Fluids and

Electrolytes
Imbalance
 Amount of body fluids
 Approximately 60% of adult’s weight consists of
fluid (water and electrolytes).
Factors that influence the amount of body fluid
are:
 Age.
 Gender.
 Body fat.
 Location and composition of body
fluid
Two fluid compartments in the body:
1. The intracellular space (fluid in the cells):
 Approximately two thirds of body fluid
located primarily in the intracellular space.
2. Extracellular space (fluid outside the cells):
further divided into:
Cont…

 Intravascular.
 Interstitial.
 Transcellular fluid spaces.
 The intravascular space:
 The fluid within the blood vessels
Components:
 Approximately 3 L plasma.
 The remaining 3 L is made up of cells.
 The interstitial space:
 Contains the fluid that surrounds the cell
and totals about 11 to 12 L in an adult
(Lymph is an example of interstitial fluid).
Cont…

 The Transcellular space:

 The smallest division.
 Approximately 1 L of the body
fluid ( e.g. cerebrospinal,
pericardial, pleural fluids,
sweat).
Fluids equilibrium

Leading concepts:
 Body fluid normally shifts between
the two major compartments (ICF,
ECF).surface
 Body exerts effort to maintain an
equilibrium between these spaces.
Electrolytes

 Are the active chemicals in body fluids

either:
 Cations (Positive charges eg. Na, K,
Mg, Ca).
 Anions (negative charges eg H, Ph).
 Chemical activity measured & expressed
in terms of milliequivalents (mEq/ litter)
 Have vary concentrations in ICF & ECF.
Major Electrolyte Content in Body Fluid

Extracellular Fluid (Plasma):

Cations:
 Sodium (Na) 142.
 Potassium (K) 5.
 Calcium (Ca) 5.
 Magnesium (Mg) 2.
Cont…

Anions:
Chloride (Cl) 103
Bicarbonate (HCO3 ) 26
Phosphate (HPO4 ) 2
Sulfate (SO4 )1
Intracellular Fluid

Cations:
 Potassium (K) 150
 Magnesium (Mg) 40
 Sodium (Na) 10
Anions:
 Phosphates and sulfates 150
 Bicarbonate (HCO3 ) 10
Routes of maintaining fluids

1. Kidneys.
2. Skin.
3. Lungs.
4. GI Tract.
Types of fluids

The fluids used in clinical

practice are usefully classified
in to:
 Colloids.
 Crystalloids.
 Blood products.
CONT…

Colloids:
Are the solutions that contain
large molecules that do not
pass the cell membranes.
Cont…

 When infused, they remain in

the intravascular compartment
and expand the intravascular
volume.
 It include:
1- 5% albumin
 CONT…

Crystalloids:
 Are the solutions that contain small
molecules that flow easily across the cell
membranes, allowing for transfer from the
blood stream into the cells and body
tissues.
CONT…

It is subdivided into:
 Isotonic.
 Hypotonic.
 Hypertonic.
CONT…

Isotonic:
The concentration of the
particles (solutes) is similar to
that of plasma.
It includes:
 5% dextrose in water.
 lactated Ringers solution.
 0.9% sodium chloride.
CONT…

Hypotonic:
 Hypotonic solutions have a lower
concentration of solutes compared
with isotonic solutions.
It includes:
0.45% sodium chloride
0.33% sodium chloride
0.2% sodium chloride
2.5% dextrose in water
CONT…

Hypertonic:
It is the solution that have a
higher solute concentration.
It includes:
1- 3% sodium chloride (3% NaCl).
Fluid Volume Disturbances
Fluid volume deficit (Hypovolemia)

Def: It is a state of decreased blood

volume more specifically, decrease in
volume of blood plasma.
 Pathophysiology

Fluid volume deficit(FVD) results from loss of body

fluids and occurs more rapidly when coupled with
prolonged in adequate intake.
Causes include:
 Haemorrhage.
 Abnormal fluid losses from vomiting, diarrhoea,
GI suctioning, sweating.
 Decreased intake, as in nausea or inability to gain
access to fluids.
Clinical Manifestations

 Decreased skin turgor.

 Oliguria.
 Concentrated urine.
 Postural hypotension.
 Weak rapid heart Rate.
 Increased temperature.
 Assessment and Diagnostic Findings

 General observation.
 Lab data.
Medical management

 When the deficit is not severe, the oral route is

preferred, provided that the patient can drink.
 When fluid losses are acute or severe, the IV
route is required.
 Accurateand frequent assessment to determine
when therapy should be slowed to avoid
volume overload.
 Therate of fluid administration is based on the
severity of loss.
 Frequent
assessment of the RFT for sever
FVD with oliguria.
 Nursing Management
 Measures fluid intake and output at least every
8 hours, and sometimes hourly.
 Vital signs monitoring.
 Skin and tongue turgor.
 Evaluating lab. Data.
 Assessment of mental function.
Fluid volume excess
(hypervolemia FVE)
 Refers to an isotonic expansion of
the ECF caused by the abnormal
retention of water and sodium.
 May be related to simple fluid
overload or diminished function.
Cont...

 Contributing factors includes (heart

failure, renal failure, and cirrhosis
of the liver.
 Excessive table salts ,excessive
administration of sodium-
containing fluids
Clinical Manifestations

 Edema.
 Distended neck veins.
 Crackles.
 Tachycardia.
Cont…

 Increased blood pressure, pulse

pressure, and central venous
pressure.
 Increased weight.
 Shortness of breath and wheezing.
Assessment and Diagnostic
Findings

 Clinicalobservation.
 Lab. Data.
 Chest x-rays.
Pharmacologic therapy

• Diuretics.
• Hemodialysis.
• Nutritional therapy.
– Dietary restriction of sodium(6
to 15 g).
Nursing Management

 Measures intake and output at

regular intervals.
 Weighed daily (0.9 kg/ day
Consider fluid retention).
 Assess breath sounds at regular
intervals in at-risk patients.
 Monitors the degree of edema.
Electrolyte Imbalances

Significance of sodium:
 Most abundant electrolyte (135 to 145 mEq/L)
 necessaryfor muscle contraction and the
transmission of nerve impulses.
 Determinant of ECF osmolality.
Sodium deficit (hyponatremia)

 Causes of lost may be vomiting, diarrhoea,

sweating, the use of diuretics, particularly with
a low-salt diet & deficiency of aldosterone.
 Poor parenteral fluids.
 Irrigation of nasogastric tubes with water
instead of normal saline solution.
 Drinking (psychogenic polydipsia).
 Clinical Manifestations

 Depend on the cause (poor skin turgor, dry mucosa,

decreased saliva production, orthostatic fall in
blood, nausea, abdominal cramping, neurologic
changes, including altered mental status, are
probably related to the cellular swelling and
cerebral edema.
 If Na is < (115 mmol/L)→ signs of increasing
intracranial pressure, such as lethargy, confusion,
muscle twitching, hemiparesis, papilledema, and
seizure.
Assessment and Diagnostic
Findings

 Clinically.
 Lab data.
Medical Management

 Sodium replacement.
 Water restriction.
Nursing Management

• Identify patients at risk for hyponatremia.

• Abnormal losses of sodium or gains of water
are noted.
• GI manifestations, such as anorexia, nausea,
vomiting, and abdominal cramping, are also
noted.
• Alert for central nervous system changes such
as lethargy, confusion, muscle twitching, and
seizures.
 Sodium excess (hypernatremia)

Pathophysiology:
• The common cause of hypernatremia is fluid
deprivation in unconscious patients.
• Administration of hypertonic enteral feedings
without adequate water supplements.
• Watery diarrhoea and greatly increased insensible
water loss (hyperventilation, effects of burns).
• Diabetes insipidus.
Clinical Manifestations

 Primarily neurologic (restlessness and weakness in

moderate hypernatremia, disorientation, delusions,
and hallucinations in severe hypernatremia.
 Dehydration.
 Ifhypernatremia is severe, permanent brain damage
can occur.
 Thirstis strong defender of serum sodium levels in
healthy.
Medical Management

 Measures to lower the serum sodium

level (hypotonic or isotonic electrolyte
solution eg, 0.3% sodium chloride).
Nursing Management

 Careful monitoring of Fluid losses and gains.

 Inrisky patient we should assess (abnormal losses of
water, low water intake, large Na intake, medications
with a high sodium content, increase thirst or elevated
body temperature.
 Carful monitoring for changes in behaviour, such as
restlessness, disorientation,and lethargy.
Potassium

Significance of potassium:
 98% ICF & 2% ECF.
 Important in muscle activity.
 Concentration ranges from 3.5 to 5.5
mEq/L.
 80% through excreted kidneys.
 20% is lost through bowel and sweat.
 Potassium deficit (hypokalemia)

Causes:
 Gastrointestinal losses.
 Hyperaldosteronism lead to severe potassium depletion.
 Diuretics.
Clinical Manifestations

 Clinicalsigns develop below level of 3 mEq/L .

Include fatigue, anorexia, nausea, vomiting, muscle
weakness, leg cramps, decreased bowel motility and
parethesia.
 Ifprolonged, result in an inability of the kidneys to
concentrate urine ( polyuria, nocturia) and excessive
thirst.
 Assessment and Diagnostic
Findings

 Proper history.
 Clinical finding.
 Lab data.
Management

 Increased intake in the daily diet. If mild

to moderate symptoms can be treated with
oral replacement.
 IV replacement for sever symptoms (40 to 80
mEq/day).
 As it is life-threatening, the nurse needs to
monitor for early S&S in patients at risk.
 Potassium excess (hyperkalemia)

Etiology:
 More dangerous ( arrest).
 More common with renal insufficiency.
 Haemolysis of the sample before analysis.
 Drawing blood above a site of K infusion.
 Clinical Manifestations

 Itaffect the myocardium more significant at a

concentration above 7 mEq/L(7 mmol/L)
 Manifestation includes: prolong PR interval until
disappearance with continuous rise, prolonged QRS
complex, ventricular dysrhythmias and cardiac arrest
may occur at any point in this progression.
 Severe hyperkalemia causes skeletal muscle
weakness, paralysis, related to a depolarization
block in muscle.
 With very high serum potassium levels Paralysis
of respiratory and speech muscles can also occur.
 Additionally, GI manifestations, such as nausea,
intermittent intestinal colic, and diarrhoea.
 Assessment and Diagnostic Findings

 Patient history.
 Clinically.
 Lab data.
Medical Management

 An immediate ECG should be obtained to detect

changes ( Peaked T waves).
 Innon acute situations, restriction of dietary
potassium & potassium-containing medications.
 Emergency therapy

 With dangerously level it may be necessary to

administer IV calcium gluconate to antagonize the
action of hyperkalemia on the heart (lasting about
30 minutes).
 Caution ECG monitoring during administration of
Ca for bradycardia which is an indication to stop
the infusion.
 IV administration of regular insulin and a hypertonic
dextrose for 30 minutes to several hours.
 Dialysis.
 Periodic check of serum K levels and monitoring of
at risk patients.