Fluid and Electrolytes,

Balance and Disturbances

By:
Samson Ehe Teron
Mechanism for fluid and
electrolyte movement

osmosis filtration

diffusion

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osmosis

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diffusion

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diffusion

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filtration

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Fluid and electrolyte
balances

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cations

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 sodium potassium

calcium magnesium

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Electrolytes are measured
milliequivalent per litre
of water
(mEq / L)
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 Equivalent refers to the chemical
combining power of a substance or
the power of cations to unite with
anions to form molecules

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#
 most abundant cat ion in the
extracellular fluid
sodium is regulated by

Salt intake Aldosterone

Urinary output

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 functions
Maintain balance of extracellular fluid, thereby
it controls the movements of the water between
fluid compartments

Transmission of nerve impulses

Neuro muscular and myocardial impulse

transmission
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Normal concentration
of sodium

135 to 145
mEq/L
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Main intracellular cat ion
Helps in maintaining fluid balance of
the intracellular fluid
Potassium is regulated by

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 functions
Regulates neuromuscular excitability and muscle
contraction

Needed for glycogen formation and protein

sunthesis

Correction of acid base imbalances. Potassium

ion can be exchanged with hydrogen ion (H+)
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Normal concentration
of potassium

3.5 to 5.3
mEq/L
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#
Calcium is the most abundant element
in the body
Calcium is extracellular fluid
Regulated by the action of
Thyroid gland parathyroid gland

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Parathyroid hormone (PTH) controls
the balance among bone calcium,
gastrointestinal absorption and
kidney excretion of calcium.

Thyrocalcitonin from the thyroid

gland inhibits the release of calcium
from bones, thus playing a minor
role in determining serum calcium
levels.
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 functions
Maintenance of cell membrane, its integrity and
structure

Conduction of nerve impulses in the skeletal

muscle

Stimulation and depolarization and contraction

of cardiac muscles
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 functions
Aids in blood coagulation

Growth and formation of bones

Muscle relaxation

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Normal concentration
of calcium

4 to 5
mEq/L
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#
Magnesium is the second most
important cat ion in the
intracellular fluid

It has an inhibitory effect on

skeletal muscles.

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 functions
Precipitation of metabolic activities of cells

Enzyme activity

Neuro chemical activity

Muscular excitability

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Normal concentration
of magnesium

1.5 to 2.4
mEq/L
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anions

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 chloride
phosphate

bicarbonate

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#
Phosphate is a buffer anion in
extracellular and intracellular fluid

Phosphate absorption is through

gastrointestinal tract in a range of 3 to
12 mg/100 ml

Calcium and phosphate are inversely

proportional.

When one rises the other falls

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Serum phosphate is regulated by

kidneys

Parathyroid hormone

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Activated vitamin D

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 functions
Development and maintenance of bones and
teeth

Promotes normal neuromuscular action

Participates in carbohydrate metabolism

Assist in acid base regulation

Maintains levels of ATP ( Adenosine

Triphosphate) and thus energy levels #
Normal concentration
of phosphate

2.5 to 4.5
mEq/L
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#
Chlorides are found in extracellular and
intracellular fluids

The chloride ion balances the cations

within the extracellular fluid

The ion exchange helps to maintain the

electrical neutrality

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Chloride is regulated through
kidneys

The dietary intake of chloride and

the amount excreted in urine are
closely related

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Normal concentration
of chloride

100 to 106
mEq/L
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#
Bicarbonate is found in extracellular
and intracellular fluids

It is a major chemical buffer in the

body

Regulation is through kidneys

It is an essential component of the

carbonic acid-bicarbonate buffering
system essential to acid base balance
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 Normal arterial
bicarbonate value

22 to 26
mEq/L
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 Normal venous
bicarbonate value
24 to 30
mEq/L
In venous blood, bicarbonate
is measured as
carbondioxide content

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FLUID VOLUME
DISTURBANCES

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 Fluid
volume deficit

hypovolemia
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 Fluid Volume Deficit
Mild 2% of body weight loss

Moderate 5% of body weight loss

Severe 8% or more of body

weight loss

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 Pathophysiology
results from loss of
body fluids and occurs
more rapidly when coupled
with decreased fluid
intake

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 Clinical manifestations

Acute Weight loss

Decreased skin turgor

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Concentrated urine

flattened neck veins

Postural hypotension

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Weak, rapid, heart rate

Oliguria

Increased temperature

Decreased central venous pressure

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 Nursing Diagnosis
Fluid volume Deficit r/t
Insufficient intake, vomiting, diarrhea,
hemorrage, m/b dry mucous membranes

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 Nursing management
Restore fluids by oral or IV
Treat underlying cause
Monitor I & O at least every 8
hours
Daily weight
Vital signs
Skin turgor
Urine concentration
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 Fluid
volume excess

hypervolemia
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 Pathophysiology
may be related to
fluid overload or
diminished function of the
homeostatic mechanisms
responsible for regulating
fluid balance
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Contributing factors

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 Clinical manifestations

Edema

Distended neck veins

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Tachycardia

Increased blood
Pressure

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Increased weight

crackles

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 Nursing Diagnosis
Fluid volume excess r/t
CHF, excess sodium intake,
renal failure

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 Nursing management
Preventing FVE

Detecting and Controlling FVE

Teaching patients about edema

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Electrolyte Imbalances

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SODIUM

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 Sodium
Normal range 135 to 145 mEq/L

Primary regulator of ECF

volume (a loss or gain of sodium is
usually accompanied by a loss or
gain of water)

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HYPONATREMIA

Sodium level
less than 135
mEq/L
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 causes
Vomiting Diarrhea

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Sweating Diuretics

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Clinical manifestations

Poor
skin Dry
turgor mucosa

Decreased
saliva Anorexia
production vomiting

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Clinical manifestations

Nausea/
Orthostatic
abdominal
hypotension
cramping

Confusion
Altered &
mental lethargy
status

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Nursing interventions
Assess clinical manifestations

Monitor fluid intake and output, vital

signs and lab data.

Encourage food and fluids high in Na

Limit water intake.

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HYPERNATREMIA

Sodium level
more than 145
mEq/L
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 CAUSES
Loss of fluids

Water deprivation

Excessive salt intake

Conditions like Diabetes

insipidus, heatstroke
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 Pathophysiology
- Fluid deprivation in patients who
cannot perceive, respond to, or
communicate their thirst
- Most often affects very old, very
young, and cognitively impaired
patients

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 Clinical manifestations
- Thirst

- Sticky mucous membranes

- Flushed skin

- Postural hypotension

- Dry, swollen tongue

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Nursing interventions
Monitor intake and output

Monitor behavioural changes

Monitor lab findings

Encourage fluids

Monitor diet as ordered(salt

restriction)
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POTASSIUM

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 Normal serum potassium
concentration is 3.5 to 5.5 mEq/L

Major Intracellular electrolyte

and 98% of the bodys potassium is
inside the cells

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HYPOKALEMIA

Potassium level
less than 3.5
mEq/L
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 CAUSES
Loss of K+ in the form of
vomittings ,GI suction

poor K intake

diuretics

steroid administration

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 Clinical manifestations
Muscle weakness
Leg cramps
Fatigue
Lethargy
Anorexia
Nausea, vomitting
Decreased bowel sounds
Decreased bowel motility
Cardiac dysrhythmias
Depressed deep tendon reflex #
 Nursing interventions

Monitor heart rate and rhythm

Monitor clients receiving DIGITALIS
Administer oral K+ as ordered with
food /fluids
Administer IV K+ as ordered ,flow
rate not more than 10-20 meq/hr
Teach patients about potassium rich
diet and to reduce potassium wastage
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HYPERKALEMIA

Potassium level
more than 5.5
mEq/L
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 Causes
Decreased renal potassium excretion as
seen with renal failure and oliguria

High potassium intake

Renal insufficiency

Shift of potassium out of the cell as

seen in acidosis #
 Clinical manifestations
Skeletal muscle weakness/paralysis
ECG changes such as peaked T waves,
widened QRS complexes
Heart block

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 Nursing interventions
Monitor ECG changes telemetry

Administer Calcium solutions to

neutralize the potassium

Monitor muscle tone

Give Kayexelate

Give Insulin and D50W

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CALCIUM

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 Normal serum calcium level is 4
to 5 mEq/L

More than 99% of the bodys

calcium is located in the skeletal
system

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HYPOCALCEMIA

Calcium level
less than 4
mEq/L
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 Causes
- Vitamin D/Calcium deficiency
- Primary/surgical
hyperparathyroidism
- Pancreatitis
- Renal failure

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Clinical Manifestations

Tetany and cramps in muscles of

extremities

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Trousseaus sign carpal
spasms

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Chvosteks sign cheek
twitching

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Seizures, mental changes

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ECG shows prolonged QT
intervals

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 Nursing interventions
- IV/PO Calcium Carbonate or Calcium
Gluconate

- Encourage increased dietary intake

of Calcium

- Monitor neurlogical status

- Establish seizure precautions

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HYPERCALCEMIA

Calcium level
more than 5
mEq/L
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 Causes
- Hyperparathyroidism

- Prolonged immobilization

- Thiazide diuretics

- Large doses of Vitamin A and D

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 Clinical manifestations
- Muscle weakness, nausea and
vomiting

- Lethargy and confusion

- Constipation

- Cardiac Arrest

(high level)
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 Nursing interventions

- Eliminate Calcium from diet

- Monitor neurological status

- Increase fluids (IV or PO)

- Calcitonin

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MAGNESIUM

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Normal serum magnesium level
is 1.5 to 2.4 mEq/L

Thought to have a direct

effect on peripheral arteries
and arterioles

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HYPOMAGNESEMIA

magnesium
level less than
1.5 mEq/L

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 Causes
- Chronic Alcoholism

- Diarrhea, or any disruption in small

bowel function

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- TPN

- Diabetic ketoacidosis

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#
 Clinical manifestations
- Neuromuscular irritability
- Positive Chvosteks and Trousseaus
sign
- EKG changes with prolonged QRS,
depressed ST segment, and cardiac
dysrhythmias
- May occur with hypocalcemia and
hypokalemia

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 Starved possible cause of
hypomagnesemia
Seizures
Tetany
Anorexia and arrhythmias
Rapid heart rate
Vomiting
Emotional lability
Deep tendon reflexes increased

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Nursing interventions
- IV/PO Magnesium replacement,
including Magnesium Sulfate
- Give Calcium Gluconate if
accompanied by hypocalcemia
- Monitor for dysphagia, give soft
foods
- Measure vital signs closely

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 Foods high in Magnesium:
Green leafy vegetables

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 Nuts

Legumes

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Seafood

Chocolate

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HYPERMAGNESEMIA

magnesium
level more than
2.4 mEq/L

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 Causes
- Renal failure
- Untreated diabetic ketoacidosis
- Excessive use of antacids and
laxatives

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 Clinical manifestations
- Flushed face and skin warmth

- Mild hypotension

- Heart block and cardiac

arrest

- Muscle weakness and even paralysis

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 RENAL
Reflexes decreased (plus weakness
and paralysis)
ECG changes (bradycardia and
hypotension)
Nausea and vomiting
Appearance flushed
Lethargy (plus drowsiness and
coma)
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 Nursing interventions
- Monitor Mg levels
- Monitor respiratory rate
- Monitor cardiac rhythm
- Increase fluids
- IV calcium for emergencies

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PHOSPHORUS

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 Normal serum phosphorus
level is 2.5 to 4.5 mg/100 ml

- Phosphate levels vary inversely

to calcium levels

- High Calcium = Low Phosphate

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 HYPO
PHOSPHOTEMIA

Phosphorus
level less than
2.5 mEq/L

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 Causes
- Most likely to occurs with
overzealous intake or
administration of simple
carbohydrates

- Severe protein-calorie
malnutrition (anorexia
or alcoholism)
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Clinical manifestations
- Muscle weakness
- Seizures and coma
- Irritability
- Fatigue
- Confusion
- Numbness
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 Nursing interventions
- Prevention is the goal
- IV Phosphorus for severe
- Prevention of infection
- Monitor phosphorus levels
- Increase oral intake of
phosphorus rich foods
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 Foods rich in phosphorus
- Milk and milk products
- Poultry
- Whole grains
- Organ meats
- Nuts
- Fish
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 HYPER
PHOSPHOTEMIA

Phosphorus
level more than
4.5 mEq/L

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 Causes
- Renal failure

- Chemotherapy

- Hypoparathyroidism

- High phosphate intake

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 Clinical manifestations

- Tetany
- Muscle weakness
- Similar to Hypocalcemia because
of reciprocal relationship

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 Nursing interventions
- Treat underlying cause

- Avoid phosphorus rich foods

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