Fluid & Electrolytes

Dr Sherif A. Nassib
MD Internal Medicine
Internal Medicine & Intensive Care
Consultant
Al Azhar University

Fluids and Electrolytes

Water
Adults: 40% EFC, 60% ICF
Electrolytes
Chemicals, when dissolved in water, will divide into
charged particles.
The number and type of electrolytes are critical,
there is a delicate balance
Cations (+): Positively charged ions
Anions (-): Negatively charged ions

 Neighborhood

analogy:

House (intracellular) compartment.

Yard (interstitial) compartment.
street (intravascular) compartment.
A

70 kg. (154 lb) person has

approximately 42-45 liters of water
distributed as follows:
ICF: 28-30 L
Interstitial: 10.5 L
Intravascular: 3.5 - 5 L

Fluid Compartments
Intracellular Fluid Compartment (ICF)
within the cell
major cation: potassium
major anion: phosphate
Extracellular

Fluid Compartment (ECF)

outside the cell
major cation: sodium
major anion: chloride

Movement of Electrolytes

Diffusion: movement of substances from higher

concentration to lower concentration Example:
Peritoneal dialysis and gas exchange

Active Transport: cell membrane actively

transports electrolyte to the direction needed,
regardless of concentration on either side.
Example: sodium potassium pump

Movement of Water

Filtration: pressure in arteries creates pressure into

arterioles, which force fluid through arteriole wall . The
movement between capillaries to interstitial fluid .

Osmosis: water moves from more water (fewer particles) to

less water (more particles). Low concentration to high
concentration.

Osmotic Pressure: drawing power of water depends on

number of particles in solution.

Osmosis

Osmolality:

number of particles of an electrolyte in a solution

normal serum osmolality 285 295 mOsm /kg (2(Na+ + K+) +

glucose + urea) all in mmol/L

determines movement toward higher osmolality

Isotonic: solution with the same osmolality as plasma, ex : NS, LR

Hypotonic: solution with lesser solute concentration than plasma,

ex: 0.45% saline, 0.33% saline, 2.5% dextrose . (cells swell)

Hypertonic: solution with greater solute concentration than

plasma, ex: 5% dextrose in 0.45 saline, 5% dextrose in NS, 5% LR,
3% saline

Fluid and Electrolyte Control

Blood Pressure: all filtration depends on BP

Blood Proteins: colloid osmotic pressure plasma proteins .

Without colloid pressure you will notice edema and decrease in BP

Fluid Intake: decreased blood volume and increased blood volume

concentration. Water is the end product in the breakdown of food.

Excretion:

Kidneys: 1500cc/day
filters 170L/day but only 1.5L/day becomes waste
clinical symptoms after 75% deterioration during renal disease
influenced by ADH (posterior pituitary)
influenced by aldosterone (adrenal cortex)

Skin: 1200 3000 cc/day

insensible: continuous and is not perceived by individual . Avg
adult: 6ml/kg/day
sensible: occurs through excessive perspiration, is perceived by
individual

Lung: 400 cc/day

GI tract: 1000 cc/day

Hormones:
ADH: holds fluid in (osmolality high, ADH high)
Aldosterone: causes sodium to be retained (saving water)

Common Fluid and Electrolyte Imbalances

Sodium:

normal adult: 135-145mEq/L,

responsible for H2O movement

Hyponatremia

< 130

mmol

Causes:

Kidney disease, Adrenal Insufficiency, GI

losses, Increased sweating, diuretics, metabolic
acidosis, interruption of Na K pump with decreased
cell K and decreased serum Na

S/S: weak rapid pulse, hypotension, dizziness, anxiety,

abdominal cramps, nausea, vomiting, diarrhea, coma and
convulsions, cold/clammy skin, personality change
Labs: serum Na <135mEq/L, serum osmolality
<280mOsm/Kg, and urine specific gravity <1010
Tx: increase salt intake. Hypertonic saline.

 Hypernatremia > 145 mmol

Causes:

Ingestion of large amounts of salt solution

(near drowning, IV), too many salt tablets, increased
aldosterone secretion.

S/S: severe nausea/vomiting, decreased UO, thirst, dry,

flush, CNS changes agitation, hyperactivity
Labs: serum Na >145mEq/L, serum osmolality
>295mOsm/Kg, and urine specific gravity <1030
Tx: increase large amounts of water, IV fluid

 Hypokalemia < 3.5 mmol

Causes:

use of diuretics (Lasix), diarrhea and vomiting

S/S: fatigue, weakness, decrease appetite, heart arrhythmia (flat T

wave and depressed ST segments)
Tx: oral supplements, IV K replacement

Hyperkalemia > 5.6 mmol

Causes:

IV running too fast with K, taking K without Lasix (Dr

may DC Lasix and forget to DC K supplement), kidney failure

S/S: irritability, nausea, diarrhea, cardiac arrhythmias/standstill,

muscle paralysis
Tx: restriction of K intake (renal failure restrict), oral meds to excrete
K in intestines (lactulose), enema solution that exchanges Na for K,
severe kidney dialysis

Calcium normal adult: 4.5 - 5.6 mg/dl

Hypocalcaemia

Causes: rapid administration of blood containing

citrate, hypoalbuminemia, hypoparathyroidism,
Vit D deficiency, neoplastic diseases, and
pancreatitis.

S/S: numbness and tingling of fingers and circumoral

region, hyperactive reflexes, positive Trousseaus sign
(carpopedal spasm with hypoxia), positive Chvosteks
sign (contraction of facial muscles when facial nerve
tapped), tetany, muscle cramps, pathological
fractures with chronic hypocalcemia

Lab: serum Ca <4.5mEq/L and ECG changes .

TX: Calcium gluconate 10%, 10mg, over 10 min.

 Hypercalcemia
Causes:

Hyperparathyroidism, metastatic bone

tumors, Pagets disease, osteoporosis, prolonged
immobilization

S/S: decreased muscle tone, anorexia, nausea, vomiting,

weakness, lethargy, low back pain from kidney stones,
decrease LOC, cardiac arrest
Lab: (total calcium > 14 mg/dl). Serum ionized Ca levels
>5mEq/L, x-ray showing generalized osteoporosis,
widespread bone cavitation, and radioplaque urinary
stones, elevated BUN >25mg/ml, elevated creatinine
>1.5mg/100ml caused by FVD or renal damage due to
urolithiasis.
Tx: saline, furosemide, calcitonin, steroids,
Pisphosphonates

Magnesium: norm adult: 1.2-2mEq/L

Hypomagnesemia
Causes: Inadequate intake: malnutrition and alcoholism, inadequate
absorption: diarrhea, vomiting, nasogastric drainage, fistulas, excessive
dietary calcium (competes magnesium for transport sites ) small intestine
diseases hypothyroidism, Excessive loss resulting from thiazide diuretics,
aldosterone excess, polyuria
S/S: Muscular tremors, hyperactive deep tendon reflexes, confusion,
disorientation, tachycardia, positive Chvostek's and Trousseau's signs
Lab: serum magnesium < 1.2 mEq/L (also associated with hypocalcemia
and hypokalemia)
Tx: 50% MgSO4 must be diluted to 10% or 20%. (saline is used as diluent,
Ringer is not advised because calcium in Ringers solution will counteract
the action of magnesium.

 Hypermagnesemia
Causes:

Renal failure, excessive parenteral

administration of magnesium

S/S: in acute hypermagnesemia: hypoactive

deep tendon reflexes, shallow and slow
respirations and heart rate, hypotension, flushing
Lab: serum magnesium > 2.5 mEq/L.
Tx; Haemodialysis is the treatment of choice, IV
calcium gluconate to antagonize
hypermagnesemia.

Fluid Imbalances
Isotonic Imbalances: Loosing
fluids and electrolytes in equal
amounts.

Fluid Volume Excess )hypervolemia)

H2O and Na retained in isotonic proportions

Increase volume of fluid that can be handled by body

Causes:

S/S:

JVD
Pulse full and bounding
Increase BP
Weight gain
Rapid respiration
Edema
Pulmonary edema

Labs:

excess IV fluid
CHF
Renal Failure

decrease RBC count

false decrease BUN, <10mg/
<10mg/100ml
electrolytes essentially unchanged
may see initial decrease in Na

Tx:

administer diuretics
dialysis

Fluid Volume Deficit (FVD): hypovolemia

Causes:

GI (vomiting, diarrhea)
Loss of blood or plasma, hemorrhage, burns
Fever
Decreased oral intake of fluids
Use of diuretics
Increased perspiration

S/S:

Postural hypotension
Increased HR
Decreased BP
Tachycardia
Oliguria

Labs:

Very young and very old are affected quickly

> 1025 specific gravity

increased hematocrit, >50%
increased BUN, >25mg/100ml

Tx: increase fluid intake

Third-Space Syndrome:

Loss of ECF into a body cavity

Causes:

Portal Hypertension
Small bowel obstruction
Peritonitis
Burns (can result in the shift of up to 5 10L out of ECF spaces)

S/S:

Hypotension
Increased abdominal girth (with small bowel obstructions, ascites)

Labs:

Decreased serum sodium, <135mEq/L

Decreased albumin, <3.5g/100ml

Tx:

Correct the cause.

Diuretics.
Dialysis.

Nursing Assessment For Fluid Imbalances

At Risk: Very young/old, chronic diseases, trauma, burns, therapies,

and GI losses

History:
Heart Disease
Vomiting
Weight loss
Dietary changes
IV/TPN

Physical Exam:
edema, JVP, lung sounds

Lab Data:
Electrolytes
Hematocrit
BUN
Specific Gravity

Correcting Fluid Imbalances

Nursing Implementation

Daily weights

Replacement of Fluids

Enteral replacement

Fluid restriction

Parenteral replacement

IV Solutions

Hydrating Solutions

ex:

a. NS .9%
b. NS .45%NaCl
c. NS .22%
d. Dextrose in water (D5W) 5% Dextrose

e. Dextrose in saline' D5NS, D5 1/2, D5 1/4

Maintenance Solutions

ex:

Ringer Lactate

Na, K, Ca, Cl, and lactate in roughly same concentration as plasma

Replacement Solutions

used to replace concurrent losses of water and electrolytes in

normal amounts, resembles what is lost

ex:

IV fluid and electrolytes

TPN
Blood

Complications

of IV therapy

Phlebitis inflammation pain, warmth, redness

traveling along vein
Infiltration no longer in vein Swelling,
pallor, cool Elevate extremity, apply warmth
Infection Pain, erythema (redness), purulent
drainage
Bleeding

Infection Control of IV Therapy

Patient
fluid imbalances
electrolytes
IV bags
change every 24 hours, 4hours for blood
Tubing
change every 48 hours
Dressing changes
per hospital policy
Site
peripheral, central venous, PICC (peripherally inserted
central catheter)

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