WATER AND

ELECTROLYTE
BALANCE
EDUARDO V. BONGAT JR, MD,PTRP,RN, RM, MN, LPT
 OBJECTIVES

1 2 3
To understand the concept of To identify and understand the To incorporate water and
water and electrolyte balance in concepts surrounding water and electrolyte balance in the nursing
the body and how nutrition and electrolyte balance in the body process and nursing
diet affects homeostasis in the responsibilities in the hospital
body. setting
 WATER
• Water is a component of all body cells and constitutes from 50% to
60% of the body weight of normal adults. 
• The percentage is higher in males than females because men usually
have more muscle tissue than women. The water content of muscle
tissue is higher than that of fat tissue. The percentage of water
content is highest in newborns (75%) and decreases with age.
• Body water is divided into two basic compartments: intracellular and
extracellular. Intracellular fluid (ICF) is water within the cells and
accounts for about 65% of total body fluid (Figure 9-1). Extracellular
fluid (ECF) is water outside the cells and accounts for about 35% of
total body fluid. Extracellular fluid is found in the intravascular fluid
(water in the bloodstream), interstitial fluid, and glandular secretions.
 WATER

Water is the major It is a solvent for nutrients It is necessary for the It functions as a lubricant In addition, it cools the Serves as a shock absorber
component of blood and waste products and hydrolysis of nutrients in in joints and in digestion.  body through perspiration
plasma.  helps transport both to and the cells, making it and may, depending on its
from body cells by way of essential for metabolism.  source, provide some
the blood.  mineral elements
WATER
INTAKE
WATER
INTAKE
 FLUID AND ELECTROLYTE
BALANCE 

• Homeostasis is the dynamic process in which the body maintains balance by

constantly adjusting to internal and external stimuli.
• For optimum health there must be homeostasis. For this to exist, the body must be in
fluid and electrolyte balance. This means the water lost by healthy individuals
through urination, feces, perspiration, and the respiratory tract must be replaced in
terms of both volume and electrolyte content. 
 FACTORS LEADING TO FLUID
DEFICIT AND EXCESS
FACTORS FLUID DEFICIT FLUID EXCESS
ENVIRONMENTAL FACTOR Exposure to sun or high atmospheric
temperatures
PERSONAL BEHAVIORS FASTING EXCESSIVE SODIUM OR WATER
FAD DIETS INTAKE
EXERCISE WITHOUT ADEQUATE
FLUID REPLACEMENT VENOUS COMPRESSION DUE TO
PREGNANCY
PSYCHOLOGICAL INFLUENCES DECREASED MOTIVATION TO DRINK LOW PROTEIN INTAKE DUE TO
DUE TO FATIDUE, DEPRESSION ANOREXIA
EXCESSIVE USE OF LAXATIVES,
ENEMAS, ALCOHOL, AND CAFFEINE
 FACTORS LEADING TO FLUID
DEFICIT AND EXCESS

FACTORS FLUID DEFICIT FLUID EXCESS

CONSEQUENCES OF DISEASES FLUID LOSSES DUE TO FEVER, FLUID RETENTION DUE TO RENAL
WOUND DRAINAGE, VOMITING, FAILURE, CARDIAC CONDITIONS,
DIARRHEA, HEAVY MENSTRUAL CONGESTIVE HEART FAILURE,
FLOW, BURNS CIRRHOSIS, CANCER, AND
IMPAIRED VENOUS RETURN
DIFFICULTY OF SWALLOWING DUE
TO ORAL PAIN, FATIGUE,
NEUROMUSCULAR WEAKNESS,
EXCESSIVE URINARY OUTPUT DUE
TO UNCONTROLLED DIABETES
MELLITUS AND DIABETES
INSIPIDUS
 IMPLICATIONS OF WATER AND
ELECTROLYTES

Fluid retention. Retention of Loss of sodium. Excessive loss of

sodium is associated with fluid sodium is associated with decreased
retention. volume of body fluid.

Loss of body fluids. FVD results

Trauma. Trauma causes release of
from loss of body fluids and occurs
intracellular potassium which is
more rapidly when coupled with
extremely dangerous.
decreased fluid intake.
 CONCEPTS

• Fluid overload. Fluid volume excess may be related to a simple fluid overload

or diminished function of the homeostatic mechanisms responsible for regulating
fluid balance.
• Low or high electrolyte intake. Diets low or excessive in electrolytes could also
cause electrolyte imbalances.
• Medications. There are certain medications that could lead to electrolyte imbalances when
taken against the physician’s orders.
 FLUIDS

• Water lost through urine is known as sensible (noticeable) water loss. Insensible (unnoticed)
water loss is in feces, perspiration, and respiration. 
• The body must excrete 500 ml of water as urine each day in order to get rid of the waste
products of metabolism
• Water moves through cell walls by osmosis.
•  Water flows from the side with the lesser amount of solute to the side with the greater solute
concentration.
 ELECTROLYTES

• The electrolytes sodium, chloride, and potassium are the solutes that maintain the
balance between intracellular and extracellular fluids. 
• Potassium is the principal electrolyte in intracellular fluid. 
• Sodium is the principal electrolyte in extracellular fluid. 
• Osmolality is the measure of particles in a solution. 
• When the electrolytes in the extracellular fluid are increased, ICF moves to the ECF in an
attempt to equalize the concentration of electrolytes on both sides of the membrane. This
movement reduces the amount of water in the cells.
 CONCEPTS

• The cells of the hypothalamus (regulates appetite and thirst) then become dehydrated, as do
those in the mouth and tongue, and the body experiences thirst.
• The hypothalamus stimulates the pituitary gland to excrete ADH (antidiuretic hormone)
whenever the electrolytes become too concentrated in the blood or whenever blood volume
or blood pressure is too low. (This measurement is called vascular osmotic pressure.)
• The ADH causes the kidneys to reabsorb water rather than excrete it. 
 CONCEPTS

• At such times, thirst causes the healthy person to drink fluids, which provide the water and
electrolytes needed by the cells. 
• When the sodium in the ECF is reduced, water flows from the ECF into the cells,
causing cellular edema. 
• When this occurs, the adrenal glands secrete aldosterone, which triggers the kidneys
to increase the amount of sodium reabsorbed. 
• When the missing sodium is replaced in the ECF, the excess water that has been drawn from
the ECF into the cells moves back to the ECF, and the edema is relieved.
 CONCEPTS

• The amount of water used and thus needed each day varies, depending on age, size, activity,
environmental temperature, and physical condition.
• The average adult water requirement is 1 ml (milliliter) for every calorie in food consumed.
• For example, for every 1,800 kcal in food consumed, one needs to drink 7.5 glasses of fluid. 
 CONCEPTS

• For optimal health, it is recommended that adults drink at least thirteen 8-ounce glasses of
fluid a day, preferably eight glasses of water but at least seven of water and five of other
fluids. 
• Youth, fever, diarrhea, unusual perspiration, and hyperthyroidism increase the requirement.
 DEHYDRATION

• When the amount of water in the body is inadequate, dehydration can occur. It can be caused
by inadequate intake or abnormal loss. 
• Such loss can occur from severe diarrhea, vomiting, hemorrhage, burns, diabetes mellitus,
excessive perspiration, excessive urination, or the use of certain medications such
as diuretics. Symptoms of dehydration include low blood pressure, thirst, dry skin, fever,
and mental disorientation
 DEHYDRATION

• As water is lost, electrolytes are also lost. Thus, treatment includes replacement of
electrolytes and fluids.
• Electrolyte content must be checked and corrections made if necessary.
• A loss of 10% of body water can cause serious problems. 
• Blood volume and nutrient absorption are reduced, and kidney function is upset.
• A loss of 20% of body water can cause circulatory failure and death. Infants, for example,
are at high risk of dehydration when fever, vomiting, and diarrhea occur.
• Intravenous fluids are often necessary if sufficient fluids cannot be consumed by mouth.
 SIGNS OF DEHYDRATION

• Decrease in urine output.

• Weight loss (% body weight): 3–5% for mild, 6–9% for moderate, and 10–15% for severe
dehydration. 
• Eyes appear sunken; tongue has increased furrows and fissures.
• Oral mucous membranes are dry.
• Decreased skin turgor (normal skin resiliency). 
• Changes in neurological status may occur with moderate to severe dehydration.
 POSITIVE WATER BALANCE

• Some conditions cause an excessive accumulation of fluid in the body. 

• This condition is called positive water balance. 
• It occurs when more water is taken in than is used and excreted, and edema results.
• Hypothyroidism, congestive heart failure, hypoproteinemia (low amounts of protein), some
infections, some cancers, and some renal conditions can cause such water retention because
sodium is not being excreted normally.
 POSITIVE WATER BALANCE

• Fluids and sodium may then be restricted. 

• Excess water drinking is a recognized characteristic of schizophrenia. Also it has been
reported that acute psychological stress had led to excessive water drinking that resulted in
brain damage (Mukherjee et al., 2005). 
• Those without a medical or psychological condition are not prone to excess water intake.
 ACID BASE BALANCE

• In addition to maintaining fluid and electrolyte balance, the body must also maintain acid-
base balance.
• This is the regulation of hydrogen ions in body fluids (pH balance).
• In a water solution, an acid gives off hydrogen ions and a base picks them up.
•  Hydrochloric acid is an example of an acid found in the body. It is secreted by the stomach
and is necessary for the digestion of proteins.
• Ammonia is a base produced in the kidneys from amino acids. Acidic substances run from
pH 1 to 7, with the lowest numbers representing the most acidic (which contain the most
hydrogen ions).
 ACID BASE BALANCE

• Alkaline substances run from pH 7 to 14, with the alkalinity increasing with the number (as
the number of hydrogen ions decreases). 
• A pH of 7 is considered neutral. 
• Blood plasma runs from pH 7.35 to 7.45. Intracellular fluid has a pH of 6.8. 
• The kidneys play the primary role in maintaining the acid-base balance by selecting which
ions to retain and which to excrete. For the most part, what a person eats affects the acidity
not of the body but of the urine.
 BUFFER SYSTEMS

• The body has buffer systems that regulate hydrogen ion content in body fluids.
• Such a system is a mixture of a weak acid and a strong base that reacts to protect the nature
of the solution in which it exists. In a normal buffer system, the ratio of base to acid is 20:1.
• For example, when a strong acid is added to a buffered solution, the base takes up the
hydrogen ions of the strong acid, thereby weakening it.
• When a strong base is added to a solution, the acid of the buffer system combines with this
base and weakens it. A mixture of carbonic acid and sodium bicarbonate forms the body’s
main buffer system.
 BUFFER SYSTEMS

• Carbonic acid moves easily to buffer a strong alkali, and sodium bicarbonate moves easily to
buffer a strong acid. 
• Amounts are easily adjusted by the lungs and kidneys to suit needs. For example, the end
products of metabolism are carbon dioxide and water, and together they can form carbonic acid. 
• The hemoglobin in the blood carries carbon dioxide to the lungs, where the excess is excreted. If
the amount of carbon dioxide is more concentrated than it should be, the medulla oblongata in the
brain causes the breathing rate to increase. 
• This increase, in turn, increases the rate at which the body rids itself of carbon dioxide. 
• Excess sodium bicarbonate is excreted via the kidneys. The kidneys can excrete urine from pH
4.5 to pH 8. 
• The pH of average urine is 6.
 CLINICAL MANIFESTATIONS

• Fluid volume deficit. Clinical signs and symptoms include acute weight loss, decreased skin turgor,
oliguria, concentrated urine, orthostatic hypotension, a weak, rapid heart rate, flattened neck veins,
increased temperature, thirst, decreased or delayed capillary refill, cool, clammy skin, muscle
weakness, and cramps.
• Fluid volume excess. Clinical manifestations for FVE include edema, distended neck veins, and
crackles.
• Hyponatremia. Signs and symptoms include anorexia, nausea and vomiting, headache, lethargy,
dizziness, confusion, muscle cramps and weakness, muscular twitching, seizures, dry skin, and
edema.
• Hypernatremia. The signs and symptoms are thirst, elevated body temperature, hallucinations,
lethargy, restlessness, pulmonary edema, twitching, increased BP and pulse.
 CLINICAL MANIFESTATIONS

• Hypomagnesemia. Clinical manifestations include neuromuscular irritability, positive Trousseau’s

and Chvostek’s sign, insomnia, mood changes, anorexia, vomiting, and increased deep tendon
reflexes.
• Hypermagnesemia. Signs and symptoms are flushing, hypotension, muscle weakness, drowsiness,
hypoactive reflexes, depressed respirations, and diaphoresis.
• Hypophosphatemia. Signs and symptoms include paresthesias, muscle weakness, bone pain
and tenderness, chest pain, confusion, seizures, tissue hypoxia, and nystagmus.
• Hyperphosphatemia. Clinical manifestations are tetany, tachycardia, anorexia, nausea and vomiting,
muscle weakness, and hyperactive reflexes.
 CLINICAL MANIFESTATIONS

• Hypokalemia. Clinical manifestations are fatigue, anorexia, muscle weakness, polyuria, decreased bowel

motility, paresthesia, ileus, abdominal distention, and hypoactive reflexes
• Hyperkalemia. Signs and symptoms include muscle weakness, tachycardia, paresthesia, dysrhythmias,
intestinal colic, cramps, abdominal distention, and anxiety.
• Hypocalcemia. The signs and symptoms are numbness, tingling of fingers, toes, and circumoral region,
positive Trousseau’s sign and Chvostek’s sign, seizures, hyperactive deep tendon reflexes, irritability, and
bronchospasm.
• Hypercalcemia. The signs and symptoms include muscle weakness, constipation, anorexia, nausea and
vomiting, dehydration, hypoactive deep tendon reflexes lethargy, calcium stones, flank pain, pathologic
fractures, and deep bone pain.
 DIETARY ALTERATIONS

• Clients who are required to limit both their salt and liquid intake will probably be unhappy with their diets. 
• In such cases, it is helpful when the dietitian can discuss realistic ways of planning menus for them and
with them. T
• hese menus should be based, of course, on good nutrition, but they also must be based on the client’s
normal habits and desires as much as is possible. 
• The client’s former diet should be reviewed with the client. 
• The high-salt and high-liquid foods should be pointed out and alternative foods presented in a positive
manner.
 COMPLICATIONS

• Dehydration. Fluid volume deficit could result in dehydration of the body tissues.

• Cardiac overload. Fluid volume excess could result in cardiac overload if left untreated.
• SIADH. Water is retained abnormally in SIADH.
• Cardiac arrest. Too much potassium administered could lead to cardiac arrest.
 MANAGEMENT

• Isotonic electrolyte solutions. These solutions are used to treat the hypotensive patient with FVD
because they expand plasma volume.
• Accurate I&O. Accurate and frequent assessments of I&O should be performed when therapy
should be slowed or increased to prevent volume deficit or overload.
• Dialysis. Hemodialysis or peritoneal dialysis is performed to remove nitrogenous wastes and control
potassium and acid-base balance, and to remove sodium and fluid.
• Nutritional therapy. Treatment of fluid and electrolyte imbalances should involve restrictions or
enforcement of the concerned electrolyte.
 PHARMACOLOGIC MANAGEMENT

• AVP receptor agonists. These are new pharmacologic agents that treat hyponatremia by
stimulating free water excretion.
• Diuretics. (Thiazide, Loop, and Potassium Sparing) To decrease fluid volume in FVE,
diuretics are administered.
• IV calcium gluconate. If serum potassium levels are dangerously elevated, it may be
necessary to administer IV calcium gluconate.
• Calcitonin. Calcitonin can be used to lower the serum calcium level and is particularly
useful for patients with heart disease or heart failure who cannot tolerate large sodium loads.
 NURSING MANAGEMENT | ASSESSMENT

• I&O. the nurse should monitor for fluid I&O at least every 8 hours, or even hourly.
• Daily weight. Assess the patient’s weight daily to measure any gains or losses.
• Vital signs. Vital signs should be closely monitored.
• Physical exam. Physical exam is needed to reinforce other data about a fluid or electrolyte
imbalance.
 NURSING MANAGEMENT | DIAGNOSIS

• Excess fluid volume related to excess fluid intake and sodium intake.

• Deficient fluid volume related to active fluid loss or failure of regulatory mechanisms.
• Imbalanced nutrition: less than body requirements related to inability to ingest food or
absorb nutrients.
• Imbalanced nutrition: more than body requirements related to excessive intake.
• Diarrhea related to adverse effects of medications or malabsorption.
 NURSING MANAGEMENT | PLANNING

• Planning and goals for fluid and electrolyte imbalances include:

• Maintenance of fluid volume at a functional level.
• Display of normal laboratory values.
• Demonstration appropriate changes in lifestyle and behaviors including eating patterns and
food quantity/quality.
• Reestablishment and maintenance of normal pattern and GI functioning.
 NURSING MANAGEMENT |
INTERVENTIONS
• Monitor turgor. Skin and tongue turgor are indicators of the fluid status of the patient.
• Urine concentration. Obtain urine sample of the patient to check for urine concentration.
• Oral and parenteral fluids. Administer oral or parenteral fluids as indicated to correct the deficit.
• Oral rehydration solutions. These solutions provide fluid, glucose, and electrolytes in concentrations that
are easily absorbed.
• Central nervous system changes. The nurse must be alert for central nervous system changes such as
lethargy, seizures, confusion, and muscle twitching.
• Diet. The nurse must encourage intake of electrolytes that are deficient or restrict intake if the electrolyte
levels are excessive.
 NURSING MANAGEMENT | EVALUATION

• Maintained fluid volume at a functional level.

• Displayed normal laboratory results.
• Demonstrated appropriate changes in lifestyle and behaviors including eating patterns and
food quantity/quality.
• Reestablished and maintained normal pattern and GI functioning.
•QUESTIONS?