FLUID ELECTROLYTE Intravascular (IV)
(BALANCE & IMBALANCES)\ ● Within vascular space
● Measured with blood tests
Total Body Water (TBW) ● ⅓ of ECF
- Adults: 60% of TB weight in kilograms
- Infants: 70-80% of TB weight - decrease as Transcellular Fluid
the child grows older. ● Small but important compartment
● Includes:
- Fatty tissue contains less water than ○ Cerebrospinal fluid
muscles. ○ Gastrointestinal (GI) tract
- Older adults tend to lose muscle mass as ○ Pleural spaces
they age - decreasing the percentage of ○ Synovial Spaces
body. ○ Peritoneal fluid spaces
Functions of Body Fluids Mechanism Controlling Fluid and Electrolyte
- Facilitate the transport of nutrients, Movement
hormones, proteins and other molecules into ● Diffusion
cells. ● Facilitated diffusion
- Aid in the removal of cellular metabolic ● Active transport
wastes. ● Osmosis
- Provide the medium in which cellular ● Hydrostatic pressure
metabolism takes place. ● Oncotic pressure
- Regulate body temperature
- Provide lubrication of musculoskeletal Diffusion
joints. - Movement of molecules and Ions from an
- Acts as a component in all body cavities. area of higher concentration to an area of
lower concentration
Compartments Facilitated diffusion
Intracellular fluid (ICF)- ⅔ of TBW - Very similar to diffusion
Extracellular fluid (ECF)- - Specific carrier molecules involved to
- Intravascular (plasma) accelerate diffusion
- Interstitial Active Transport
Transcellular - Process in which molecules move against
concentration gradient
Intracellular Fluid (ICF) - Example: sodium-potassium pump
● Fluid located within cells - ATP is energy source
● 42% of body weight Osmosis
● Most prevent cations is potassium (k+) - Movement of fluid from and area of lower
● Most prevalent anion is phosphate (PO4-) solute concentration to an area of higher
solute concentration
Extracellular Fluid (ECF) Osmotic Pressure
● Fluid spaces between cells (interstitial fluid) - Amount of pressure required to stop osmotic
and the plasma space (intravascular fluid) flow of water
- Determined by concentration of solutes in
Interstitial solution
● Most prevalent anion is chloride (Cl-) Osmolality
● Most prevalent cation is sodium (Na+) - The number of milliosmoles (standard unit
● Expands and contracts of osmotic pressure) per kg of solvent:
expressed as milliosmoles per kg
(mOsm/kg) (the term osmolality is used Pituitary Regulation
more often than osmolarity to evaluate - Under control of hypothalamus
serum and urine). - Posterior pituitary release ADH acts on the
- Expressed as milliosmoles per kg distal renal tubules to > increased rate of
(mOsm/kg) water reabsorption > leading to decreased
Hydrostatic Pressure urine output thus increased blood volume.
- Force within a fluid compartment - stress , nausea, nicotine, and morphine also
- Major force that pushes water out of stimulates ADH release.
vascular system at capillary level Adrenal Cortical Regulation
Oncotic Pressure - Adrenal cortex releases hormones to
- Osmotic pressure exerted by colloids in regulate both water and electrolytes
solution - Glucocortecoids
- Protein (albumin) is major colloid in - Mineralocorticoids
vascular system - Aldosterone is a mineralocorticoid with
potent sodium-retaining and potassium
Fluid Shifts excreting capability.
- Plasma to interstitial fluid shift results in
edema REGULATORY MECHANISMS OF FLUID
- Elevation of hydrostatic pressure AND ELECTROLYTE BALANCE
- Decrease in plasma oncotic
pressure Renal Regulation
- Elevation of interstitial oncotic - Kidneys are primary organs for regulating
pressure fluid and electrolyte balance.
Interstitial Fluid to plasma - Selective reabsorption of water and
- Fluid drawn into plasma space whenever electrolytes.
there is increase in plasma osmotic or - Excretion of electrolyte occurs.
oncotic pressure - Renal tubules are sites of action of ADH and
aldosterone.
Fluid Spacing
First Spacing Renin Angiotensin Aldosterone System
- normal distribution of fluid in ICF and ECF. Goal: to increase BP
Second Spacing 1. Blood pressure drops.
- abnormal accumulation of interstitial fluid ↓
Third Spacing 2. Sympathetic Nervous System (stimulates)
- fluid accumulation in part of body where it ↓
is not easily exchanged with ECF. 3. Kidney: Juxtaglomerular System
> increase RENIN
Hypothalamic Regulation ↓
Osmoreceptors in hypothalamus sense fluid deficit or 4. Activates Angiotensinogen
increase in plasma osmolality/ osmolarity. ↓
↓ 5. Creates Angiotensin I
Stimulates thirst and antidiuretic hormonen(ADH) ↓
release. 6. ACE (angiotensin converting enzyme)
↓ *found in the surface lung, kidney,
Result in increased free water and decreased plasma endothelium, converts angiotensin I to
osmolarity. ↓
7. Angiotensin II
*constricts vessels and increase blood
volume
Cardiac Regulation FLUID RESTORATION
- Atrial natriuretic factor (ANF) is released by Oral Rehydration
the cardiac atria in response to atrial - Mild- can be replaced orally
pressure. - Avoid cola drinks- sugar content may lead to
- ANF causes renal vasodilation and increased osmotic diuresis
urinary excretion of sodium and water. Intravenous Rehydration
Insensible Water Loss - Calculated on the basis of clients weight,
- Invisible vaporization from lungs and skin. presence at any cardiac, renal or pulmonary
- Approximately 900 ml per day is lost disorders.
- Excessive sweating leads to loss of water - Isotonic FVD- treated with isotonic
and electrolytes. solutions.
- Hypertonic FVD- treated with hypotonic
FLUID VOLUME DEFICIT solutions/ hypertonic solutions
- electrolyte are lost in the same proportion as - Blood loss of less than 1L= PNSS
they exist in normal body fluids (isotonic or PLR
FVD) Nursing Management:
- Dehydration refers to loss of water alone Goal: restore fluid and electrolyte balance
with increased serum sodium level Assessment
(hyperosmolar FVD) - History of fluid losses
Causes: - Assess vital signs every 2-4 hours
- Fluid loss from vomiting, diarrhea, GI - Assess for postural BP and Pulse changes
suctioning, sweating, decreased intake, and - Assess for peripheral vein filling daily
inability to gain access to fluid. - Monitor intake and output, daily weights
Risk factors: accurately.
- diabetes insipidus, osmotic diuresis, - Weight loss: Mild: 2% weight loss(1-2L)
hemorrhage, coma, and third space shifts Moderate: 3% weight loss
Manifestations: (3-5L)
- Thirst, behavioral changes, (apprehension, Severe: 8% weight loss (5-10L)
apathy, lethargy, confusion, restlessness), - Loss of 1 kg (2.2 lbs) equals 1L fluid loss
rapid weight loss (5%), decreased skin - Assess oral cavity between gums and cheeks
turgor, furrowed tongue, anorexia and for dryness and the tongue for longitudinal
nausea, numbness and tingling of hands and furrows.
feet, oliguria, concentrated urine, postural - Check skin turgor.
hypotension, rapid and weak pulse, Goal: Prevent physical injury
increased temperature, cool and clammy - Frequent mouth care (mucous membrane
skin due to vasoconstriction, increased RR, dries due to dehydration)
muscle weakness. - Monitor IV flow rate- observe for
Laboratory data: circulatory overload, pulmonary edema
- Elevated BUN, serum, creatinine, increased related to potential fluid shift when
hematocrit, and possible serum electrolyte compensatory mechanisms begin)
changes - Monitor vital signs, including level of
Medical Management: consciousness ( decreasing BP and level of
- Provide fluids to meet body needs consciousness indicate continuation of fluid
- Fluid restoration loss)
FLUID VOLUME EXCESS Doctors Ordered Sodium Restricted Diets
- Due to fluid overload or diminished 2000-3000mg
homeostatic mechanisms - Low salt or no added salt
Risk factors: - Sodium restriction is mild.
- Heart failure, renal failure, and cirrhosis of - All high sodium foods are omitted.
the liver, psychogenic polydipsia, increased - A minimum amount of salt is used for
secretion of ADH in response to stress, cooking.
drugs, anesthetics. - No salt is added at the table.
Contributing Factor: 1000mg
- Excessive dietary sodium or - Sodium restriction is moderate.
sodium-containing IV solutions, increased - Food is cooked without salt.
ingestion, tube feedings, intravenous - Foods high in sodium are omitted.
infusions, multiple tap water enemas. - Vegetables high in sodium are restricted.
Manifestation: - Salt free products are used.
- Behavioral changes (irritability, apathy, - Diet planning is necessary.
confusion,disorientation), headache, 500mg
anorexia,nausea, cramping, edema; - Sodium restriction is severe.
distended neck veins; abnormal lung - Follow restrictions above plus
sounds(crackles); tachycardia;increased BP, - Milk ! cup/day
pulse pressure, and CVP; increased weight - Egg 1 per day
(5%); increased UO; shortness of breath; - Meat 4 oz per day
and wheezing, pink frothy sputum,
productive cough. IV FLUIDS
Goal: Maintain oxygen to all cells Isotonic
Position: - LR
- Semi-fowler’s or fowler’s to facilitate/ - PNSS (0.(%NSS)
improve gas exchange - NM
- Fluid restrictions and sodium restrictions (if Hypotonic
necessary) - D5W
Goal: promote excretion of excess fluid - Isotonic in bag
- Medications as ordered: diuretics, digitalis, - dextrose= quickly
protein infusion. - metabolized= hypotonic
- If in kidney failure: may need dialysis. - D2.5W
- Assist client during paracentesis, - 0.45%NSS
thoracentesis, phlebotomy - 0.3%NSS
Goal: maintain fluid balance - 0.2%NSS
- Daily weights. Hypertonic
- Measure all edematous parts, abdominal - D50W
girth. - D10W
- Intake and output. - D5NSS
- Limit fluids by mouth - D5LR
- Strict monitoring of IV fluids - 3%NSS
Goal: Prevent tissue injury
- Skin and mouth care as needed.
- Elevate feet for edema and discoloration
when client is out of bed.
ELECTROLYTES cramping, muscle weakness, increased ICP,
Functions: seizures.
- Maintain osmolality of body fluid Signs & Symptoms:
compartment. - Stupor / coma
- Regulate balance of acids. - Anorexia (nausea and vomiting)
- Aid in the neurologic and neuromuscular - Lethargy
conduction. - Tendon reflexes (decreased)
- Limp muscles (numbness)
Sodium (135-145 mEq/L - Orthostatic hypotension
- Controls osmotic pressure (BP, blood - Seizure/ headaches
volume) - Stomach cramping
- Essential for neuromuscular functioning- - Neurological symptoms occur when sodium
causes excitability of the neurons that levels fall below 120mEq/L
innervate the smooth muscles Medical Management;
- A decrease causes increased excitability of - Water restriction (if caused by water excess)
the neurons that innervate smooth muscles. - Sodium replacement (if caused by low
- When ECF sodium is decreased, the adrenal sodium)
glands send aldosterone to the kidneys- - Moderate hyponatremia (125 mEq/L): 0.9%
sodium is reabsorbed. NaCl or LR solution
- When ECF sodium is elevated, ECF - Severe hyponatremia: hypertonic solutions
osmolality also is elevated, ADH is of 3% normal saline (if there is cellular
secreted- increases tubular reabsorption of swelling)
the water. - If caused by water excess, fluid restriction is
- Aids in maintenance of acid-base balance. needed (800-1000ml/day)
- Not symptomatic until the level reaches 125 - If severe symptoms (seizures) occur, small
mEq/L amount of intravenous hypertonic saline
solution (3% NaCl) is given- priority
Hyponatremia intervention- monitor for manifestations of
- Serum sodium less than 135 meq/L fluid overload.
- Results from loss of sodium-containing - If associated with abnormal fluid loss, fluid
fluids or from water excess. replacement with sodium-containing
- Sodium loss in excess of water. solution is needed.
- Prolonged diuretic therapy, excessive burns, Nursing Management:
excessive diaphoresis, prolonged vomiting, - Assessment and prevention, monitoring of
nasogastric suction, diarrhea, laxative abuse, dietary sodium and fluid intake,
renal disease. identification and monitoring of at-risk
- Water gain in excess of sodium: patients and the effects of medications
- Excessive administration of water, (diuretics and lithium), daily weights,
IV of D5W, psychogenic provide safety.
polydipsia.
- Anorexia or acute alcoholism. Hypernatremia
- adrenal insufficiency(low levels of - Serum sodium greater than 145 mEq/L
aldosterone) - Elevated serum sodium occurring with water
- SIADH loss or sodium gain
Manifestations: - Causes- hyperosmolality leading to cellular
- Headache, confusion, restlessness and dehydration
irritability (115 mEq/L), decreased LOC, - Primary protection is thirst from
poor skin turgor, dry mucosa, decreased hypothalamus
salivation, decreased BP, nausea, abdominal
- Causes: excess water loss (insensible water
loss, watery stool, excess sodium
administration, diabetes insipidus, heat
stroke, and hypertonic IV solutions.
Manifestation:
- Thirst; elevated temperature; dry, swollen
tongue; sticky mucosa.
- Decreased cardiac contractility.
- Weakness
Neurologic Symptoms:
- Due to sensitivity to fluid shifting - 155
mEq/L or more (brain cells shrink)
- Restlessness, agitation, lethargy,
hyperactive, reflexes, seizures, rigid
paralysis)
- Excess sodium completes with calcium in
the slow calcium channel of the heart.
Signs and Symptoms:
- Flushed skin and fever (low-grade).
- Restlessness, irritable, anxious, confused.
- Increased blood pressure and fluid retention.
- Edema; peripheral and pitting.
- Decreased urine output and dry mouth.
- Skin flushed.
- Agitation.
- Low -grade fever.
- Thirst.
Medical Management:
- 0.9% NaCl- allows sodium to decrease
slowly.
- 0.2% or 0.45% NaCl, D5W
- Serum sodium levels must be reduced
gradually to avoid cerebral edema- reduce
the level to not more than 2 mEq/L for the
first 48 hours.
Nursing Management:
- Asses medication history and diet history.
- Avoid caffeinated and alcoholic beverages.
- Ensure adequate fluid intake.
- Skin care.
- Monitoring of vital signs and body weight.
- Assess mentation.
- Monitor for symptoms of osmotic diuresis
when D5W is administered continuously.
- Oral care.
- Monitor for potassium imbalance.
