(Syndrome of Inappropriate Antidiuretic Hormone
Secretion): too much ADH is released causing the body to
retain water, which dilutes the sodium level)
Signs and symptoms of hypochloremia tend to be
associated with whatever is causing the low level (rather
than the level being low itself, so you want to look at what
is causing the low level to identify the signs and
symptoms) and tends to look like hyponatremia signs and
symptoms but you may see:
Dehydration (increased heart rate, decrease blood
pressure, fever)
Vomiting, diarrhea, lethargic
Hyperchloremia
High chloride in the blood ( >105 mEq/L)
Causes:
High intake of sodium (IV fluids…hypertonic fluids or too
much saline)
Not drinking enough water or losing too much water
(vomiting, diabetes insipidus: urinating so much fluid,
sweating)
Losing too much bicarb via diarrhea
Metabolic acidosis (kidney failure or medications that
cause it)
Hyperaldosteronism (Conn’s Syndrome)…too much
production of aldosterone (retain sodium along with fluid
and excrete potassium)
Corticosteroids
Signs and Symptoms tend to be associated with whatever
is causing the high level (rather than the level being high
itself) so you want to look at what is causing the high level
to identify the signs and symptoms) and it may look like
hypernatremia and acidosis signs and symptoms.
Potassium
What is Potassium?
It’s an electrolyte that is mainly found in the intracellular
part of the cell (inside of the cell) compared to the
extracellular (outside of the cell), which is where sodium is
mainly found. Sodium and potassium are affected by each
other.
Typically, if the sodium levels increase (potassium
decreases) and sodium level decreases (potassium
increases). Therefore, potassium helps with fluid balance
like sodium, especially inside the cell. In addition,
potassium is responsible for nerve impulse conduction and
muscle contraction.
Normal levels: 3.5-5 mEq/L
Hypokalemia:
Low potassium in the blood (<3.5 mEq/L)
Causes:
Medications (diuretics “loop diuretics”, corticosteroids,
too much insulin (moves potassium from the blood into
the cell which depletes the blood level)
Cushing’s Syndrome (high cortisol…sodium retention…low
potassium)
Not consuming enough potassium (starvation)
losing from vomiting, GI suction, sweating
Signs and Symptoms of Hypokalemia:
Try to remember everything is going to be SLOW and LOW.
Don’t forget potassium plays a role in muscle and nerve
conduction so muscle systems are going to be messed up
and affect the heart, GI, renal, and the breathing muscles
for the lungs.
7 L’s (Low)
Lethargy (confusion)
Low, shallow respirations (due to decreased ability to use
accessory muscles for breathing)
Lethal cardiac dysrhythmias (ST depression, shallow T
wave, projecting U wave)
Lots of urine (frequent urination…kidneys unable to make
the urine concentrated)
Leg cramps
Limp muscles (decrease deep tendon reflexes)
Low BP & Heart
Hyperkalemia
High potassium in the blood (>5 mEq/L)
Causes:
Cellular movement of potassium from the intracellular to
extracellular
Burns
Rhabdomyolysis (break down of muscle tissue which
releases potassium from the damaged muscle tissue into
the blood)
Addison’s Disease: low secretion of aldosterone (regulates
water and sodium in kidneys by causing the kidneys to
reabsorb water and sodium and excrete potassium
Low amount of aldosterone would cause the kidneys to
not reabsorb much sodium but excrete it and reabsorb
more potassium and increase blood levels
Renal failure (unable to excrete potassium and builds up in
blood)
Excessive intake of potassium
Medications (potassium-sparing diuretics: spironolactone,
ACE inhibitors, NSAIDS)
Signs and Symptoms of Hyperkalemia:
“Murder”
Muscle weakness
Urine output little or none (renal failure)
Respiratory failure (due to muscle weakness)
Decreased cardiac contractility (weak pulse/low HR)
Early: muscle twitches/cramps
Rhythm changes: Tall peaked T-waves, prolonged PR
interval (increased higher p-wave not
visible)hyperkalemia, ekg changes, tall peaked t waves,
electrolytes, nursing
_____
Calcium
What is Calcium?
Calcium plays a huge role in bone and teeth health along
with muscle contraction/nerve transmission, and blood
clotting. Calcium is absorbed in the GI system (so a diet
rich in calcium is essential for maintaining calcium blood
levels), and it’s stored in the bones. Therefore, if blood
levels drop the bones will release some calcium in the
blood to help maintain levels, but this can be unhealthy
overtime and lead to osteoporosis.
To maintain balanced calcium blood levels, it has to have Low intake of calcium (lactose intolerance)
some help from:
low vitamin D intake

chronic kidney disease (wasting calcium)

Vitamin D helps play a role in calcium absorption in the GI
system. In addition, hormones play a role with maintaining
balanced calcium levels like:
medications:
bisphosphonates (help make bones stronger: decreases
the release of calcium from the bones into the blood
which can lower blood levels of calcium)

antibiotics…aminoglycosides (“mycin”)…waste calcium by

Parathyroid hormone (PTH): it’s found in the parathyroid the kidneys
gland
anticonvulsants (phenobarbital, phenytoin) alters vitamin
D levels

Calcitonin: it’s found in the thyroid gland Signs and Symptoms of Hypocalcemia

Therefore, any problem with these hormones or the Muscles and nerves will majority be affected “CRAMPS”
structures that produce these hormones can lead to an
imbalance of calcium levels.

Remember “CRAMPS”

In addition, phosphorus and calcium affect each other in

the opposite way. For instance, if phosphorus levels are
Convulsions
high in the blood, calcium will decrease and vice versa.
They are always doing the opposite (remember this
because it is important for the causes of hypocalcemia).
Reflexes hyperactive

Normal calcium level: 8.5 to 10.5 mg/dL

Arrhythmias (prolonged QT interval)

Hypocalcemia:
Muscle spasms in calves or feet (tetany)

Low calcium in the blood (<8.5 mg/dL)

Positive Signs

Causes:
Trousseau’s and Chvostek’s

Trousseau’s Sign: You do this by using a blood pressure

Low parathyroid hormone (removal or surgery of
cuff and place it around the upper arm and inflate it to a
parathyroid gland or of the neck…thyroidectomy…
pressure greater than the systolic blood pressure and hold
damages structures that help support calcium levels)
it in place for 3 minutes. If it is positive: hand will draw in
toward the body and flexion will occur at the wrist, thumb, EKG changes shortened QT intervalekg changes
and MCP (metacarpophalangeal) joints but the fingers hypercalcemia, short qt interval high calcium, nursing,
remain extended.trousseau's sign, hypocalcemia, signs electrolytes
symptoms, nursing, electrolytes, nclex

Chvostek’s Signs: shows nerve hyperexcitability of the

facial nerve (CN VII) Absent reflexes (decreased), altered mental status,
abdominal distention from constipation
To elicit this response you would tap via the masseter
muscle at the jaw’s angle and the facial muscles on the
same side of the face will contract momentarily (the lips
Kidney Stone formation
will twitch).chvostek sign, hypocalcemia, signs symptoms,
nursing, electrolytes, nclex

Sensation of tingling and numbness (paresthesia)…

Magnesium
fingers/toes
What is Magnesium?

Hypercalcemia:
Magnesium is another major ion found inside the cell just
like potassium. Magnesium plays a big role with muscle
and nerve function.
High calcium in the blood (>10.5 mg/dL)

For example, it plays a big role with how ATP works with
Causes:
the sodium-potassium pump. Magnesium helps by binding
with ATP (which needs mag ions to function) so 3 sodium
ions can move out of the cell and 2 potassium ions can
hyperactive parathyroid (too much calcium released into move in the cell…without proper mag levels this function
the blood) fails to work properly.sodium potassium pump,
electrolytes, nursing
high intake of vitamin D or calcium supplements

cancer that has spread to the bones (breaks down the

bones which leaks into the blood and increases levels)

medications: thiazide diuretics, lithium (affects parathyroid Also, mag helps with muscle relaxation. Calcium and mag
and increase levels) are competitors in muscle contraction. In a nutshell,
calcium plays a vital role in muscle contraction, and
Signs and Symptoms: magnesium challenges the binding spot of calcium to
cause muscles to relax. Therefore, without enough
magnesium to calm muscle contractions down, cramping
and spasms may occur.
Overall WEAK”

Plus, magnesium is vital for how nerves transmit signals,

Weakness of muscles (profound)
how our vessels work to maintain blood pressure, and how
the heart muscle contracts.
Magnesium is absorbed in the gut, specifically the small
intestine (keep this in mind…because if there is a problem
with the small intestine, magnesium absorption can be Weakness
affected). In addition, it’s excreted through the kidneys.

Increased deep tendon reflexes

When magnesium levels are imbalanced, many times
other electrolytes imbalances will occur as well
(specifically potassium and calcium levels).
Normal magnesium level: 1.5-2.5 mg/dL
Torsade’s de pointes (abnormal heart rhythm that leads to
sudden cardiac death…seen in alcoholism) Tetany
(seizures) and other EKG changes that go along with
calcium and potassium decreasetorsades-de-pointes,
hypomagnesemia, low magnesium, electrolytes, nursing

Hypomagnesemia:
Calcium and potassium levels low (presents together)

Low magnesium level in the blood: (< 1.5 mg/dL)

Hypertension

Causes:
Hypermagnesemia:

Not consuming enough magnesium

High magnesium level: > 2.5 mg/dL
Other electrolyte imbalances presenting

Wasting magnesium via the kidneys (diuretics)

Causes:
Malabsorption by the small intestine or usage of PPIs
“proton pump inhibitors”

Alcoholism, bowel disorders etc.
Signs and Symptoms of Hypomagnesemia
When magnesium is too low to calm things down,
excitability will be occurring (opposite for
hypermagnesemia).
Not very common…but can happen when trying to correct
hypomagnesemia (too much given)
Labor and delivery patients receiving magnesium sulfate
for treatment of preeclampsia (assessing reflexes…don’t
want them decreased or absent…means too much mag)
Kidney function is impaired because the kidneys are
responsible for excreting magnesium

Signs and Symptoms of Hypermagnesemia

“Twitch”

Every system of the body is “Lethargic” (opposite of

hypomagnesemia where the body systems are
Trouesseau’s Sign & Chvostek’s Sign (positive due to experiencing hyperexcitability)
hypocalcemia)

Note: You will typically only see symptoms in severe cases
of hypermagnesemia (mild cases the patient may be
asymptomatic)
Lethargy (profound)
Phosphate helps build bones/teeth and plays a role in
nerve/muscle function. Majority of the phosphate is
stored in the bones. Therefore, it plays a vital role in bone
and teeth health. It’s absorbed through food we eat and is
excreted through the kidneys (if there is a renal
insufficiency, phosphate levels can be high because the
kidneys are failing to excrete it).

Also, the parathyroid gland plays a role in the regulation

phosphate just like it did with calcium.
EKG changes with prolonged PR & QT interval and
widened QRS complex

Tendon reflexes absent/grossly diminished

It’s important to remember that calcium and phosphate
can many times influence each other in opposite ways. For
example, when calcium levels increase, in turn phosphate
Hypotension levels decrease (vice versa).

Arrhythmias (bradycardia, heart blocks) Vitamin D plays an important role in phosphate absorption
as well.

Red and hot face (flushing)

Hypophosphatemia

GI issues (nausea, vomiting)

Low phosphate level in the blood (<2.5 mg/dL)

Impaired breathing (due to skeletal weakness)

Causes:

Confusion (neuro impairment)

Long-term usage of aluminum-based antacids (blocks the
absorption of phosphate by the intestines)

Phosphate Starvation or refeeding syndrome

What is phosphate? This happens when food is reintroduced after the body has
been in starvation mode (hence the body went into
survival mode and is depleted of almost everything). When
nutrition is introduced, the body releases insulin due to
Normal phosphate level: 2.5-4.5 mg/dL
the increased blood sugar from the food, which causes the
body to rapidly use the already low stores of phosphate.
Phosphate is needed by the body’s cells to change glucose
into energy. This process further depletes phosphate
levels).
Over usage of phosphate containing laxatives (fleets
Overactive parathyroid gland (parathyroid plays a role in enema)
maintaining calcium and phosphate levels and it normally
inhibits reabsorption of phosphate by the kidneys) Over usage of vitamin D supplements

Low vitamin D intake Rhabdomyolysis: break down of muscle occurs and

myoglobin enters bloodstream and causes kidney failure…
Severe burns (moves phosphate intracellularly) leading to the inability to excrete phosphate)

Alcoholism (malabsorption and poor diet) Hypoparathyroidism (normally PTH inhibits the
reabsorption of phosphate, but when underactive it cause
Signs and Symptoms of Hypophosphatemia phosphate to be absorbed by the kidneys)

Signs and Symptoms of Hyperphosphatemia

Typically seen when the levels are severely low (not mildly)

Hypocalcemia will be seen

“Bone”

Convulsions

Bone pain and fractures

Reflexes hyperactive

Osteomalacia (softening of bones) results in bowing of the

legs…affect growth in children (shorter)osteomalacia,
rickets, hypophosphatemia, nursing, fluid, electrolytes Arrhythmias

Neuro status changes (irritability, confusion, seizures) Muscle spasms in calves or feet, tetany, seizures

Pruritus* (itching…found in many patient with renal

failure)
Erythrocyte destruction (red cells destroyed leading to
hemolytic anemia)

Signs of Chvostek and Trousseau’s

Hyperphosphatemia

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