Fluid and Electrolytes:

Balance & Disturbances

By:

Jay Aries T. Gianan

EMT-B, RM, RN, LPT, MAN
Objectives:
• What is fluid and electrolyte balance?
• Bodily fluids
• Electrolytes
• What are the types of electrolytes &
their roles?
• What are the types of electrolytes
imbalances?
• How to manage electrolytes
imbalance?
What is fluid and electrolytes balance?
 Fluid and electrolytes balance
• Fluid and electrolyte balance is a
dynamic process that is crucial for life
and homeostasis.

• Homeostasis – state of equilibrium

Bodily fluids
• Bodily fluids are liquids that
come from inside human bodies
and help transport nutrients
and expel waste from human
cells.
To balance water output, an
average adult must have daily
fluid intake of approximately:
A. 500-900 ml.
B. 1,000-2,000 ml.
C. 2,000-3,000 ml.
D. 4,000-6,000 ml.
Electrolytes
• Electrolytes are ions that are found in your
body fluids. They help to conduct electricity,
energy, help control body fluids and
maintain homeostasis in the body
• “Electric lights” – light up your body with
energy
• Cations that carry positive charges
• sodium, potassium, calcium,
magnesium, and hydrogen ions.
• Anions carry negative charges
• chloride, bicarbonate, phosphate,
sulfate, and proteinate ions.
Body compartments
ECF is primarily composed of:
A. Aqueous fluid
and lymphatic fluid.
B. CSF and interstitial fluid.
C. Interstitial and intravascular
fluids.
D. Vascular fluid and CSF.
What are the types of electrolytes & their
roles?
“K+ing” Potassium (3.5-5.0 mEq/L)
• King of action & contraction esp.
in heart & skeletal muscles
keeping each muscle cells
charged
• Obtain thru (fruits & green leafy
veggies)
• Absorbed in intestines &
excreted in the body via bowels
& kidneys
 “Salty” Sodium (135-145 mEq/L)
• Always followed by water paparazzi (where Na+
• Works w/ K+ to energize the cell
goes H2O flows) in the sodium potassium pump
• Major cation in extracellular fluid
• Buffers out acid base imbalances
• Obtain in salty foods, processed foods, fast foods,
meats, cheeses
• Absorbed in the small intestine excreted in
kidneys
• Functions:
• Maintain blood volume
• Maintain blood pressure
• Keep pH balance
• Regulated by:
• ADH (antidiuretic hormone)
• Add Da H2O
• Aldosterone (holds sodium in the body)
“Magnum” Magnesium (Mg++) 1.3-2.1
mEq/L
• Keep law & order in the muscles of your body
• Protein synthesis
• Nerve function
• Blood sugar control
• Obtained in spinach, almonds, yogurt
• Absorbed in small intestines & excreted by
kidneys
• Loves to stimulate parathyroid hormone w/c
regulates calcium
• Magnesium & calcium are BFF
• Mg is required in Ca++ & Vit. D absorption w/c fights
tooth decay by binding Ca to tooth enamel
 “Cocky” Calcium (Ca++) 9.0-10.5 mEq/L
• Most abundant cation in the body 99% found in • Regulated by 3 main hormones
bones • Parathyroid hormone
• Obtained in fruits, veggies, almonds, dairy • ↑ Ca++ concentration in the
products, green veggies blood
• Absorbed in small intestine & excreted by • Calcitonin hormone
kidneys • Puts a ton of Ca++ into the
• Has love affair w/ Vit. D bones
• Calcitriol
• Make things strong (3Bs)
• Controls blood Ca++ by
• Strong bones stopping calcitonin
• Strong blood (clotting factors)
• Strong beats (heart beats)
• BFF w/ Mg++
• If Mg++ is low, Ca++ fill the role of Mg++
“Punk” Phosphate “3.0-4.5” mEq/L

• Obtained in meat, poultry, fish, nuts,

beans &dairy products
• Bone & teeth formation, repair cell
tissues
• If Ca++ ↑, phosphate is ↓ (vice versa)
• Regulated by parathyroid hormone
w/c regulates Ca++ too
• Ca++ worst enemy
• Works inversely
“4 Eyed” Chloride 98-106 mEq/L
• Always following around her sister
salty Always find where Na+ is:
• Table salt, sea salt, seaweed,
tomatoes, olives & others
• Absorbed in small intestines &
excreted in kidneys
• Functions is to aid her sister salty Na+
• Maintain blood volume
• Maintain blood pressure
• Keep pH balance
 • Test taking skills!
• Write the lab values
Electrolyte food sources • 10x before you study
• 10x after you study
• Potassium – green leafy vegetables (spinach)
• Bananas, avocados, salt substitutes
• Sodium – canned foods, processed foods
• Cheeses, fast foods
• Magnesium - green leafy vegetables
• Spinach, almonds, yogurt
• Calcium - green leafy vegetables
• Almonds, oranges, dairy products
• Phosphate – dairy meat & beans
• Chloride – found w/ salt & salt substitutes
Electrolyte Depletion Causes
• Vomiting
• GI tract (gastro intestinal) stomach &
intestines
• NGT (nasogastric tube) suctioning
• Pooping
• Diarrhea
• Stoma drainage (colostomy or ileostomy)
• Peeing
• Urinary tract (renals to urethra)
• Sweating
• From exercise
• Diaphoresis (fever, stress, heat exhaustion)
• Burn patients (high risk for fluid loss)
What are the types of electrolytes
imbalances?
Hyperkalemia (↑5.0 mEq/L)
• Heart – tight & contracted
• ST elevation & peaked T waves
• Severe = V Fib or cardiac Standstill
• Hypotension, bradycardia
• GI tract – tight & contracted
• Diarrhea
• Hyperactive bowel sounds
• Neuromuscular – tight & contracted
• Paralysis of extremities
• Increased DTR
• Profound muscle weakness
• Words like “profound & severe” – late & serious
signs
• Priority patients
Causes of Hyperkalemia (↑5.0 mEq/L)
• Medication – ACEI, Spironolactone,
NSAIDS
• Acidosis
• Cellular destruction - burns
• Hypoaldosteronism
• Increase K+ intake – IV solutions, meds
• Nephrons (broken) – Renal Failure
• Excretion problems – dialysis pts.
• Which patient below would have
a potassium level of 5.5?
a. A. A 76 year old who reports
taking Lasix (Furosemide) four
times a day
b. A patient with Addison’s disease
c. A 55 year old woman who have
been vomiting for 3 days
consistently
d. A patient with liver failure
Nursing intervention Hyperkalemia (↑5.0
mEq/L)
• Monitor EKG
• ST elevation & peak T waves
• Diet
• No salt substitutes
• No fruits
• No green leafy veggies
• Kayexalate – “Sodium polystyrene
sulfonate” S/E: diarrhea
• Prepare bedside commode
• IV sodium bicarb – corrects acidosis
• IV calcium gluconate
• Helps ↓ neuromuscular irritability
• Diuretics (K+ wasting) & dialysis
• Furosemide – loop diuretics
• Hydrochlorothiazide – thiazide diuretics
 Hypokalemia (↓3.5 mEq/L)
• Heart – Low & Slow
• Flat T waves, ST depression & prominent
U wave
• Muscular – Low & Slow
• Decreased DTR
• Muscle cramping
• Flaccid paralysis (paralyzed limbs)
• GI – Low & Slow
• Decreased motility, hypoactive to absent
bowel sounds
• Constipation
• Abdominal distention
• Paralytic ileus, paralyzed intestines
• PRIORITY for SBO (small bower
obstruction)
• After obtaining an EKG on a
patient you notice that ST
depression is present along with
an inverted T wave and
prominent U wave. What lab
value would be the cause of this
finding?
a. Magnesium level of 2.2
b. Potassium level of 5.6
c. Potassium level of 2.2
d. Phosphorus level of 2.0
Causes of Hypokalemia (↓3.5 mEq/L)
• GI Loss – vomiting, diarrhea
• Osmotic diuresis
• Thiazides & loop diuretics
• Severe acid imbalance
• Hyperaldosteronism (Cushing
syndrome)
• Other meds (corticosteroids, insulin,
antibiotics)
• Transcellular shift (insulin, albuterol –
pushes insulin in cell)
Nursing intervention of Hypokalemia (↓3.5
mEq/L)
• Watch heart rhythm, resp. status, GI & renal
status – BUN & creatinine
• Watch for magnesium level, glucose, sodium
level
• <2.5: give K+ as an infusion for almost 4 hrs
• Do not give IV, SubQ/IM it will kill the pt.
• Put the pt in cardiac monitor
• Watch for EKG changes
• Hold Lasix, thiazides (K+ wasting)
• Hold digoxin
• Doctor will order K+ sparring
• Diet: K+ rich foods (oranges, green leafy
veggies, tomatoes, avocadoes)
Hypernatremia (↑145 mEq/L)
• Big & bloated
• Skin
• Flush “red & rosy”
• Edema “waterbed skin”
• Low grade fever
• Polydipsia
• Excess thirst
• Late & serious sign
• Swollen dry tongue
• GI = nausea & vomiting
• Increased muscle tone
Causes of Hypernatremia (↑145 mEq/L)
• Hypercortisolism (Cushing syndrome)
& hyperventilation
• Increase Na+ intake (oral/IV)
• GI feeding, w/o adequate H2O
supplement
• Hypertonic solution (3% saline)
• Sodium excretion ↓ d/t corticosteroid
• Aldosterone problems (reabsorption
of sodium)
• Loss of fluids (dehydrated, fever,
sweating)
• Thirst impairment
Nursing intervention of Hypernatremia
(↑145 mEq/L)
• Restrict Na+ intake: no processed
foods
• Patient safety: confused & agitated
• MD may order an isotonic/hypotonic
IV (0.45% NS)
• give slowly – risk for cerebral edema
• Educate about diet
• Monitor for S/S of ↑ Na+ level
Hyponatremia (↓135 mEq/L)
• Depressed & Deflated
• Neuro = seizures & coma
• Heart = tachycardia & weak
thready pulses
• Respiratory arrest
Types of Hyponatremia (↓135 mEq/L)
• Euvolemic hyponatremia
• H20 increases, Na+ stay the same
• SIADH, diabetic insipidus, Addison's
disease, adrenal insufficiency
• Hypovolemic hyponatremia
• Pt. becomes dehydrated will cause loss of
blood volume
• Vomiting, diarrhea, NG suction, diuretic
therapy, burns, excessive sweating
• Hypervolemic hyponatremia
• H2O & Na+ both ↑ leading to volume
overload & Na+ become diluted
• CHF, kidney failure, liver failure
Causes of Hyponatremia (↓135 mEq/L)
• Na+ excretion ↑ w/ renal problems,
NG suction, vomiting, diuretics,
sweating, diabetes insipidus,
↑aldosterone secretion
• Overload of fluids (CHF, hypotonic
solution, liver failure)
• Na+ intake low, low NaCl diet or NPO
• ADH hormone over secreted (SIADH),
adrenal insufficiency
 Nursing intervention of Hyponatremia (↓135
mEq/L)
• Watch cardiac, respi, neuro, renal & GI status
• Hypovolemic: administer IV Na+ solution to
restore fluids & Na+ (3% saline hypertonic sol)
• Close monitoring d/t fluid overload
• Hypervolemic: restrict fluids (some Dr. order
diuretics)
• Renal patient > dialysis
• SIADH pt.: restrict fluid, tx diuretics hormone
antagonists
• Declomycin(tetracycline) don’t give w/ food or
dairy products – affects absorption
• Pts. Taking lithium – observe for lithium toxicity
Hyperchloremia (↑107 mEq/L)
• Nearly same as high sodium
• Nausea & vomiting
• Swollen dry tongue
• confusion
Causes of Hyperchloremia (↑107 mEq/L)
• Hypernatremia (high Na+))
• Trauma (head injury)
• Dehydration (severe diarrhea &
metabolic acidosis)
• Hyperparathyroidism
• Respiratory alkalosis
(hyperventilating)
Nursing intervention of Hyperchloremia
(↑107 mEq/L)
• Treat the causes
• Restore fluid imbalance
• IV LR (Lactated Ringers)
• Sodium bicarbonate
Hypochloremia (↓97 mEq/L)
• Nearly same as low sodium
• Excessive diarrhea, Vomiting
Sweating
• Fever only difference w/ low
sodium
• Hypotension
• Dysrhythmias
• Dyspnea, DOB, SOB d/t
Causes of Hypochloremia (↓97 mEq/L)
• Chloride lose from fluid loss
• (vomiting, diarrhea, NGT suction,
sweating, fever & burns)
• Hyponatremia
• Addison’s Disease
• Medications (diuretics)
• PH imbalances
• metabolic alkalosis d/t vomiting
Nursing Management of Hypochloremia
(↓97 mEq/L)
• Salty solutions
• IV NS or 0.45% NS
• Avoid free water
• l/t hemodilution
Hypermagnesemia (↑2.1 mEq/L)
• Cardiac – calm & quiet
• Heart block
• Prolonged PR intervals
• Vitals = bradycardia, hypotension
• Deep tendon reflexes – calm & quiet
• Hyporeflexia – decreased DTR
• Lungs – calm & quiet
• Depressed shallow respirations
• GI – calm & quiet
• Hypoactive bowel sounds
Causes of Hypermagnesemia (↑2.1 mEq/L)
• DKA (diabetic ketoacidosis)
• Antacids
• Tums, relieve heartburn
• Renal failure
• K+ excess
• Hyperkalemia (high K+)
• Addison’s disease
Nursing intervention of Hypermagnesemia
(↑2.1 mEq/L)
• Hemodialysis • Diet: Avoid this!!
• Backup kidney • Chocolate, cauliflower, vegetables
• Takes out the extra magnesium • Avocado
• IV calcium gluconate • Milk
• Decrease muscle tension • Pork & peas, peanut butter
• Calcium glues the muscle down • Oranges
(less tense & twitchy) • Nuts
• Monitor labs & DTR’s • Bananas
• Deep tendon reflexes
Hypomagnesemia (↓1.3 mEq/L)
• Cardiac – buck wild
• EKG: ST depression, T wave
inversion, torsades de pointes
• Severe: V Fib
• Vitals: Tachycardia
• Deep tendon reflexes – buck wild
• Hypereflexia – increased DTR
• Tetany
• Eyes – buck wild
• Abnormal eye movements
(nystagmus)
• GI – buck wild
• Diarrhea
Causes of Hypomagnesemia (↓1.3 mEq/L)
• Consumption of alcohol in
excess
• Stops Mg+ absorption
• Really large fluid loss
• NG suction, vomiting, diarrhea or
diuretics
• Antibiotics (aminoglycoside)
• Young mothers
• High risk for malnutrition
Which patient is at most risk for
hypomagnesemia?
a. A 55 year old chronic alcoholic
b. A 57 year old with
hyperthyroidism
c. A patient reporting overuse of
antacids and laxatives
d. A 25 year old suffering from
hypoglycemia
Nursing intervention of Hypomagnesemia
(↓1.3 mEq/L)
• Safety w/ swallowing • Diet: Eat this!!
• Coma & seizures, increased • Chocolate, cauliflower, vegetables
muscle tone • Avocado
• IV magnesium sulfate • Milk
• Caution: give slowly, l/t slow the • Pork & peas, peanut butter
heart rate • Oranges
• Monitor • Nuts
• Respiratory status & reflexes • Bananas
• Clonus reflex
Hypercalcemia (↑10.5 mEq/L)
• Swollen & slow-moans, groans &
stones
• Constipation
• Bone pain
• Stones
• Renal calculi (kidney stones)
• Deep tendon reflexes
• Decreased DTR
• Severe muscle weakness
• Decreased HR & RR
• Increased BP
Causes of Hypercalcemia (↑10.5 mEq/L)
• Hyperparathyroidism

• Antacids

• Malignancies cancer cells

• Low phosphate
• Inverse relationship to calcium
Nursing intervention of Hypercalcemia
(↑10.5 mEq/L)
• Safety
• Lasix (furosemide) loop diuretics
• IV phosphate
• Monitor: EKG, I&O, kidney stones
• Fluids: Normal saline (↓chance of kidney
stones)
• Avoid high Ca++ foods (LSD)
• Leafy veggies: spinach, collard greensm rhubarb
• Sardines & tofu
• Dairy: cheese, milk, yogurt
• Serious case - dialysis
• Treat w/ Ca++ reabsorption inhibitors
• Aspirin, NSAIDs
Hypocalcemia (↓9.0 mEq/L)
• Trousseau’s signs
• Chvostek’s signs
• Diarrhea
• Circumoral tingling
• Tetany
• Weak bones (risk for fracture)
• Weak clotting (risk for bleeding)
• Weak heart beats (cardiac
dysrhythmias)
• Ventricular tachycardia
• You are taking a patient’s blood pressure
manually. As you pump up the cuff above the
systolic pressure for a few minutes you
notice that the patient develop a carpal
spasm. Which of the following is true?
a. A. The patient is having a normal nervous
response to an inflating blood pressure
cuff that is inflated above the systolic
pressure
b. This is known as Trousseau’s Sign and is
present in patients with HYPERcalcemia
c. This is known as Chvostek’s Sign
d. This is known as Trousseau’s Sign and is
present in patients with hypocalcemia
 Causes of Hypocalcemia (↓9.0 mEq/L)
• Low parathyroidism (PTH ↑ blood Ca++)
• Thyroidectomy (check the calcium
levels)
• Pancreatitis
• Oral meds (PTH ↑ blood Ca++)
• Laxatives, loop diuretics (furosemide)
• Corticosteroids, anti seizure (Dilantin),
phenobarbital, phosphate enemas, citrate
• Wound drain – GI wounds
• Chronic diseases – Celiac & Crohn’s disease
• Chronic kidney issues
• Diuretics & corticosteroids
• Antibiotics
• Low vitamin D & low magnesium
• Increased phosphate in the blood
Nursing intervention of Hypocalcemia (↓9.0
mEq/L)
• Food high in Ca++
• Leafy greens
• Sardines
• Dairy: cheese, milk, yogurt
• Administer meds
• Calcium acetate (Phoslo)
• IV calcium, w/ Vit D
• Aluminum hydroxide antacids (tums)
• Safety – risk for falls, fractures & bleeding &
dysrhythmias
• Teach:
• Take : calcium boosters (Mg supplements & Vit D
• Avoid: calcium depletors – laxatives, loop diuretics
Hyperphosphatemia (↑4.5 mEq/L)
• Trousseau’s signs
• Chvostek’s signs
• Diarrhea
• Circumoral tingling

• Weak bones (risk for fracture)

• Weak clotting (risk for bleeding)
• Weak heart beats (cardiac
dysrhythmias)
• Ventricular tachycardia
Causes of Hyperphosphatemia (↑4.5 mEq/L)
• Excess vitamin D
• Hyperparathyroidism
• Decreased calcium release = high
phosphorous
• Low calcium (hypocalcemia)
• Decreased excretion
Nursing intervention Hyperphosphatemia
(↑4.5 mEq/L)
• ADD it
• Vit D (cautious use w/ CKD)
• Ca++ supplements (antacids & Ca++
acetate)
• Phosphate binders
• EXCRETE it
• Loop diuretics, dialysis
• DILUTE it
• IV NS (normal saline
• AVOID
• High phosphorous foods
• Dairy, meats & beans
Hypophosphatemia (↓3.0 mEq/L)
• Swollen & slow-moans, groans &
stones
• Constipation
• Bone pain
• Stones
• Renal calculi (kidney stones)
• Deep tendon reflexes
• Decreased DTR
• Severe muscle weakness
• Decreased HR & RR
• Increased BP
Causes of Hypophosphatemia (↓3.0 mEq/L)
• Vomiting
• Antacids
• Pee
• d/t hyperparathyroidism
• d/t oncogenic osteomalacia
• Alcoholism
• Poo
• Thermal burns
• hyperglycemia
Nursing intervention of Hypophosphatemia
(↓3.0 mEq/L)
• Oral phosphorous w/ Vit D
• Ensure safety
• Risk for falls – weak bones
• Encourage eat phosphorous rich foods
• Fish, organ meats, nuts, pork,
chicken, beef
• Observe pts on TPN, for muscle pain &
weakness (rhabdomyolysis)
• <1 mEq/L – ATP order IV phosphate
• Watch Ca++ level
• EKG changes
• Check for BUN & creatinine
Who among the following has
increased risk for an electrolyte
imbalance?
a. An 8 month old with a fever of
102.3 ‘F and diarrhea
b. A 55 year old diabetic with
nausea and vomiting
c. A 5 year old with RSV
d. A healthy 87 year old with
intermittent episodes of gout
A clinical manifestation not found
in hypokalemia is:
A. Muscle weakness
B. Oliguria
C. Postural hypotension
D. Bradycardia
The nurse should expect that a
patient with mild fluid volume
excess would be prescribed a
diuretic that blocks sodium
reabsorption in the distal tubule,
such as:
A. Bumex
B. Demadex
C. HydroDIURIL
D. Lasix
Nursing intervention for a patient
with a diagnosis of hyponatremia
includes all of the following
except:
A. Assessing for symptoms of
nausea and malaise.
B. Encouraging the intake of low-
sodium liquids such as coffee or
tea.
C. Monitoring neurologic status
D. Restricting tap water intake.
To supplement a diet with foods
rich in potassium, the nurse
should recommend the addition
of:
A. Fruits such as bananas and
apricots
B. Green leafy vegetables
C. Milk and yogurt
D. Nuts and legumes
The most characteristic
manifestation of hypocalcemia
and hypomagnesemia is:
A. Anorexia and nausea.
B. Constipation
C. Lack of coordination
D. Tetany
 Activity
An 85-year-old woman is brought to the
hospital with a decreased fluid intake
for the past 4 days and weakness. She is
not in respiratory distress. Her
laboratory test results are as follows:
sodium 145 mEq/L; potassium 1.9
mEq/L; chloride 86 mEq/L.
• What fluid and electrolyte is the
patient experiencing?
• Outline the nursing plan of care to
address the patient’s fluid and
electrolyte or acid–base disorders.
• Give the rationale for the nursing
interventions for this patient.