Adult Health Nursing -1

Fluid and Electrolyte

Imbalance
 Objectives
• At the end licture the students will be able
to
• Fluid and Electrolyte Balance
• Homeotasis, positive and negative
feedback
• System involved in feedback mechanism
• Fluid regulations mechanism
• Classification of body Fluids
 FLUID AND ELECTROLYTE
BALANCE
• Fluid and electrolyte balance is a dynamic
process that is crucial for life and
homeostasis.
• Fluid occupies almost 60% of the weight
of an adult.
• Body fluid is located in two fluid
compartments: the intracellular space and
the extracellular space.
• Electrolytes in body fluids are active
chemicals or cations that carry positive
 Cont'd
• Electrolytes in body fluids are active
chemicals or cations that carry positive
charges and anions that carry negative
charges.
• The major cations in the body fluid are
sodium, potassium, calcium,
magnesium, and hydrogen ions.
• The major anions are chloride,
bicarbonate, sulfate, and proteinate ions.
 Homeostasis
• Homeostasis
• Homeostasis is the dynamic process in
which the body maintains balance by
constantly adjusting to internal and
external stimuli.Homeostasis
• Negative and Positive Feedback
• Feedback is the relaying of information
about a given condition to the appropriate
organ or system.
Negative and Positive Feedback

• Negative feedback.
• Negative feedback occurs when the
body reverses an original stimulus for
the body to regain physiologic balance.
• Positive feedback
• . Positive feedback enhances or
intensifies the original stimulus.riginal
 Cont'd
• Example.
• Blood pressure control and maintenance
of normal body temperature are examples
of negative feedback while blood clotting
after an injury and a woman in labor are
examples of positive feedback.
Systems involved in Feedback
• The major systems involved in feedback
are the nervous and endocrine systems.
• Nervous system.
• The nervous system regulates
homeostasis by sensing system deviations
and sending nerve impulses to appropriate
organs.
• Endocrine system. The endocrine
system uses the release and action of
hormones to maintain
 Body Fluids.
• Fluids make up a large portion of the body,
which is approximately 50%-60% of the
total body weight.
• Location of Fluids
• Main compartments
• .Body fluids are divided between two main
compartments: the intracellular fluid and
the extracellular fluid compartments.
 Cont'd
• Intracellular fluid
• . Intracellular fluid functions as a stabilizing
agent for the parts of the cell, helps
maintain cell shape, and assists with
transport of nutrients across the cell
membrane, in and out of the cell.
• Extracellular fluid.
• Extracellular fluid mostly appears as
interstitial tissue fluid and intravascular
fluid.
Fluid Regulation Mechanisms
• The thirst center.
• The thirst center in the hypothalamus
stimulates or inhibits the desire for a
person to drink.
• Antidiuretic hormone.
• ADH regulates the amount of water the
kidney tubules absorb and is released in
response to low blood volume or in
response to an increase in concentration
of sodium and other solutes in the
 Cont'd
• The RAA system
• . The RAA system controls fluid volume, in
which when the blood volume decreases,
blood flow to the renal juxtaglomerular
apparatus is reduced, thereby activating
the RAA system.
• Atrial natriuretic peptide
• . The heart also plays a role in correcting
overload imbalances, by releasing ANP
from the right atrium.
 Normal Intake and Output
• Daily intake
• . An adult human at rest takes appropriately 2,500 ml
of fluid daily.
• Levels of intake. Approximate levels of intake
include fluids 1, 200 ml, foods 1, 000 ml, and
metabolic products 30 ml.
• Daily output. Daily output should approximately
equal in intake.
• Normal output. Normal output occurs as urine,
breathing, perspiration, feces, and in minimal
amounts of vaginal secretions.
 Overhydration and Edema
• Overhydration. Overhydration is an
excess of water in the body.
• Edema. Edema is the excess
accumulation of fluid in interstitial tissue
spaces, also called third-space fluid.
• Cause of edema. Edema is caused by a
disruption of the filtration and osmotic
forces of the body’s circulating fluids.
• Treatment of edema. Diuretics are
commonly given for systemic edema.
 Dehydration
• Dehydration is a deficiency of body water
or excessive loss of water.
• External causes
• .External causes of dehydration include
prolonged sun exposure and excessive
exercise, as well as diarrhea, vomiting,
and burns.
• Treatment of dehydration. Supplemental
fluids and electrolytes are often
adminstered.
 ELECTROLYTES
• An electrolyte is a substance that will
disassociate into ions when dissolved in
water.
• Origins
• . Electrolytes are found in the form of
inorganic salts, acids, and bases.
• Active chemicals
• . Electrolyte concentrations are measured
according to their chemical activity and
expressed as milliequivalents.
 Cont'd
• Ions.
• Each chemical element has an electrical
charge, either positive or negative.
• Intracellular electrolytes.
• Important intracellular electrolytes are
potassium, magnesium, sulfate, and
phosphate, and the most dominant cation
iss potassium while the most dominant
anion is phosphate.
 Cont'd
• Extracellular electrolytes.
• Important extracellular electrolytes include
sodium, chlorine, calcium, and
bicarbonate, and the most essential cation
is sodium while chlorine is the most
important anion.
 Fluid and Electrolyte Transport
• Total electrolyte concentration affects the body’s fluid
balance.
• The body cells. Nutrients and oxygen should enter
body cells while waste products should exit the body.
• The cell membrane.
• The cell membrane separates the intracellular
environment from the extracellular environment.
• Permeability.
• The ability of a membrane to allow molecules to
pass through is known as permeability.
 Permeability of Membranes
• Freely permeable membranes
• These membranes allow almost any food
or waste substance to pass through.
• Selectively permeable.
• The cell membrane is selectively
permeable, meaning that each cell’s
membrane allows only certain specific
substances to pass through.
 Passive Transport
• Passive transport. Passive transport
mechanisms include diffusion, osmosis,
and filtration.
• Diffusion. Diffusion, or the process of
“being widely spread”, is the random
movement of molecules from an area of
higher concentration to an area of lower
concentration.
• Filtration. Filtration is the transport of
water and dissolved materials
 Cont'd
• Osmosis.
• Osmosis is the diffusion of a pure solvent,
such as water, across a semipermeable
membrane in response to a concentration
gradient in situations where the molecules
of a higher concentration are non
diffusible.
 Active Transport
• Mechanisms
• . Active transport mechanisms require
specific enzymes and an energy
expenditure in the form of adenosine
triphosphate (ATP).
• Processes. Active transport processes
can move solutes “uphill”, against the
normal rules of concentration and
pressure.
 Fluid and Electrolyte Balance
• Fluid and electrolyte balance is vital for
proper functioning of all body systems.
• Osmolarity.
• This is the property of particles in a
solution to dissociate into ions.
• Electroneutrality.
• This is the balance of positive and
negative charges.
 Acid-Base Balance
• Acid-base balance is another important
aspect of homeostasis.
• Acid, Bases, and Salts
• Acid. An acid is one type of compound
that contains the hydrogen ion.
• Base.
• A base or alkali is a compound that
contains the hydroxyl ion.
 Cont'd
• Salt.
• A salt is a combination of a base and an
acid and is created when the positive ions
of a base replace the positive hydrogen
ions of an acid.
• Important salts
• The body contains several important salts
like sodium chloride, potassium chloride,
calcium chloride, calcium carbonate,
calcium phosphate, and sodium
 Potential of Hydrogen
• pH. The symbol of pH refers to the
potential or power of hydrogen ion
concentration within the solution.
• Low pH. If the pH number is lower than 7,
the solution is an acid.
• High pH. If the pH is greater than 7, a
solution is basic or alkaline.
• Neutral pH. If the pH is 7, then the
solution is neutral.
 Cont'd
• Changes.
• A change in the pH of a solution by one pH unit
means a tenfold change in hydrogen
concentration.
• Buffers
• A buffer is a chemical system set up to resist
changes, particularly in hydrogen ion levels.
• Bicarbonate buffer system. Sodium
bicarbonate and carbonic acid are the body’s
major chemical buffers.
 Cont'd
• Carbon dioxide.
• The major compound controlled by the lungs is
CO2, and the respiratory system can very rapidly
compensate for too much acid and too little acid
by increasing or decreasing the respiratory rate,
thereby altering the level of CO2.
• Bicarbonate. Bicarbonate ions are basic
components in the body, and the kidneys are key
in regulating the amount of bicarbonate in the
body.
 Cont'd
• Measurement of arterial blood gas.
• The pH level and amounts of specific gases in the
blood indicate if there is more acid or base and
their associated values.
• Respiratory acidosis.
• Respiratory acidosis occurs when breathing is
inadequate and PaCO2 builds up.
• Metabolic acidosis. In metabolic acidosis,
metabolism is impaired, causing a decrease in
bicarbonates and a buildup of lactic acid.
 Cont'd
• Metabolic alkalosis.
• Metabolic alkalosis occurs when
bicarbonate ion concentration increases,
causing an elevation in blood pH.
 Classification
• There are different fluid volume
disturbances that may affect an individual.
• Fluid volume deficit or hypovolemia
occurs when loss of ECF volume exceeds
the intake of fluid.
• Fluid volume excess or hypervolemia
refers to an isotonic volume expansion of
the ECF caused by the abnormal retention
of water and sodium in approximately the
same proportions in which they normally
 Cont'd
• Disturbances in electrolyte balances are common
in clinical practice and must be corrected.
• Hyponatremia refers to a serum sodium level that
is less than 135 mEq/L
• Hypernatremia is a serum sodium level higher
than 145 mEq/L.
• Hypokalemia usually indicates a deficit in total
potassium stores.
• Hyperkalemia refers to a potassium level greater
than 5.0 mEq/L.
 Cont'd
• Hypocalcemia are serum levels below 8.6
mg/dl.
• Hypercalcemia is calcium level greater than
10.2 mg/dl.
• Hypomagnesemia refers to a below-normal
serum magnesium concentration.
• Hypophosphatemia is indicated by a value
below 2.5 mg/dl.
• Hyperphosphatemia is a serum phosphorus
level that exceeds 4.5 mg/dl in adults.
 Pathophysiology
• Nurses need an understanding of the
pathophysiology of fluid and electrolyte balance
to anticipate, identify, and respond to possible
imbalances.
• Concentrations. Electrolyte concentrations
vary from those in the ICF to those in the ECF.
• Sodium.
• Sodium ions outnumber any other cations in the
ECF; therefore it is essential in the fluid
regulation of the body.
 Cont'd
• Potassium.
• The ECF has a low concentration of
potassium and can tolerate only small
changes in its concentrations..
• Maintenance. The body expends a great
deal of energy in maintaining the sodium
and potassium concentrations through cell
membrane pumps that exchange sodium
and potassium ions.
 Cont'd
• Osmosis. When two different solutions
are separated by a membrane that is
impermeable to the dissolved substances,
fluid shifts from the region of low solute
concentration to the high solute
concentration until the solutions are of
equal concentrations.
• Diffusion. Diffusion is the natural
tendency of a substance to move in an
area of higher concentration to an area of
 Causes
• Fluid retention. Retention of sodium is
associated with fluid retention.
• Loss of sodium. Excessive loss of
sodium is associated with decreased
volume of body fluid.
• Trauma. Trauma causes release of
intracellular potassium which is extremely
dangerous.
• Loss of body fluids. FVD results from
loss of body fluids and occurs more rapidly
 Cont'd

• 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.
 Cont'd
• Medications.
• There are certain medications that could
lead to electrolyte imbalances when taken
against the physician’s orders.
 Clinical Manifestations
• Signs and symptoms that occur in fluid
and electrolyte imbalances are discussed
below.
• 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
 Cont'd
• 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.
 Cont'd
• Hypernatremia.
• The signs and symptoms are thirst,
elevated body temperature, hallucinations,
lethargy, restlessness, pulmonary edema,
twitching, increased BP and pulse.
• Hypokalemia.
• Clinical manifestations are fatigue,
anorexia, muscle weakness, polyuria,
decreased bowel motility, paresthesia,
ileus, abdominal distention, and
 Cont'd
• 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.Cont'd
 Cont'd
• 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.
• Hypomagnesemia
• . Clinical manifestations include neuromuscular
irritability, positive Trousseau’s and Chvostek’s
sign, insomnia, mood changes, anorexia,
vomiting, and increased deep tendon reflexes.
 Cont'd
• 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
 Cont'd
• Hyperphosphatemia.
• Clinical manifestations are tetany,
tachycardia, anorexia, nausea and
vomiting, muscle weakness, and
hyperactive reflexes.
 Complications
• Fluid and electrolyte imbalances could
result in complications if not treated
promptly.
• 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.
 contin...
• Cardiac arrest. Too much potassium
administered could lead to cardiac
arrest.esult
 Assessment and Diagnostic
Findings
• BUN. BUN may be decreased in FVE due
to plasma dilution.
• Hematocrit. Hematocrit levels in FVD are
greater than normal because there is a
decreased plasma volume.
• Physical examination.
• Physical exam is necessary to observe the
signs and symptoms of the
imbalances.Assessment
 Cont'd
• Serum electrolyte levels. Measurement
of electrolyte levels should be performed
to check for presence of an imbalance.
• ECG. ECG changes can also contribute to
the diagnosis of fluid and electrolyte
imbalance.
• ABG analysis. ABG analysis may reveal
acid-base imbalances.Cont'd
 Medical 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
 Cont'd
• 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 therapy
• AVP receptor agonists
• . These are new pharmacologic agents
that treat hyponatremia by stimulating free
water excretion.
• Diuretics.
• To decrease fluid volume in FVE, diuretics
are administered.
 Cont'd
• 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
• Nurses may use effective teaching and
communication skills to help prevent and
treat various fluid and electrolyte
disturbances.
• Nursing Assessment
• Close monitoring should be done for
patients with fluid and electrolyte
imbalances.
 contin...
• 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.
 Cont'd
• Physical exam.
• Physical exam is needed to reinforce
other data about a fluid or electrolyte
imbalance.
 Cont'd
• Diagnosis
• The following diagnoses are found in
patients with fluid and electrolyte
imbalances.
• Excess fluid volume related to excess
fluid intake and sodium intake.
• Deficient fluid volume related to active
fluid loss or failure of regulatory
mechanisms.
 Cont'd

• Imbalanced nutrition: more than body

requirements related to excessive intake.
• Diarrhea related to adverse effects of
medications or malabsorption
• I&O
• .The nurse should monitor for fluid I&O at
least every 8 hours, or even hourly.
Nursing Care Planning & Goals
• 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 Interventions
• There are specific nursing interventions for
fluid and electrolyte imbalances that can
aid in alleviating the patient’s
• 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
 Cont'd
• 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
 Cont'd
• Diet.
• The nurse must encourage intake of
electrolytes that are deficient or restrict
intake if the electrolyte levels are
excessive.
• Evaluation
• Evaluation of the care plan can check the
effectiveness of the treatments. The
interventions are deemed effective if the
client has:
 Evaluation cont'd
• 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.
 Discharge and Home Care
Guidelines
• After hospitalization, treatment and maintenance
of the condition must continue at home.
• Diet. A diet rich in all the nutrients and electrolytes
that a person needs should be enforced.
• Fluid intake. Fluid intake must take shape
according to the recommendations of the
physician.
• Follow-up. A week after discharge, the patient
must return for a follow-up checkup for evaluation
of electrolyte and fluid status.
 Cont'd
• Medications
• . Compliance to prescribed medications
should be strict to avoid recurrence of the
condition.
 Documentation Guidelines
• Data should be documented for future medical
and legal references. The nurse must
document:
• Individual findings, including factors affecting
ability to manage body fluids and degree of
deficit.
• I&O, fluid balance, changes in weight, urine
specific gravity, and vital signs.
• Results of diagnostic testing and laboratory
studies.
 Cont'd
• Plan of care.
• Client’s responses to treatment, teaching,
and actions performed.
• Attainment or progress toward desired
outcome.
• Modifications to plan of care.