NCM 105 (FLUIDS AND ELECTROLYTES) PRELIM COVERAGE

LECTURE 1. CARE OF THE CLIENT WITH PROBLEMS IN FLUIDS

AND ELECTROLYTES • Transcellular
Learning Outcomes: • 1-3% of body weight
FUNDAMENTAL CONCEPTS OF FLUIDS AND ELECTROLYTES • Approximately 1-2 L
• Body Fluids Definition and its Distribution • Cerebrospinal fluid, pericardial fluid, synovial
• Electrolytes Definition, Anion and Cation fluid, pleural fluids
• General Functions of Electrolytes • Sweat
• Movements of Water and Electrolytes: Passive and • Digestive secretions
Active Transport
• Systemic Routes of Gains and Losses Approx. Body Compartments in a 70-KG Adult
• Homeostatic Mechanisms
Remember!!
Balance between fluids and electrolytes is essential to your
body’s homeostasis.

BODY FLUIDS
• Refers to body water in which electrolytes are
dissolved.
• Been described as “a sea within”
• Water is the largest single constituent of the body,
representing 60% (approx.) of the body’s weight
Note:
Factors that influence amount of body fluids
• There is a continuous exchange of fluid between the
o Age
fluid compartment, of these spaces, only the plasma
o Sex
is directly influenced by the intake or elimination of
o Body Fat
fluid from the body.
Functions of Body Fluids
• Third-space fluid shift or “third spacing” where there
• Transport nutrients to the cells and carries waste
is a loss of ECF into a space that does not contribute
products away from the cells.
to the equilibrium between ICF and ECF.
• Maintains blood volume.
• “Third Spacing” occurs in:
• Regulates body temperature.
o Ascites
• Serves as aqueous medium for cellular metabolism. o Burns
• Assists in digestion of food through hydrolysis. o Peritonitis
• Acts as solvents in which solutes are available for cell o Bowel obstruction
function. o Massive bleeding into a joint or body cavity.
• Serves as medium for the excretion of waste products.
ELECTROLYTES
Body Fluids are Distributed in the Body in Two Compartments • Chemical compounds in solution that have the ability
1. Intracellular Fluid Compartment (ICF) to conduct an electrical current.
2. Extracellular Compartment (ECF) • They break into ions:
a. Intravascular Fluid o Cations carry positive charges;
b. Interstitial Fluid o Anions carry negative charges
c. Transcellular ▪ Sodium – primary cation in the ECF;
important in regulating fluid volume
Intracellular Fluid Compartment (ICF) ▪ Chloride – primary anion in the ECF
• Fluid inside the cells ▪ Potassium – primary cation in the
• Contains 2/3 of body fluids ICF
• Located primarily in skeletal muscle mass ▪ Phosphates and sulfates – primary
anions in the ICF
Extracellular Compartment (ECF)
• Outside the cell General Functions of Electrolytes:
• Contains 1/3 of body fluids • Promote neuromuscular irritability
• Maintains blood volume and serves as the transport • Maintain body fluid volume and osmolality.
system to andVfrom the cells • Distribute body water between compartments
• ECF subdivided further into: • Regulate acid-base balance
o Intravascular fluid
o Interstitial fluid Concentrations of Extracellular and Intracellular Electrolytes
o Transcellular in Adults
• Intravascular Fluid
o Fluid within blood vessels
o Contain plasma (3L out of the average 6L
blood volume)
• Interstitial Fluid
o Fluids that surround the cell (1L to 12L)
o Ex: Lymph

OSMOSIS, OSMOLALITY, OSMOLARITY

Osmosis
• Movement of fluid from an area of lower
concentration to higher concentration across the
semi-permeable membrane.
• Normal serum osmolality is 280-300mOsm/kg.
• Osmolality of ECF and ICF is always equal.
 o Movement of ions from an area of lesser to
greater
o concentration with an ion pump.
o Ex: Na –K pump
o The Na-K pump performs active transport
which actively moves potassium from the
ECF to the ICF.
o Active transport is the use of energy to
create movement against a concentration
gradient.

SYSTEMIC ROUTES AND GAINS AND LOSSES

• Healthy people gain fluids by drinking and eating, and
their average intake and output (I&O) of water are
Osmolality approximately equal.
• Reflects the concentration of fluid that affects the
movement of water between fluid compartments by
osmosis. (mOsm/kg)
• Also measures the ability of a solution to create
osmotic pressure and affect movement of water.
(mOsm/kg)

Osmolarity REGULATION OF BODY FLUIDS AND ELECTROLYTES

• Reflects the concentration of solutions. (mOsm/L) Kidneys
• Daily urine volume: 1 to 2 L
REGULATION OF FLUIDS WITHIN THE BODY COMPARTMENTS • Normal output should be 1 mL/kg/hr
Starling’s Law of Capillary Forces Skin
• Hydrostatic Pressure • Insensible water loss through the skin: 600 mL
• Osmotic Pressure
Adrenal Glands
Passive Transport • The adrenal glands secrete aldosterone.
• Oncotic Pressure Lungs
o The osmotic pressure generated by large • The lungs regulate fluid by releasing water as vapor
molecules (especially proteins) in solutions. with every exhalation. Every time you exhale, water is
o Is the osmotic pressure exerted by proteins lost
(ex. albumin) Gastrointestinal Tract
• Tonicity • Usual loss is around 100 to 200 mL
o Is the ability of all the solutes to cause an Cardiovascular system
osmotic driving force that promotes water • Pumps and carries fluids and other good stuff
movement from one compartment to throughout the body, to the vital organs, especially to
another the kidneys
• Diffusion Pituitary Gland
o Movement of particles from an area of • Antidiuretic hormone (ADH), which causes retention
higher to lower concentration within one of water.
compartment.
o Occurs through the random movement of
ions and molecules.
o Particles will distribute themselves evenly.
o An example is the exchange of O2 and CO2
between the pulmonary capillaries and
alveoli.

Parathyroid Glands
• The parathyroid glands secrete parathyroid hormone
(PTH).

• Filtration
o Is the process by which water and diffusible
substances move together in response to fluid
pressure. This process is active in capillary beds.
o An example is the passage of water and
electrolytes from the arterial capillary bed to the
interstitial fluid.
• This causes an increase in serum calcium by pulling it
from the bones and placing the calcium in the blood.
Active Transport
• Sodium and Potassium Pump
Thyroid Gland SODIUM
• The thyroid gland releases thyroid hormones. Food sources: bacon, ham, sausage, catsup, mustard, relishes,
• Providing energy processed cheese, canned vegetables, bread, cereals, snack
• Increasing pulse rate foods. Helps maintain the volume of body fluids. Sodium is the
• Increasing cardiac output only electrolyte that is affected by water.
• Increasing renal perfusion
• Increasing diuresis
• Ridding of excess fluid

Hypothalamus
• Thirst response
• AGE matters

Small Intestine
• Absorbs 85% to 95% of fluid from ingested food
• Delivers it into the vascular system

Lymphatic system
• Moves water and protein back into the vascular space

HYPONATREMIA
Serum sodium less than 135 mEq/L.
Hyponatremia is:
• Not enough sodium in the ECF (vascular space).
• Possibly, there is too much water diluting the blood
which makes serum sodium go down.
• Anytime there is a sodium problem there is a fluid
problem as well.

LECTURE 2. SODIUM AND POTASSIUM IMBALANCES Imbalance

Sodium deficit (hyponatremia)
LEARNING OUTCOMES Serum sodium <135 mEq/L
• Understand Sodium and Potassium Imbalance
• Describe the cause, clinical manifestations, management, Contributing Factors
and nursing interventions for the following imbalances: Loss of sodium, as in use of diuretics, loss of GI fluids, renal
➢ hyponatremia, hypernatremia, hypokalemia, and disease, and adrenal insufficiency. Gain of water, as in excessive
hyperkalemia. administration of D5W and water supplements for patients
• Plan effective care of patients with the following such receiving hypotonic tube feedings; disease states associated
imbalances. with SLADH, such as head trauma and oat-cell lung tumor;
medications associated with water retention (oxytocin and
REMEMBER certain tranquilizers); and psychogenic poly- dipsia.
Hyperglycemia and heart failure cause a loss of sodium.

Signs/Symptoms and Laboratory Findings

Anorexia, nausea and vomiting, headache, lethargy, dizziness,
confusion, muscle cramps and weakness, muscular twitching,
seizures, papilledema, dry skin,  pulse, ↓ BP, weight gain,
edema
Labs indicate: ↓ serum and urine sodium, urine specific gravity
Normal adult sodium level is 135 to 145 mEq/L. and osmolality

SODIUM Tests:
Chief electrolyte in ECF. • hyponatremia is serum electrolytes
• Assists with generation and transmission of nerve Treatment:
impulses. Depends on the cause
• An essential electrolyte of the sodium–potassium pump in • 0.9% normal saline IV
the cell membrane. • 3% Saline
• Excess sodium is excreted by kidneys. Excretion of sodium
retains potassium. Medical Management:
• Watch for FVE*
SODIUM AND POTASSIUM • Increased dietary Sodium
• If appropriate, discontinue drugs/treatments that
INVERSELY RELATED could be causing sodium
INCREASED SODIUM = DECREASED POTASSIUM • Sodium Replacement
DECREASED SODIUM = INCREASED POTASSIUM • Water Restriction
• Pharmacologic Therapy
Nursing Interventions: ✓ As with hyponatremia, seizures and brain damage are
• target the underlying cause the major complications associated with
• identify and monitor patients at risk for hypernatremia.
hyponatremia.
• monitor lab values POTASSIUM BALANCE & IMBALANCE
• monitor I&O properly and daily weight REMEMBER
• encourage diet with high sodium content

Take note of the ff:

• decreased renal function, inability to excrete excess
fluids
• water retention*
• lithium (watch out for signs of lithium toxicity)
• cardiovascular disease
Normal adult potassium level is 3.5-5.0 mEq/L.
Complications:
• Seizures and brain damage are the major POTASSIUM
complications associated with hyponatremia. • Makes skeletal and cardiac muscle work correctly.
• Also, consider what caused the hyponatremia when • Major electrolyte in the intracellular fluid.
determining what could harm your patient. • Potassium and sodium are inversely related (when
• one is up,
✓ D5W is initially an isotonic solution and provides free • the other is down).
water when dextrose is metabolized (making it a • Plays a vital role in the transmission of electrical
hypotonic solution), expanding the ECF and the ICF. impulses.
• Food sources: peaches, bananas, figs, dates, apricots,
HYPERNATREMIA oranges, melons, raisins, prunes, broccoli, potatoes,
• serum sodium greater than 145 mEq/L meat, dairy products.
• there is too much sodium and not enough water in the • Excreted by the kidneys.
body. Anything that causes an increased “water” loss or • Stomach contains large amount of potassium.
excessive sodium intake can cause hypernatremia. • Normal potassium level: 3.5 mEq/L to 5.0 mEq/L

Imbalance HYPOKALEMIA
Sodium excess (hypernatremia) • serum potassium below 3.5 mEq/L
Serum sodium >145 mEq/L • Paralytic ileus can occur from severe hypokalemia.
Abdominal distension
Contributing Factors • muscle cramps
Fluid deprivation in patients who cannot respond to thirst, • muscle weakness
hypertonic tube feedings without adequate water
supplements, diabetes insipidus, heatstroke, hyper- Imbalance
ventilation, watery diarrhea, burns, and diaphoresis. Excess Potassium deficit (hypokalemia)
corticosteroid, sodium bicarbonate, and sodium chloride Serum potassium <3.5 mEq/L
administration, and saltwater nonfatal drown- ing victims.
Contributing Factors
Signs/Symptoms and Laboratory Findings Diarrhea, vomiting, gastric suction, corticosteroid
Thirst, elevated body temperature, swollen dry tongue and administration, hyperaldosteronism, carbenicillin,
sticky mucous membranes, hallucinations, lethargy, amphotericin B, bulimia, osmotic diuresis, alkalo- sis,
restlessness, irritability, simple partial or tonic-clonic seizures, starvation, diuretics, and digoxin toxicity
pulmonary edema, hyperre- flexia, twitching, nausea,
vomiting, anorexia, ↑ pulse, and ↑ BP Signs/Symptoms
Labs indicate: ↑ serum sodium, ↓ urine sodium, ↑ urine Fatigue, anorexia, nausea and vomiting, muscle weakness,
specific gravity and osmolality, CVP. polyuria, decreased bowel motility, ventricular asystole or
fibrillation, paresthesias, leg cramps, BP, ileus, abdominal
Tests: distention, hypoactive reflexes. ECG: flattened T waves,
• serum electrolytes prominent U waves, ST depression, prolonged PR interval
Treatment:
individualized/specific depending on the cause. Tests:
• Restrict all forms of sodium: Foods can have excess • serum electrolytes
sodium as well as drugs and IV fluids. • EKG (shows flattened T wave, depressed ST segment,
• individualized/specific depending on the cause. and a U-wave)
• Restrict all forms of sodium
• Foods can have excess sodium as well as
• drugs and IV fluids.

Nursing Interventions
• Assess for abnormal losses of water or low water
intake and large gains of sodium
• provide fluids at a regular interval; if unconscious,
provide by other routes
• TOO RAPID REDUCTION IN SERUM SODIUM LEVEL
RENDERS THE PLASMA TEMPORARILY HYPO OSMOTIC
TO THE FLUID IN THE BRAIN TISSUE, CAUSING
MOVEMENT OF FLUID INTO BRAIN CELLS AND
LEADING TO CEREBRAL EDEMA.
Treatments: Tests:
• determine the cause • serum electrolytes
• High potassium diet • ECG will also be assessed
• IV or oral potassium chloride
• check for proper kidney function or good urine Treatments:
output. • depends on the primary cause.
• A good rule to remember when administering IV K is • IV insulin in conjunction with 10–50% glucose IV (IV
not to exceed 20 mEq/hour. insulin will lower the serum K by pushing it into the
✓ Clients taking a cardiac glycoside with a diuretic should be cell.
monitored closely for hypokalemia, which can potentiate • Administration of sodium polystyrene sulfonate
the cardiac glycoside and cause toxicity (Kayexalate) with 70% sorbitol
✓ switched to a potassium-sparing diuretic • Kayexalate---serum sodium as hypernatremia can
occur.
Nursing Interventions: • Diuretics to increase renal excretion of K. 10%
• PREVENTING AND CORRECTING HYPOKALEMIA calcium gluconate IV (to decrease myocardial
• Eat foods rich in potassium irritability).
• monitor I&O 40mEq is lost every 1 liter of urine • Hemodialysis
• monitor ECG and ABG • Peritoneal dialysis
• IV or oral potassium supplement • Limit high potassium foods.
Administering IV Potassium • Limit drugs which could cause retention of K
• establish adequate urine output (aldactone).
• renal function must be tested
• K should not be given by IV push or IM. Nursing Interventions:
• *Infusion pump Preventing Hyperkalemia and Correcting
• monitor the patient for any sign of hypokalemia or • Hyperkalemia
hyperkalemia. • adhere to prescribed potassium restriction
• administer and monitor potassium administration
Complications closely
• life-threatening arrhythmias
➢ arrhythmias → decreased cardiac output → Complications:
resulting in hypotension. • monitor clients for dehydration, neurological changes,
• Respiratory depression may also occur. and life-threatening arrhythmias.

HYPERKALEMIA POTASSIUM IN RELATIONTO ACID-BASE BALANCE

• serum potassium greater than 5.0 mEq/L. ✓ ACIDOSIS - HYPERKALEMIA
• In severe hyperkalemia, ascending flaccid paralysis of ✓ ALKALOSIS – HYPOKALEMIA
the arms and legs may be seen;
• this paralysis moves distal to proximal.

Imbalance
Potassium excess (hyperkalemia)
Serum potassium >5.0 mEq/L

Contributing Factors
Pseudohyperkalemia, oliguric kidney injury, use of potassium-
conserving diuretics in patients with renal insufficiency,
metabolic acidosis, Addison disease, crush injury, burns, stored
bank blood transfusions, rapid IV administration of potas sium,
and certain medications such as ACE inhibitors, NSAIDs,
cyclosporine

Signs/Symptoms
Muscle weakness, tachycardia → bradycardia, dysrhythmias,
LECTURE 3. WATER/FLUID LOSS
flaccid paralysis, paraesthesia, intestinal colic, cramps,
abdominal distention, irritability, anxiety. ECG: tall tented T
OBJECTIVES
waves, prolonged PR interval and QRS duration, absent P
• Learn about the sensible and insensible water loss
waves, ST depression
• Understand abnormal fluid loss, dehydration, and
hormones affecting the F&E
• Understand abnormal electrolyte loss, concentration
of fluids
• Learn about FVD and FVE

HOW DO WE LOSE FLUID?

1. Sensible fluid loss:
• loss that is SEEN
• urine, sweat, and feces.
• Kidneys--800 to 1500 mL/day
• NGT
2. Insensible fluid loss:
• loss that is NOT SEEN
• Occurs through the intestinal tract, lungs, and skin.
• Skin—water evaporation
• Lungs- approximately 500 mL/day
• GI-100 to 200 mL/day
Abnormal fluid loss results from a physiologic imbalances. 2. Glucose
Examples include: • The vascular space likes the particle-to-water ratio to be
✓Fever or an increased room temperature equal.
✓Severe burns • When the blood sugar is very high, as in diabetics, the
✓Hemorrhage blood has too many glucose particles compared to water
✓Emesis in the vascular space. This causes particle-induced diuresis
(PID), sometimes called osmotic diuresis.
✓Fistulas
✓Secretions
Concentration Of Fluids
✓Wound exudates • Isotonic - Exerts the same osmotic pressure as that
✓Paracentesis found in plasma.
✓Thoracentesis • Hypotonic - Exerts less osmotic pressure than that of
✓Diaphoresis blood plasma.
• Hypertonic - Exerts a higher osmotic pressure than
DEHYDRATION that of blood plasma.
The 2 types of dehydration are:
1. Mild dehydration: Fluid Volume Deficit
➢ 2% loss of body weight, which equals 1 to 2 L of Fluid volume deficit (FVD) results when fluid loss exceeds fluid
body fluid. intake.
2. Marked dehydration: ✓ sodium and water are lost in equal amounts from the
➢ 5% loss of body weight, which equals 3 to 5 L of vascular space.
body fluid. ✓ Also called hypovolemia or isotonic dehydration.
*Not the same as dehydration.
Hormones help keep electrolytes within normal
range. What causes it?
1. Insulin • Decreased intake or poor appetite
• moves potassium from the blood to the inside of • Drugs that affect fluids and electrolytes
the cell, causing the serum K to drop. • Diuresis
2. Parathyroid hormone (PTH) • Forgetting to drink and eat
• moves calcium from the bone into the blood • Poor response to fluid changes
when serum calcium levels are low. • Vomiting
• causes the serum calcium to increase. • Diarrhea
3. Calcitonin: • GI suction
• moves calcium into the bones as needed. • Diuretics
• When the serum calcium is too high, calcitonin • Impaired swallowing
increases and moves calcium from the blood into the
• Tube feedings
bone.
• Fever
• This causes serum calcium to decrease.
• Laxatives
• Hemorrhage
How do we get rid of excess electrolytes?
• Third spacing
Excess electrolytes are excreted by:
• Urine, feces, and sweat.
Signs And Symptoms
• Aldosterone: causes sodium and water retention
• Acute weight loss
while causing potassium excretion through the urine.
• Decreased skin turgor (tenting occurs)
• PTH: increases urine excretion of phosphorus and
• Postural hypotension (orthostatic hypotension)
decreases urine excretion of calcium.
• Increased urine specific gravity
Abnormal Electrolyte Losses • Weak, rapid pulse
• Vomiting • Cool extremities
• Nasogastric (NG) suction • Dry mucous membranes
• Intestinal suction • Decreased BP
• Drainage • Decreased peripheral pulses
• Paracentesis • Oliguria
• Diarrhea • Decreased vascularity in the neck and hands
• Diuretics • Decreased central venous pressure
• Kidney trauma, illness • Increased respiratory rate
• Kidney trauma, illness, or disease
Diagnostic Tests and Treatments
• Massive blood transfusions
• Laboratory testing for FVD include:
• Tumors
• serum electrolytes
• Crushing injuries
• Hct
• Chemotherapy
• Urine specific gravity
CASE IN POINT
✓ A common nursing order is “nothing by mouth” (NPO). Treatment measures:
• oral or IV fluid replacement
Substances That Can Alter Fluid Balance • if it is due to hemorrhage or blood loss---blood
1. Plasma protein: holds on to fluid in the vascular space. products
Albumin
• If a client is badly burned, malnourished (decreased Complications
protein intake), or has a disease where the liver is not • Shock.
making adequate amounts of albumin, problems can • Poor organ perfusion, leading to acute tubular
occur. necrosis and renal failure.
• Adequate albumin needed to hold fluid in the vessels may • Multiorgan dysfunction due to poor perfusion.
not exist; therefore, the fluid may leak out of the vessels • Decreased cardiac output.
into the tissues and cause shock.
Fluid Volume Excess
Fluid volume excess (FVE) results when fluid intake exceeds
fluid loss.
• Excessive retention of water and sodium in the
extracellular fluid (ECF).
• Also called hypervolemia or isotonic overhydration.

Causes
• Renal failure
• CHF
• Cushing syndrome
• Excessive sodium: from IV normal saline or lactated
• ringers(iatrogenic)or foods
• Blood product administration
• Increased ADH
• Medications
• Liver disease
• Hyperaldosteronism
• Burn treatment

Signs And Symptoms

• Jugular vein distension (JVD)
• Bounding pulse, tachycardia
• Abnormal breath sounds
• Polyuria
• Decreased urine specific gravity
• Dyspnea and tachypnea
• Increased BP
• Increased central venous pressure (CVP)
• Edema
• Productive cough
• Weight gain
• Increased central venous pressure (CVP)
• Edema
• Productive cough
• Weight gain

Diagnostic Tests and Treatments

Tests:
• Serum Electrolytes
• BUN and Creatinine
• Chest x-ray:
• If the heart is enlarged, as can be seen with an x-ray,
this could mean congestive heart failure.
Treatments:
• Treat the cause
• Loop diuretics: Furosemide (Lasix)
• Potassium-Sparing Diuretics: Spironolactone
(Aldactone)
• Dietary Sodium Restrictions

Complications
• CHF
• pulmonary edema