Fluidand

Electrolyte
NUR 108 - Spring
2014

Learning Outcomes
1.

Discuss the function, distribution, movement,

and regulation of fluids and electrolytes in the
body.

2.

Identify factors affecting normal body fluid,

electrolyte and acidbase balance.

3.

Discuss the risk factors and causes and effects

of fluid and electrolyte imbalance

4.

Collect assessment data related to the clients

fluid and electrolyte

6.

Identify examples of nursing diagnoses,

outcomes, and interventions for clients with
altered fluid & electrolyte

Fluid Regulation
Fluids move through the body by:

Osmosis

Diffusion

Filtration

Active transport

Regulated by fluid Intake & Output

Regulated by the movement of substances

dissolved in water and its movement

between body compartments

Diffusion

Movement of molecules through a

semipermeable membrane from an area of
higher concentration to an area of lower
Copyright 2012 by Pearson
concentration.

Osmosis

Water molecules move from the less

concentrated area to the more
concentrated area, attempting to equalize
the concentration of solutions on two sides
Copyright
2012 by Pearson
of a membrane.

Active Transport

ATP energy is used to move Na and K molecules

across a semipermeable membrane against their
concentration gradients from a < concentration area
to one of > concentration.

Filtration

Arterial blood pressure > colloid osmotic pressure, so that

water and dissolved substances move out of the capillary into
the interstitial space.
Venous blood pressure is < colloid osmotic pressure, so that
water and dissolved substances from the interstitial space
move into the capillary.

Osmotic Pressure

Osmolality/Osmolarity is the concentration of a

solution which creates osmotic pressure

Osmolality: concentration of solutes per Kg/water
Osmolarity: concentration of solutes per L/sol.

Osmotic (oncotic) pressure is the pulling force of

a solution for water

Osmolality pressure: 275 295 mOsm/L
Adult: 285 295 mOsm/L
Child: 275 290 mOsm/L

Osmotic Pressure

Plasma protein (albumin) in blood exert oncotic

pressure that opposes the hydrostatic pressure

and holds fluid in the vascular compartment to
maintain vascular volume.
Osmotic pressure will hold fluids in the vascular

system but increased hydrostatic pressure is

higher than the osmotic pressure and causes fluid
to filter out.
Sodium major solute in plasma
Urea (BUN) & Glucose - increases serum

osmolality when present in large amts.

Isotonic
Isotonic has same osmolality as

normal plasma
Used to replace extracellula fluids
Expand vascular volume quickly
N.S., Ringers sol., Lactated

Ringers (LR)
D5W: (becomes hypotonic when

metabolized and expands

intra/extracellular fluids)

Hypotonic
Hypotonic has lower osmolality

than normal plasma < 290

Water is pulled out of blood vessels

into the cells

Decreases vascular vol.
O.45% NS,

0.225% NS

Used to prevent cellular dehydration

Monitor VS, LOC, circulatory

depletion, cerebral edema. DO NOT

Hypertonic
Hypotonic has higher osmolality than

normal plasma < 290

Causes fluids to shift from cells into

vascular compartment, promotes diuresis

Increases vascular volume
3%NS, 5%NS
Monitor for vascular overload, urine

output, lung sounds, neuro status, serum

sodium levels

Colloid Solutions
Colloid large solute (protein), that does

not pass tjrough cell or capillary

membranes
Hypertonic Volume expanders
Increases colloids increases osmolality
Pulls fluid from tissue into blood vessels by

osmosis
Albumin 25%, Dextran, Hetastarch
Manitol or Osmmitrol pulls fluid from

third spaces, tissues and cells into blood

Regulation of Body Fluid

Homeostasis regulates the volume &

composition of body fluids

Renal system
Endocrine system
Cardiovascular system
Respiratory system
Gastrointestinal system

Regulating Body Fluids

Fluid intake
Thirst

mechanism
Fluid output
Urine
Insensible

loss
Feces

Maintaining

homeostasis
Kidneys
ADH
Renin-

angiotensinaldosterone
system
Atrial natriuretic

Regulating Body Fluids

Fluid intake balances fluid loss
Thirst mechanism if the primary regulator of fluid

intake
*Fluid is lost through 4 routes:
Urine (1400-1500 mL/24 hrs.)
Skin perspiration (350-400 mL)
Lungs (350-400 mL by water vapor)
Intestines (chyme 1500 mL)

At least 500 mL of fluid is obligatory lost by

Chemical Regulation of
Fluids
ADH
is released when BP or blood
volume decrease (or osmolality inceases)
Results in renal reabsorption of water to

increase vascular volume

Aldosterone conserves sodium
Kidneys retain Na and excrete K

Glucocorticoids promote renal retention

of sodium and water

Chemical Regulation of
Atrial
Natriuretic Peptide (ANP) lowers
Fluids
blood volume by:

Causing vasodilation or
Suppressing of the renin-angiotensin

system
Brain Natriuretic Peptide (BNP) decreases

blood volume by:

Vasodilating arteries and veins
Decreasing the release of aldosterone
Diuresis & excretion of Na and H2O

Distribution of Body
Fluids
1. Intracellular

(ICF)

Inside cell
2/3 total body
fluids

Copyright 2012 by Pearson

2. Extracellular
(ECF)
Outside the cell
1/3 total body
fluids
intravascular
20%
interstitial 75%

Body Fluids
Transcellular fluids:
CSF
Lymph fluid
Biliary fluid
Pancreatic fluids
Intraocular fluid
Peritoneal fluids
Synovial fluid

These fluids are vital to normal cell

Distribution of Body Fluids

in Infants
Adult

ECF 15-20%
ICF 40-45%

Infant

ECF 45%
ICF 35%

Infants have a higher percentage of

interstitial fluid
Full-term newborn body wt approx. 80%
Premature infant approx. 90%
Adult (from puberty to age 60) 60%
Elderly (> 60 yrs) 45%

Functions of Body Fluids

Water is vital to health & normal cellular

function
A vital medium for metabolic reactions
Transports nutrients, waste products,

hormones, other substances

Acts as a lubricant, insulator and shock

absorber
Regulates body temperature
Aids in digestion & peristalsis

Sources of Body Water

*Sources

of body water

Ingested liquids & foods

Tube feeding & parenteral liquids
Oxidation of foods & body tissues

Avenues of normal loss of body water

Kidneys & intestinal tract
Skin evaporation of perspiration
Exhaled moisture through lungs

Types of Water Losses

Vomiting

Paracentesis

Burns

Loss of injured

Wound

exudate
Gastric suction
Colitis
Stools
Urine

spaces as edema
Third spacing

intestinal pooling
Draining intestinal

fistulae
Drainage tubes

Third-spacing of body fluids

Body fluids shift into a body space that is

not easily exchanged with the ECF

Produces fluid vol. deficit
Produces fluid vol. excess in space

unavailable for body use

Pleural, peritoneal, pericardial, joint

cavity, interstitial space, tissue (edema),

Third-space fluid loss cannot be measured

Clinical Manifestation
of Third-spacing

Ascites 5-10 L or more larger amts.

Acute peritonitis - 4-6 L in 24 hrs.
Pancreatitis - 6-10 L
Burns - fluid loss in 1st 48-72 hrs.
Pleural effusion
Crushing injuries
Blockage of lymphatic system
Hypoalbuminemia - osmotic pull of plasma

proteins

Causes of Third Spacing

Injury or inflammation caused by trauma
Malnutrition - low protein albumin in

starvation
Liver dysfunction Cirrhosis
High vascular hydrostatic pressure from

heart failure, ESRD, vascular fl. overload

Clinical Manifestation of
Fluid Volume Deficit (FVD)

Tachycardia, hypotension r/t reduced blood

volume
Decreased urine volume 30 mL
Postural hypotension
Low central venous pressure
Poor skin turgor and tongue turgor

Dehydration Concept
Isotonic dehydration: involves equal losses

of all fluid components

Hypotonic dehydration: involves greater

losses of electrolytes
Decreases osmolality, ECF decreases

Hypertonic dehydration: involves greater

losses of ECF volume that electrolytes

Increases osmolality

Assessing Dehydration
Thirst, or excessive thirst
Urine concentration, dark, low urine volume
Specific gravity > 1.030
Dry skin, dry mucous membranes
Decrease turgor & skin elasticity
Sunken eyes, sunken fontaneles < 18 mo.
Hypotension, postural hypotension
Weakness, lightheadedness, syncope
Acute weight loss

Diagnostic Lab Values

Hemoconcentration plasma is more

concentrated than normal

Elevated Hct, BUN, Sodium, Glucose
Elevated specific gravity
Elevated osmolality (> 300 mOsm/Kg)

Risk Factors
Age: Infants and Elderly
Gender and body fat
Obesity (fat holds less water than muscle)
Acute illness: gastroenteritis (n/v), burns,

stokes, SIADH causing diabetes insipidus

Surgery resulting in fluid or blood loss
NG suctioning; Large wound drainage
Liver disease, renal disease, DM
Medications and excess alcohol consumption
Heat exposure, malnutrition

Nursing Diagnoses
Fluid volume deficit/excess r/t excessive fluid

loss or decrease fluid intake

Risk for deficient fluid volume r/t N/V
Risk for hypovolemic shock r/t fluid loss
Risk for injury r/t altered sensorium/or

dizziness
Risk for impaired skin integrity r/t skin and

mucous membrane dryness

NANDA Nursing Diagnoses

Fluid & Electrolyte Imbalances as evidence

of: (etiology)

Impaired Oral Mucous Membrane

Impaired Skin Integrity
Decreased Cardiac Output
Activity Intolerance
Risk for Injury
Acute Confusion

Nursing Interventions
Monitor VS, & mucous membranes
Monitor lung sounds
Monitor mental status
Monitor I&Os and IV fluids
Monitor urine status
Oral or parenteral replacement of fluids
Monitor IV fluids (prevent overload)

Electrolytes

Regulating Electrolytes
Sodium - Na
Potassium - K
Calcium - Ca
Magnesium - Mg
Chloride - Cl
Phosphate - PO4
Bicarbonate - HCO3

Sodium (Na)
135-145 mEq/L -

Hyper/Hyponatremia
Most abundant electrolyte in ECF
Contributes to serum osmolality

has a profound effect on cellular

dehydration
Reasorbed or excreted by kidneys
Pulls chloride and water along with

it

Risk Factors: Sodium

Imbalance
Infants:
immature kidneys up to age 2
Lose more fluid via skin for their size than

adults
High BMR, produce more heat, req. more water

Elderly: have less water composition

Less muscle mass & more fat composition
Kidneys function decreases, cannot

compensate imbalances or excrete heavy

solute loads (tube feedings)
Diminished thirst, pancreatic function & glucose

tolerance

Assess Sodium Imbalance in:

GI, Post-op, cancer, wounds fluid loss, n/v,

diarrhea, NG suction
Burns loss of fl & electrolytes thru tissue

damage
Brain trauma CVA, tumors, cerebral edema,

altered ADH regulation

Liver disease altered serum albumin
Renal disease decrease output, altered fl. &

electrolytes
DM osmotic changes in hyper-hypoglycemia

Potassium (K)
Serum: 3.5 5.0 mEq/L

Hper/Hypokalemia

ICF: 125-140 mEq/L

Major intracellular fluid cation
Vital for muscular & cardiac function
Aids in maintaining acid-base balance
Daily injestion needed
Foods: fruits, vegetables, meats, fish and

salt substitutes

Assess Potassium Imbalance

in:
Use of potassium-wasting diuretics
Excessive GI loss
Starvation, bulimia
Hyperglycemia; Diabetes insipidus, Cushings

syndrome
Increase aldosterone: heart failure,

hypertensive crisis, cirrhosis, renal disease

Heat-induced diaphoresis

Treatment:
Potassium replacement in hypokalemia
Medication: black

box
Monitor labswarning
Monitor V.S, cardiac status (teley or monitor)
IV infusion: K is a vesicant; causes phlebitis

& tissue necrosis (avoid IVP or IM)

P.O. never crush or break tab/capsules,

adm. after meals to prevent GI upset

Avoid salt substitutes

Hyperkalemia > 5
mEq/Lof K as a result of
Retention
decreased or inadequate urine
output
Excessive release of K from the cells

due to traumatic injury, burns, cell

lysis, acidosis
Excessive infusion of IV solutions

containing K
Various drugs

Causes of Hyperkalemia
Blood transfusions
Drugs
Beta-blockers, K sparing diuretics, NSAIDs,

Aminoglycosides, Chemotherapy

Increased dietary intake with decreased urine

output

Excessive salt substitute or K supplements

Acute or chronic renal failure, Diabetes
Burns, severe infections, trauma, crush

injuries

Metabolic acidosis, Insulin deficiency

S/Sx of Hyperkalemia
Neuromuscular alerts
Muscle weakness in lower extremities
Flaccid paralysis
Muscle hyperactivity or Irritability,

Cardiac Alerts

HR, BP, cardiac output, arrhythmias, cardiac arrest

GI Problems
Nausea, explosive diarrhea, abdominal

cramping

GU Problems: oliguria, anuria

Assessment of Diagnostic Tests

Serum K greater then 5 mEq/L
Decreased arterial pH, (indicating acidosis)
ECG abnormalities:

Arrhythmias

ECG changes:
Tall,

tented T wave

Flattened

P wave

Prolonged
Widened

PR interval

QRS complex

Depressed

ST segment

Treatment
In Mild cases
Loop diuretics;

Restricted dietary K

In Moderate to Severe cases

Acute symptomatic cases need hemodialysis
Kayexalate with sorbitol - results in loose BMs

Emergency measures
Monitor ECGs
Treat acidosis
Use IV regular insulin therapy
Administer IVs

Nursing Actions
Assess vital signs
Anticipate cardiac monitoring
Monitor I & O -- report output < 30 mL/hr
Adm. a slow IV infusion of Calcium

Gluconate
Assess for clinical signs of hypoglycemia
Muscle weakness
Syncope
Hunger
Diaphoresis

Calcium (Ca)
Serum: 8.5 10.5 mg/dL

hyper/Hypocalcemia
99% body Ca stored in skeletal system
Essential for muscle contraction, nerve

impulse conduction, bone & teeth rigidity,

lactation, clotting regulation in converting
prothrombin to thrombin
Regulated by PTH vs. Calcitonin hormone

Risk Factors: Calcium

Imbalance

Deficiencies in Vit. D

High intake of phosphorus, proteins

Calcium interferes with iron absorption
Rapid massive infusions of blood

transfusions
Citrate toxicity leading to hypocalcemia

Alcoholism

Assess Calcium Imbalance in:

Neuromuscular irritability
Trousseaus sign- carpal spasms w BP cuff

inflation
Chvosteks sign facial nerve tapping causes

twitching
Post-menopausal women
Osteoporosis, osteopenia; Ricketts disease
Post- thyroidectomy, parathyroidectomy
Chrons disease; Hypothyroidism
Immobility: clients in prolong bedrest

Hypocalcemia
Total serum Ca < 8.9 mg/dL
Ionized serum Ca < 4.5
mg/dL

Insufficient intake or excessive loss

Occurs with malabsorption problems

Causes
Severe burns,

Infections
Alcoholics with

poor nutritional
intake
Renal alerts
Diuretics
Especially loop

diuretics

Drugs;

Cisplatin,
Gentamycin

Low albumin levels

Alkalosis
Breast Feeding
Pancreatic

insufficiency

Signs and Symptoms

Be alert for Neurological changes
Anxiety, Confusion, Irritability
Seizures
Twitching, muscle cramps, tremors,

tetany
Hyperactive deep tendon reflexes
Decreased cardiac output and arrhythmias

Diarrhea

Treatment
Acute hypocalcemia requires IV Ca
Mag replacement may also be needed
Chronic hypocalcemia needs vitamin D

supplement
Dietary changes
Diagnostic tests: ECG, labs

Nursing Actions
Assess for risk of hypocalcemia
Monitor vital signs, respiratory status
Cardiac monitor
Check Chvostek's and Trousseaus signs
Assess and monitor IV line and IV meds
Monitor labs
Client teaching

Hypomagnesemia
< 1.5 mEq/L

Hypermagnesemia
> 2.5 mEq/L
GI and GU systems regulate Mag levels
Must measure along with serum albumin
Must also consider Ca, K, PO4 levels and Ph
Most common risk factor of

hypermagnesemia is
Renal insufficiency

Causes of Hypomagnesemia
Poor dietary intake of magnesium
Chronic alcoholism
Prolonged IV fluids in clients on TPN

Absorption problems
Malabsorption syndromes, steatorrhea
Ulcerative colitis, Crohns disease, Bowel

resection
Pancreatic insufficiency, cancer

GI problems
Prolonged diarrhea, fistulas, laxative abuse,

Causes of
Urinary
Problems
Hypomagnesemia
Primary aldosteronism, hyperparathyroidism
Diabetic ketoacidosis
Use of amphotericin B, cisplatin,

aminoglycosides
Loop or thiazide diuretics

Other causes
Sepsis
Serious burns
Wounds requiring debridement

Signs and Symptoms

CNS

Cardiovascular

Seizures

Tachycardia

Altered LOC

Hypertension

Confusion

ECG changes

Delusions

GI tract

Depression

Anorexia

Hallucinations

Nausea

Emotional lability

Vomiting
Dysphagia

Signs and Symptoms

Neuromuscular system
Tremors, twitching, tetany
Muscle weakness, leg and foot cramps
Chvosteks sign and Trousseaus sign
Hyperactive deep tendon reflexes
muscle weakness which leads to:
Laryngeal

stridor; Respiratory

difficulties
Paresthesia

Diagnostic Tests
Evaluate serum levels < 1.5 mEq/L
Decreased serum albumin level
Decreased K or Ca
ECG changes
Elevated serum levels of cardiac

glycosides in clients receiving these drugs

Treatment
Varies with cause and degree of severity
Usually involves replacement therapy
Real important to read the label on the Mag.

Sulfate vial as it comes in more than one

concentration
Foods: sunflower seeds, legumes, dark green

leafy vegetables, cocoa, seafood whole grains

and nuts

Nursing Actions
Assess mental status, neuromuscular status,

and dysphagia
Especially check DTRs, tremors, tetany,
Chvosteks Facial twitching when the facial

nerve is tapped
Trousseaus signs - Carpal spasm when the

upper arm is compressed

Memory Jogger

S = seizures
T = tetany

A = anorexia and arrhythmias

R = rapid heart rate
V = vomiting
E = emotional lability
D = deep tendon reflexes increased

Chloride (Cl)
Hypochloremia:

< 95 mEq/L

Hyperchloremia:

> 108 mEq/L

Essential for acid-base & electrolyte balances

Cl imbalance occur with sodium imbalance
Acts as a buffer between O2 & CO2 exchange
Utilized in forming HCL acid in the stomach
Foods: table salt, eggs, milk, cheese, dates,

canned vegetables, crabs, fish, olives, rye,

turkey

Hypochloremia
Causes:
Na, K imbalances, metabolic alkalosis
Diabetic acidosis, SIADH, CHF
Acute infections
Metabolic stress conditions: burns, fevers

heat exhaustion
Vomiting, bulimia, diarrhea, tap water enemas

Treatment
Replacement therapy: appropriate foods, oral

salt tablets, or KCL tablets

IV infusions of NaCl or KCL for critical

conditions
Dietary changes
Obtain ABGs - maintain acid-base balance
Panic value: < 80 mEq/L

Nursing Interventions
Assess for:

Muscle twitching, tremors, Slow

shallow breathing, Hypotension, cardiac
symptoms, anorexia

Monitor for fluid imbalances: ECF loss,

vomiting, perspiration, diarrhea

Dietary teaching: low sodium diet, review

foods high in chloride

Hyperchloremia
Causes:
Na, K, CO2 imbalances, metabolic acidosis
Injections of drugs: salicylates,

corticosteriods, some diurectics

Dehydration states, endocrine disturbances
GI losses, renal changes
Watch for: deep rapid breathing, weakness,

lethargy, stupor, unconsciouness

Treatment
Decrease chloride intake
Withdraw chloride-containing

agents
Diuretics excretes chloride

Nursing Intervention
Monitor acid-base, respirations, cardiac status
Monitor VS and I&O

Increase fluid intake, dietary

changes
Maintain adequate hydration
IV sol. 0.45% NaCL or D5W (act as

hypotonic)
Client education: avoid foods high in chloride,

restrict processed foods

Phosphate (PO4)
A major component of ATP in cellular

metabolism
Newborns have twice the adult level
Essential for RBC, NS and muscle function
Needed for bone and teeth formation
Helps regulate calcium and renal acid-base
Role in metabolism of CHO, Proteins, fats
Foods: organ meats, meat, fish, poultry,

eggs, milk, legumes, whole grains, nuts

Hypophosphatemia
< 2.5 4.5 mg/dL or
< 1.7 to 2.6 mEq/L
Causes
Adm. Of glucose, insulin and TPN can shift

PO4 into cells from ECF

Decreased intestinal absorption from Vit. D

deficiency, malabsorption, starvation

Phosphate binders, antacids (mag.,

aluminum)
DKA, alcoholism, severe burns, resp.

alkalosis

Treatment
Labs: PO4 levels, mag, calcium
ABGs watch for metabolic acidosis
X-rays: may show skeletal changes
Replacement therapy
Avoid phosphate binders
Monitor cardiac function
Monitor for other electrolyte imbalances

Assess for:
Levels < 2.0
Anemia, bruising, bleeding
Slurred speech, confusion, seizures, coma
Muscle weakness, tremors, tetany
Chest pain, dysrhythmias r/t decreased O 2,

hypoxemia
Decreased GI functions: gastric atony, ileus
Will lead to acid-base imbalance, cardiac

arrest

Hyperphosphatemia
> 4.5 mg/dL

or

> 2.6 mEq/L

Causes
Shifting from cells into ECF
Respiratory or lactic acidosis
Rhabdomyolysis muscle dysfunction r/t

breakdown of striated muscle.

caused by heat stroke, viral infection, tissue

trauma, increased metabolic/catabolic state

Renal insuficiency
Excess vit. D; infants fed cows milk

Nursing Management
Nursing history
Physical assessment
Clinical measurement
Review of laboratory test results
Evaluation of edema
Nursing diagnosis
Planning
Implementation & Evaluation

NANDA Nursing Diagnoses

Fluid Volume Deficient
Fluid Volume Excess
Risk for Imbalanced Fluid Volume
Risk for Deficient Fluid volume

NANDA Nursing Diagnoses

Fluid & Electrolyte Imbalances as evidence of:

(etiology)

Impaired Oral Mucous Membrane

Impaired Skin Integrity
Decreased Cardiac Output
Activity Intolerance
Risk for Injury
Acute Confusion

Desired Outcomes
Maintain or restore normal fluid balance
Maintain or restore normal balance of

electrolytes
Prevent associated risks
Tissue breakdown, decreased cardiac

output, confusion, other neurologic signs

Practice Guidelines for

Facilitating Fluid Intake
Explain reason for required intake & amt.

needed

Establish 24 hour plan for ingesting fluids

Identify fluids client likes and use those
Help clients select foods that become

liquid at room temperature

Supply cups, glasses, straws

Serve fluids at proper temperature
Encourage participation in recording intake
Be alert to cultural implications

Practice Guidelines
Restricting Fluid Intake
Explain reason and amount of restriction
Help client establish ingestion schedule
Identify preferences and obtain
Set short term goals; place fluids in small

containers
Offer ice chips and mouth care
Teach avoidance of ingesting chewy, salty,

sweet foods or fluids

Encourage participation in recording intake

Evaluation of Edema

Palpate for edema over

the tibia, behind the
medial malleolus, and over
the dorsum of each foot
Copyright 2012 by Pearson

Four-point scale for

grading edema.

Nursing Interventions
Monitoring
Fluid intake and output
Cardiovascular and respiratory status
Results of laboratory tests

Assessing
Clients weight
Location and extent of edema, if present
Skin turgor and skin status
Specific gravity of urine
Level of consciousness, and mental status

Nursing Interventions
Fluid intake modifications
Dietary changes, dietary consult
Parenteral fluid, electrolyte, and blood

replacement
Other appropriate measures such as:
Administering RX medications and

oxygen
Providing skin care and oral hygiene
Positioning the client appropriately

Promoting Fluid and

Electrolyte
Consume
6-8 glasses water daily
Balance
Avoid foods with excess salt, sugar, caffeine
Eat well-balanced diet
Limit alcohol intake
Increase fluid intake before, during, after

strenuous exercise
Replace lost electrolytes

Promoting Fluid and

Electrolyte Balance
Maintain normal body weight

Learn about, monitor, manage side effects

of medications
Recognize risk factors
Seek professional health care for notable

signs of fluid imbalances

Teaching Client to Maintain

Fluid and Electrolyte Balance
Promoting & monitor fluid and electrolyte

balance

Maintaining food and fluid intake

Promote Safety
Medications
Measures specific to clients problems
Referrals
Community agencies and other sources of

help

Correcting Imbalances
Oral replacement
If client is not vomiting or experiencing

excessive fluid loss

If GI tract is intact
If gag & swallow reflexes are intact

Fluid restrictions may be necessary for

fluid retention
Vary from NPO to precise amt. ordered
Dietary changes

Oral Supplements
Potassium (KCL)
Calcium
Multivitamins
Sports drink

Parenteral fluid and electrolyte

replacement interventions are required
if oral supplements cannot be ingested

Documentation
Vital signs, I & O, rhythm strips
Assessment findings
Lab results, x-rays
Interventions and client responses
Safety measures
Client teaching

Question 1

An elderly nursing home resident has

refused to eat or drink for several days
and is admitted to the hospital. The
nurse should assess for which of the
following?

1.

Increased blood pressure

2.

Weak, rapid pulse

3.

Moist mucous membranes

4.

Jugular vein distention

Rationales 1
1.

Increased blood pressure indicates fluid

volume excess.

2.

Correct. A client that has not eaten or

drank anything for several days would be
experiencing fluid volume deficit.

3. Moist mucous membranes indicates fluid

volume excess.
4. Jugular vein distention (JVD) indicates
fluid volume excess.

Research & Present

1. Hyperkalemia vs. Hypokalemia
2. Hypernatremia vs. Hyponatremia
3. Hypercalcemia vs. Hypocalcemia
4. Hyperphoshpatemia vs. Hypophosphatemia
5. Hypermagnesemia vs. Hypomagnesemia
6. Hyperchloremia vs. Hypochloremia
7. Metabolic alkalosis
8. Metabolic acidosis

Chapter

Acid-Base
Balance

52

Regulation Acid-Base
pH Balance

Huma
n
Blood
7.4
Copyright 2012
by Pearson

Buffers
Body fluids are maintained between pH of
7.35 and 7.45 by:
Buffers
Respiratory system
Renal system:

Prevent excessive

changes

in pH

Major buffer in ECF is

HCO3 and H2CO3

Other buffers include:
Plasma proteins

Copyright 2012 by Pearson

Education, Inc.

Lungs
Regulate acid-base balance by eliminating or

retaining carbon dioxide

Does this by altering rate/depth of

respirations

Faster rate/more depth = get rid of

more CO2 and pH rises

Slower rate/less depth = retain

CO2 and pH lowers

Kidneys
Regulate by selectively excreting or

conserving bicarbonate and hydrogen ions

Slower to respond to change

Factors Affecting Body Fluid,

Electrolyte, and Acid-Base
Chronic diseases

Age
Balance
Gender

Acute conditions

Body size

Medications

Environmenta

Treatments

l temperature
Lifestyle

Extremes of age
Inability to

food

access
and fluids

Risk Factors for Electrolyte and

Acid-Base Imbalances
Chronic diseases
Cancer
CAD, CHF, CVD
Endocrine disorders (Cushings & DM)
Malnutrition
Pulmonary disease
Renal disease

Risk Factors for Electrolyte and

Trauma
Acid-Base

Imbalances

Crush injuries; Head injuries

Burns
Drug Therapy
Diuretics
Steriods
Aldactone, aldosterone inhibiting

agents

Risk Factors for Electrolyte and

Acid-Base Imbalances

Gastroenteritis

Nasogastric suctioning
Fistulas
IV Therapy - TPN

Acid-Base Imbalances
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis

Nursing History
Current history & past medical history
Diabetes mellitus
Chronic lung diseases
Medications
Functional & socioeconomic factors
Developmental factors
Fluid and Nutritional intake
Fluid output

Nursing History:
Chronic Diseases

Respiratory: COPD, Asthma, Cystic Fibrosis

Heart failure
Kidney diseases
Cushings syndrome, Addisons disease
Cancer
Malnutrition, Anorexia nervosa, Bulimia
Ileostomy

Nursing History:
Acute Conditions
Acute gastroenteritis
Bowel obstruction
Head injury or decreased LOC
Trauma: burns, crushing injuries
Surgery
Fever, draining wounds, fistulas

Nursing History:
Treatments
Chemotherapy
IV therapy and TPN
Nasogastric suction
Enteral feedings
Mechanical ventilation
Meds: Diuretic, Anti-hypertensive therapy,

Corticosteroids, NSAID drugs

Physical Assessment
Focus on the skin
Oral cavity and mucous membranes
Eyes
Cardiovascular system
Respiratory system
Neurologic status
Muscular system

Physical Assessment: SKIN

Color, temp, moist, turgor, edema
Flushed, pale
Warm, very dry or cool, diaphorectic
Poor turgor: remains tented several seconds.
Eyes: periorbital edema (puffy),
Edema: rings are tight, shoes fit tight or eave

impressions on feet
Fontanels in infants: sunken, soft vs. Bulging,

firm
Compress & inspect skin over dorsal foot,

Physical Assessment:
Oral Cavity
Make a visual inspection
Mucous membranes dry, dull in

appearance
Tongue dry with cracks

Physical Assessment:
Cardiovacular System

HR auscultate sounds, rhythm & rate

Cardiac monitor: tachycardia, bradycardia,

irregular dysrhythmias
Palpate peripheral pulses weal or thready;

bounding
B/P postural hypotension, Korotkoffs sounds
Breathing rate & patterns, depth, crackles, or

moist rales

Physical Assessment:
Neurological System

Neuro: LOC, lethargy, stupor or coma

Response to stimuli
Disoriented, confused, difficulty concentrating
Motor function: weakness, decreased motor

stregth
Deep tendon Reflex (DTP) hyperactive or

depressed

Physical Assessment:
Neurological
System
Chvosteks
sign
tap over facial nerve
Observe twitching of facial muscles
Calcium depletion

Trousseaus sign
Carpal spasm ocurring during inflation of BP

cuff
hypoclacemia

Physical Assessment:
LAB
results

Serum electrolytes
Complete blood count hematocrit, 40%-54%
Serum osmolality: Na, glucose, BUN
Urine pH 500-800 mOsm/kg.

Urine pH: Normal pH: 6.0

Urine specific gravity - Indicates urine concentration
1.010 1.025

Physical Assessment:
ABGs

Evaluates acid-base & oxygenation.

pH: 7.35 - 7.45 - acidic or alkalosis
PaO2: 80-10 mmHg PaCO2: 35-45 mmHg
HCO3-: 22-26 mEq/L
Base excess: -2 to +2 mEq/L
O2 saturation(SpO2): 95% to 98%

Respiratory Acidosis:
Hypercapnia
A state of excessive carbon dioxide in the

body.
pH < 7.35
PaCO2: > 45 mmHg (excess CO2 & carbonic

acid)
HCO3: normal, > 26 mEq/L with renal

compensation

Respiratory Alkalosis
A state of excessive loss of carbon dioxide in

the body.
pH > 7.45
PaCO2: < 35 mmHg (inadequate CO2 &

carbonic acid)
HCO3: normal, < 22 mEq/L with renal

compensation

Metabolic Acidosis
A condition characterized by a deficiency of

bicarbonate ions in the body in relation to the

amt. of carbonic acid in the body
pH < 7.35
PaCO2: normal, < 35 mmHg with respiratory

compensation
HCO3:

< 22 mEq/L (inadequate

bicarbonate)

Metabolic Alkalosis
A condition characterized by an excess of

bicarbonate ions in the body in relation to the

amt. of carbonic acid in the body
pH > 7.45
PaCO2: normal, > 45 mmHg with respiratory

compensation
HCO3: > 26 mEq/L (excess bicarbonate)

When Analyzing ABGs

Look @ each number separately
pH: acidosis vs. alkalosis
PaCO2:
If < 35 mmHg, more carbon dioxide is

being exhaled than normal alkalosis

If > 45 mmHg, Less carbon dioxide is

being exhaled than normal - acidosis

When Analyzing ABGs

HCO3 Bicarbonate:

If < 22 mEq/L, bicarbonate

levels are lower than normal,

indicting acidosis.
If > < 26 mEq/L, bicarbonate

levels are higher than normal,

indicating alkalosis.
Determine he cause of the acid-base

imbalance (look at pH)

Determine if the origin of the imbalance is

When Analyzing ABGs

Look for evidence of compensation.

Look at the value that does not

match the pH.

If PaCO2 or HCO3 is within normal range, there is no

compensation.

If PaCO2 or HCO3 is above or below normal range,

the body is compensation..

NANDA Nursing Diagnosis

Deficient or Excess Fluid Volume
Risk for Imbalanced of Deficient Fluid

Volume
Impaired Gas Exchange

NANDA Nursing Diagnosis

Fluid and Acid-base Imbalances as

evidence of: (etiology)

Impaired Oral Mucous Membrane

Impaired Skin Integrity
Decreased Cardiac Output
Ineffective Tissue Perfusion
Activity Intolerance
Risk for Injury
Acute Confusion

Planning
Maintain or restore normal fluid balance
Maintain or restore normal electrolyte balance

intracellular & extracellular compartments.

Maintain & restore pulmonary ventilation &

oxygenation.
Prevent associated risks: tissue breakdown,

decreased cardiac output, confusion, other

neurological signs.

Electrolyte Replacement
Modify fluids: push
Change diet to meet electrolyte demands
Oral electrolyte supplements
Parenteral Fluid administration