FLUIDS

AND
ELECTROLYTES

Eric B. Panopio, M.D.

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objectives:
• Describe the nature and properties of fluids and
electrolytes in the human body.
• Understand the pathophysiology behind fluid and
electrolyte imbalances.
• Identify barriers to effective maintenance of
homeostasis.
• Assess effectively the client with fluid and
electrolyte alterations.

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Fluids
• Transport gases, nutrients and wastes
• Help generate the electrical activity needed to power body function
• Take part in the transforming of food into energy
• Maintain the overall function of the body
• Functions:
• Maintains ECF
• Maintains ICF
• Maintains body temperature
• Medium for metabolic reaction within the cell
• Transporter for nutrients, waste products and other substances
• A lubricant, an insulator and shock absorber

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Fluids
• Body Water
• Infant 80 %
• Male 60 %
• Female 50 %

• Gains and Losses

• Intake:
food - 1000 ml
oxidation - 300 ml
water - 1,200 ml
• Output:
skin - 500 ml
lungs - 300 ml
feces - 150 ml
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kidneys - 1,500 ml
Composition of Body Fluids

• 60% of body consists of fluid

• Intracellular space – 40%
• Extracellular space – 20%
• Interstitial
• Intravascular
• Transcellular

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Intracellular fluid
• Also referred as the cellular fluid found within the cell of
the body
• Contains of highly concentration of ions such as K (+),PO4
(-), Mg (+) and SO4 (-)
• Approximately 2/3 of all the water in the body is in the ICF
• Vital to normal cell functioning
• Contains solute, oxygen, electrolytes and glucose
• Provides a medium in which metabolic processes of the cell
take place

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Extracellular Fluid
• Includes all the fluid outside the cells
• It constitutes approximately 1/3 of the total body water
• It includes the interstitial fluid, plasma within blood vessels
and fluid in the lymphatic vessels
• It contains Na (+), Ca (+), Cl (-), HCO3 (-)
• Transport system that carries nutrients to and waste
products from the cell

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Electrolytes
->are substances that dissociate in solution to form charge
particles or ions
->charged particles capable of conducting electricity
a. Cation->positively charged ions
-> Na, K, Ca, Mg
b. Anion->negatively ions
-> Cl, HCO3, PO4, SO4
Functions:
• Maintains fluid balance
• Contributes to acid-base regulation
• Facilitates enzyme reactions
• Transmits neuromuscular reaction

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 Major Electrolytes
• Sodium (Na)
->most abundant ECF cation
->controls and regulates water balance
• Potassium (K)
->major ICF cation
->important in maintaining ICF water balance
->involved in maintaining acid-base balance
->contributes to intracellular enzyme reactions
• Calcium (Ca)
->found mostly in the skeletal system but relatively small amount in the
ECF
->calcium on the ECF is vital in regulating muscle contraction and
relaxation, neuromuscular function, and cardiac function

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Major Electrolytes
• Magnesium (Mg)
->primarily found in the skeleton and in the ICF
->important for intracellular metabolism-involved in the
production and use of ATP
->necessary for protein and DNA synthesis within the cells
-> 1% in the ECF is involved in regulating neuromuscular and
cardiac function
->maintaining and ensuring adequate magnesium levels is an
important part of care of patients with cardiac disorders

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Major Electrolytes
• Phosphate (PO4)
-> major anion of ICF
->also found in ECF, bone, skeletal muscle and nerve tissue
->children have much higher PO4 levels than adults
->involved in many chemical actions of the cell
->essential for functioning of muscles, nerves and RBC’s
->involved in the metabolism of CHO, CHON, Fat
• Chloride (Cl)
->major anions of ECF
->functions with Na to regulate serum osmolality and blood volume
->concentration of chloride in ECF is regulated secondarily to Na
->major component of gastric juice as HCl
->involved in regulating acid-base balance
->acts as a buffer in the exchange of O2 and CO2 in RBC’s

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Major Electrolytes
• Bicarbonate (HCO3)
->present in both ICF and ECF
->primary function is to regulate acid-base balance which
is an essential component of the carbonic acid-
bicarbonate buffering system
->are regulated by the kidneys
Normal Values: ECF ICF
• Na: 135-145 mEq/L 10-14 mEq/L
• K: 3.5-5.0 mEq/L 140-150 mEq/L
• Ca: 8.5-10.5 mg/dL < 1 mEq/L
• PO4: 2.5-4.5 mg/dL 4 mEq/kg
• Cl: 98-106 mEq/L 3-4 mEq/L
• Mg: 1.8-3.0 mg/dL 40 mEq/kg

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Acid-Base Balance

• An important part of regulating the chemical balance or

homeostasis of body fluids
• Acids: substance that releases hydrogen ion in solution
• Bases or Alkalis: accept hydrogen ions in solution
• Ph: measure of relative acidity or alkalinity of a solution
• Normal Ph of Arterial Blood:7.35-7.45

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 Movements of Body Fluids
and Electrolytes

• Osmosis- is the diffusion of water caused by fluid gradient

Osmolality reflects the concentration of fluid that affects the
movement of water between fluid compartments by osmosis
Osmotic pressure is the amount of hydrostatic pressure needed
to stop the flow of water by osmosis
Tonicity- is the ability of solutes to cause osmotic driving forces
a. Isotonic – same osmolality as body fluids.
b. Hypertonic – has higher osmolality
c. Hypotonic – has lower osmolality
• Diffusion- is the movement of a substance from area of higher
concentration to one of lower concentration

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 Movements of Body Fluid
and Electrolytes
• Filtration - movement of water and solutes from an area of high
hydrostatic pressure to an area of low hydrostatic pressure

• Active Transport – process wherein substances move across cell

membrane from a less concentrated solution to a more concentrated
one with expenditure of metabolic energy

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 Regulators of Fluids and
Electrolytes
• Antidiuretic Hormone
->regulates water excretion from the kidney
->synthesized in the anterior portion of the hypothalamus

• Renin-Angiotensin-Aldosterone System
->specialized receptors in the juxtaglomerular cells of the kidneys nephrons
->respond to changes in renal perfusion
->the effect of RAA System is to restore blood volume and renal perfusion
through Na and water retention

• Atrial Natriuretic Factor

->release from cells in the atrium of the heart in response to excess blood
volume and stretching of the atrial walls
->acts on the kidney to decrease Na reabsorption
->promotes sodium wasting and acts as a potent diuretic
->inhibits thirst thus reducing fluid intake

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Fluid Volume Disturbances

Fluid Volume Deficit (Hypovolemia)

Fluid Volume Excess (Hypervolemia)

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Fluid Volume Deficit
(Hypovolemia)
• Loss of body fluid or the shift of fluids into 3rd space
• Related factors or causes:
• inadequate fluid intake
• Excessive GI fluid losses
• Excessive renal losses
• Excessive skin losses
• 3rd space losses
• Manifestations:
• Acute weight loss
• Compensatory Increase in ADH
• Increased serum osmolality
• Decreased vascular volume
• Decreased ECF volume
• Impaired temperature regulation 19
Fluid Volume Excess
(Hypervolemia)
• Causes:
• Inadequate Na and water elimination
• Excessive NA intake in relation to output
• Excessive fluid intake in relation to output
• Manifestations:
• Acute weight gain
• Increased interstitial fluid volume
• Increased vascular volume

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 PITTING EDEMA
• Is the extravasation and
accumulation of
interstitial fluid in tissues.
• Edema is gravitational and
will develop in dependent
areas of the body, for
example, in feet and legs
when one is standing for
prolonged periods.
• Is a type of edema in
which the skin surface,
when pressed by a finger,
leaves an indentation.
This edema reflects high
right atrial pressure, for
example, in heart failure.  

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Electrolyte Imbalances

Hypo and Hypernatremia

Hypo and Hyperkalemia
Hypo and Hypercalcemia
Hypo and Hypermagnesemia

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 Sodium (Na) 135-145 mEq/L

• Must be present for glucose to be transported into cells

• Controls ECF osmotic pressure
• Necessary for neuromuscular functioning
• Determines intracellular reactions
• Maintains acid base balance

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 Hypernatremia
• Implies a serum Na level above 145mEq/L
• Is characterized by hypertonicity of extracellular fluids
• Almost always the causes cellular dehydration
• Causes:
• Excessive water losses
• Watery diarrhea
• Excessive sweating
• Increased respirations due to conditions such as tracheobronchitis
• Hypertonic tube feedings
• Decreased water intake
• Oral trauma or inability to swallow
• Impaired thirst sensation
• Withholding water for therapeutic reasons
• Unconsciousness/inability to express thirst
• Excessive Na intake
• Rapid/excessive administration of Na containing parenteral solutions
• Near drowning in salt water

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Hypernatremia
• Manifestations
• Polydipsia
• Oliguria or Anuria
• Dry skin and mucous membranes
• Decreased tissue turgor
• Decreased salivation
• Headache
• Decreased reflexes
• Tachycardia
• Weak and thready pulse
• Decreased BP
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Hyponatremia
• Represents a decreased in serum Na concentration below 135mEq/L
• May be associated with high, normal or low tonicity
• Causes:
• Excessive Na losses and replacement with tap water or Na free
losses
• Vomiting
• Diarrhea
• Diuresis
• Excessive water intake in relation to output
• Excessively diluted infant formula
• Kidney disorder that impair water elimination
• Repeated irrigation of body cavities like enemas

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Hyponatremia
• Manifestations:
• Muscle cramps
• Weakness
• Headache
• Depression
• Lethargy
• Anorexia, nausea, vomiting
• Abdominal cramps, diarrhea
• Fingerprint edema

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Potassium (K) 3.5-5 mEq/L
• Excitability of nerves and muscles
• ICF osmotic pressure
• Maintains acid-base balance
• K deficit: alkalosis
• K excess: acidosis
• Anabolism: K enters cell
• Catabolism: K leaves cell

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Hypokalemia
• Decrease in serum potassium levels below 3.5 mEq/L
• Causes:
• Diet deficient in Potassium
• Inability to eat
• Diuretic therapy
• Vomiting
• Diarrhea
• GIT suction
• Manifestations:
• Polyuria
• Anorexia, nausea, vomiting
• Abdominal distention
• Muscle weakness and fatigue
• Postural hypotension
• Cardiac dysrhythmias
• Confusion and depression
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Hyperkalemia
• Refers to an increased in serum levels of K in excess of 5.0 mEq/L
• Causes:
• Excessive oral intake
• Treatment with oral K supplements
• Rapid infusion of K containing parenteral fluids
• Tissue trauma
• Burns
• Extreme exercise
• Renal failure
• Manifestations:
• Nausea and vomiting
• Intestinal cramps
• Diarrhea
• Paresthesia
• Weakness, dizziness, muscle cramps
• Risk of cardiac arrest

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Calcium (Ca) 8.5-10.5 mg/dL
• 2 types of Ca
• Ionized
• Plasma protein bound
• Free Ionized Ca is needed for
• Blood coagulation
• Muscle contraction
• Nerve function
• Bone and teeth formation
• Vitamin D and PTH increases GI Ca absorption

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Hypocalcemia
• Represents serum calcium level of less than 8.5 mg/dl
• Occurs in many forms of critical illness
• Causes:
• Hypoparathyroidism
• Hypomagnesemia
• Malabsorption
• Vitamin D deficiency
• Renal failure
• Increased pH, fatty acids
• Manifestations:
• Paresthesia
• Skeletal muscle cramps
• Abdominal spasms and cramps
• Tetany
• Hypotension
• Osteomalacia

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Hypercalcemia
• Represents a total calcium concentration greater than 10.5
mg/dl
• Causes:
• Excessive vitamin D, Calcium in the diet
• Increased levels of parathyroid hormone
• Malignant neoplasm
• Prolonged immobilization
• Manifestations:
• Polyuria
• Polydipsia
• Signs of kidney stones
• Anorexia, nausea and vomiting
• Constipation
• Muscle weakness
• Hypertension
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 Hypophosphatemia
• Commonly defined by a serum phosphorus level of less than 2.5
mg/dl in adults
• Is considered a severe at concentration of less than 1.0 mEq/L
• Can occur despite normal body phosphate stores
• Causes:
• Severe diarrhea
• Lack of vitamin D
• Hyperparathyroidism
• Alcoholism
• Recovery from malnutrition
• Administration of Insulin
• Manifestations:
• Intention tremor
• Seizure
• Muscle weakness
• Joint stiffness
• Hemolytic anemia
• Bone pain 37
Hyperphosphatemia
• Represents a serum phosphorus concentration in excess of 4.5 mg/dl in
adults
• Growing children have serum phosphate levels higher than those of adults
• Causes:
• Laxative and enemas containing phosphate
• Intravenous phosphate supplementation
• Massive trauma
• Heat stroke
• Seizures
• Tumor lysis syndrome
• Potassium deficiency
• Kidney failure
• Manifestations:
• Paresthesia
• Tetany
• Cardiac dysrhythmias

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Magnesium (1.8-3.0 mg/dL)

• Second most abundant ICF cation

• essential for neuromuscular function
• changes in serum Mg+ levels effect other electrolytes
• excreted primarily by kidneys

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Hypomagnesemia
• Represents a serum magnesium concentration of less than 1.8 mg/dl
• Is seen in condition that limit intake or increased intestinal or renal losses
• Causes:
• Alcoholism
• Malnutrition
• Malabsorption
• Small bowel bypass surgery
• High dietary intake of calcium without concomitant amount of
magnesium
• Diuretic therapy
• Manifestations:
• Nystagmus
• Positive Babinski signs
• Tachycardia
• Hypertension
• Cardiac dysrhythmias

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Hypermagnesemia
• Represents serum magnesium concentration in excess of 3.0
mg/dl
• Causes:
• IV administration of magnesium for treatment of
preeclampsia
• Excessive use of oral magnesium containing medications
• Glomerulonephritis
• Acute renal failure
• Manifestations:
• Lethargy
• Hyporeflexia
• Confusion, hypotension
• Cardiac dysrhythmias
• Cardiac arrest

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 Alterations in Acid-Base
Balance
• Metabolic Acidosis
• Involves a primary deficit in base Bicarbonate along with a
decreased in plasma pH
• The body compensates for the decrease in pH by increasing the RR
in an effort to decrease CO2 and HCO3 levels.
• Causes:
• Lactic acidosis
• Diabetic Ketoacidosis
• Fasting and starvation
• Poisoning
• Kidney failure
• Diarrhea
• Intestinal suction
• NaCl infusions

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Metabolic Acidosis
• Manifestations:
• Anorexia, nausea and vomiting
• Abdominal pain
• Weakness
• Lethargy
• General malaise
• Confusion
• Cardiac dysrhythmias
• Decrease heart rate
• Bone disease

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Metabolic Alkalosis
• Involves a primary excess of base HCO3 along with an
increased plasma pH
• The body compensates for the increase in pH by decreasing
the RR as means of increasing PCO2 and H2CO3 levels
• Causes:
• Indigestion or administration of Sodium bicarbonate
• Administration of parenteral solution containing lactate
• Vomiting, gastric suction
• Potassium deficit
• Loss of body fluids

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Metabolic Alkalosis
• Manifestations:
• Confusion
• Hyperactive reflexes
• Tetany
• Convulsions
• Hypotension
• Dysrhythmias

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Respiratory Acidosis
• Involves an increase in PCO2 and H2CO3 along with a decrease
in pH
• In chronic respiratory acidosis, there is a compensatory
increase in bicarbonate levels
• Causes:
• Drug overdose
• Head injury
• Bronchial asthma
• Emphysema
• Chronic bronchitis
• Pneumonia
• Pulmonary edema
• Respiratory distress syndrome
• Extreme obesity

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Respiratory Acidosis
• Manifestations:
• Headache
• Weakness
• Confusion
• Depression
• Paranoia
• Hallucinations
• Tremors
• Paralysis
• Skin warm

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Respiratory Alkalosis
• Involves a decrease in PCO2 and a primary deficit in carbonic acid
along with an increase in pH.
• Causes:
• Anxiety
• Hyperventilation
• Hypoxia
• Lung disease
• Fever
• Encephalitis
• Mechanical ventilation
• Manifestation:
• Constriction of cerebral vessels
• Dizziness, panic, light headedness
• Tetany
• Numbness and tingling of fingers and toes
• Cardiac dysrhythmias
• Seizures 48
Regulation of Acid-Base

Buffers:
• Carbonic Acid
• Carbon dioxide dissolved in plasma
• Serum bicarbonate (HCO3)
• Major extracellular buffer in the blood.
• Kidneys regulate its generation and excretion.

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 Arterial Blood Gas Analysis
Normal Values:
• pH - 7.35-7.45
• pCO2 - 35-45 mmHg
• HCO3 - 22-26 mEq/L

Steps in ABG Analysis:

• Determine the pH
• Low – Acidic
• High – Basic
• Determine the area affected
• Lungs – Respiratory
• Kidneys - Metabolic
• Determine the level of compensation
• Uncompensated
• Partially compensated
• Fully compensated 50
Kidney
• Functions of Kidney:
• Regulation of the water and electrolyte content of the
body.
• Retention of substances vital to the body such as protein
and glucose
• Maintenance of acid/base balance.
• Excretion of waste products, water soluble toxic
substances and drugs.
• Endocrine functions. 

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 Regulation of the Water &
Electrolyte Content of the
Body
• The kidney allows a person to eat and drink according to
their habits without changing the composition of their fluid
compartments.
• Each kidney consists of about one million nephrons. The
nephron is made up of a glomerulus and its tubule.

• The kidney is unique as it has two capillary beds arranged in

series:
• the glomerular capillaries which are under high pressure
for filtering
• and the peritubular capillaries which are situated around
the tubule and are at low pressure . This permits large
volumes of fluid to be filtered and reabsorbed.  
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Glomerular Disorders

• The cellular changes that occur with glomerular disease

includes:
• Proliferative = refers as an increase in cellular
components of the glomerulus.
• Sclerotic=an increase in the non-cellular components of
the glomerulus primarily collagen.
• Membranous=an increase in the thickness of the
glomerular capillary wall often caused by immune complex
deposition.

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Glomerular Disorders
• Acute proliferative glomerulonephritis
• The most commonly recognize form is diffused
proliferative glomerulonephritis which follows infections
caused by strains of group A beta-hemolytic streptococci
• The inflammatory response is caused by an immune
reaction that occurs when circulating immune complexes
become entrapped in the glomerular membrane
• Can be seen primarily in children
• One of the 1st symptoms is oliguria followed by proteinuria
and hematuria
• Cola-colored urine may be 1st sign of the disorder
• Sodium and water retention gives rise to edema and
hypertension
• Prognosis is favorable approximately 95% o children
recovers spontaneously
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Glomerular Disorders

• Rapidly Progressive Glomerulonephritis

• A clinical syndrome characterized by signs of severe
glomerular injury that does not have a specific cause.
• The disorder involves focal and segmental proliferation
of the glomerular cells and recruitment of monocytes.
• May be causes by a number of immunologic disorders like
SLE and Goodpasture’s syndrome.

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Nephrotic Syndrome
• Is not a specific glomerular disease but a constellation of
clinical findings that result from increase glomerular
permeability to the plasma proteins.
• Can occur/develop as primary or secondary to systemic
diseases such as DM, amyloidosis and SLE.
• Is characterized by massive proteinuria and lipiduria along with
generalized edema and hyperlipidemia.

Example:
• Membranous GLomerulonephritis
• Is the most common cause of primary nephrosis in adults.
• The disorders are caused by diffuse thickening of the GBM
due to deposition of immune complexes.
• Can be treated with corticosteroids, cytotoxic drugs may be
added.
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Nephrotic Syndrome
• Minimal Change Disease or Lipoid Nephrosis
• Is characterized by diffuse loss of the foot processes from the
epithelial layer of the glomerular membrane.
• The peak incidence is between 2 and 6 years of age.
• The cause is unknown however children who have history of URTI
may develop the disease.

• Immunoglobulin A Nephropathy
• Ex. Buerger's disease
• Is a primary type of glomerulonephritis
• Most persons are between 16-35 years of age at the time of
diagnosis
• Commonly in male
• The disorder is characterized by the deposition of IgA and
occasionally IgG
• Is preceded by URTI, GIT symptoms or a flu-like illness

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Renal Failure

• Acute Renal Failure (ARF)

• is the rapid breakdown of renal (kidney) function that
occurs when high levels of uremic toxins (waste products
of the body’s metabolism) accumulate in the blood.
• occurs when the kidneys are unable to excrete
(discharge) the daily load of toxins in the urine.
• Based on the amount of urine that is excreted over a 24-
hour period, patients with ARF are separated into two
groups:
• Oliguric: patients who excrete less than 500
milliliters per day (< 16 oz/day)
• Non-oliguric: patients who excrete more than 500
milliliters per day (> 16 oz/day)

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Renal Failure

• Both kidneys are failing when ARF occurs. One normally

functioning kidney can maintain adequate blood filtering.
• does not produce a classic set of symptoms. The most
common symptom is decreased urine output, which occurs
in 70% of patients.
• Is most easily diagnosed by an increase in blood levels of
creatinine and blood urea nitrogen (BUN). The blood level
of creatinine typically increases by 0.5 milligrams per
tenth of a liter (mg/dL) every day.
• There are several modalities of renal replacement
therapy (RRT) for patients with acute renal failure:
• Intermittent hemodialysis
• Continuous hemodialysis (used in critically ill patients)
• Peritoneal dialysis (rarely used)
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Chronic Renal Failure
• is a gradual and progressive loss of the ability of the kidneys to
excrete wastes, concentrate urine, and conserve electrolytes.
• Unlike ARF with its sudden, reversible failure of kidney
function, chronic renal failure slowly gets worse.
• It most often results from any disease that causes gradual loss
of kidney function. It can range from mild dysfunction to
severe kidney failure
• Progression may continue to end-stage renal disease (ESRD)
• usually occurs over a number of years as the internal
structures of the kidney are slowly damaged.
• In the early stages, there may be no symptoms. In fact,
progression may be so gradual that symptoms do not occur until
kidney function is less than one-tenth of normal.
• Diabetes and hypertension (high blood pressure) are the two
most common causes.

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Chronic Renal Failure

• Initial symptoms may include the following:

• Unintentional weight loss
• Nausea and vomiting
• Fatigue
• Headache
• Generalized itching (pruritus)
• Later symptoms may include the following:
• Increased or decreased urine output
• Need to urinate at night
• Easy bruising or bleeding
• May have blood in the vomit or in stools
• Decreased alertness
• Seizures
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 End:
Fluids & Electrolytes

Prepared by:
Eric B. Panopio, M.D.
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