Week 2 For Posting CH 16 Fluid and Electrolytes

Copyright © 2017, Elsevier Inc. All Rights Reserved.
FLUID AND
ELECTROLYTES
Chapter 16
Jennel Osborne, PhD, MPhil, MSN, RN
Normal Physiology
• Maintenance of homeostasis
• Composition of fluids and electrolytes kept within
narrow limits
• Water content varies with age, gender, and fat
content
Fluid Compartments
• Intracellular fluid (ICF)
• Extracellular fluid (ECF)
• Interstitial
• Intravascular (plasma)
• Transcellular
Electrolytes
Substances whose molecules dissociate into ions
when placed in water
• Cations: positively charged
• Anions: negatively charged
• Concentration of electrolytes is expressed in
milliequivalents (mEq)/L
Electrolyte Composition
• ICF
• Prevalent cation is K+
• Prevalent anion is PO43-
• ECF
• Prevalent cation is Na+
• Prevalent anion is Cl-
Mechanisms Controlling Fluid and

Electrolyte Movement
• Diffusion
• Movement of molecules across a permeable membrane
from high to low concentration
• Facilitated diffusion
• Uses carrier to move molecules

• Active transport
• Process in which molecules move against concentration
gradient
• External energy is required for this process

• Osmosis
• Movement of water “down” concentration gradient
• From a region of low solute concentration to one of high solute
concentration
• Across a semipermeable membrane

• Osmotic pressure
• Amount of pressure required to stop osmotic flow of
water
• Osmolarity measures the total milliosmoles/L of solution
• Osmolality measures the number of milliosmoles/kg of
water
Osmotic Movement of Fluids

• The osmolality of the fluid surrounding cells
affects them
• Isotonic
• Hypotonic
• Hypertonic

• Hydrostatic pressure
• Blood pressure generated by heart contraction
• Oncotic pressure
• Osmotic pressure caused by plasma proteins
Fluid Shifts
• Plasma-to-interstitial fluid shift results in edema

• Interstitial fluid drawn into plasma decreases
edema
Fluid Spacing
• First spacing: Normal distribution
• Second spacing: Abnormal (edema)
• Third spacing: Fluid is trapped where it is difficult or
impossible for it to move back into cells or blood vessels
Regulation of Water Balance

• Hypothalamic-pituitary regulation
• Osmoreceptors in hypothalamus sense fluid deficit or
increase
• Deficit stimulates thirst and antidiuretic hormone (ADH)
release
• Decreased plasma osmolality (water excess)
suppresses ADH release

• Renal regulation
• Primary organs for regulating fluid and electrolyte
balance
• Adjusting urine volume
• Selective reabsorption of water and electrolytes
• Renal tubules are sites of action of ADH and
aldosterone

• Adrenal cortical regulation
• Releases hormones to regulate water and
electrolytes
• Glucocorticoids
• Cortisol
• Mineralocorticoids
• Aldosterone

• Cardiac regulation
• Natriuretic peptides are antagonists to the RAAS
• They are produced by cardiomyocytes in response to
increased atrial pressure
• They suppress secretion of aldosterone, renin, and ADH
to decrease blood volume and pressure

• Gastrointestinal regulation
• Oral intake accounts for most water
• Small amounts of water are eliminated by
gastrointestinal tract in feces
• Diarrhea and vomiting can lead to significant fluid and
electrolyte loss
Gerontologic Considerations
• Structural changes in kidneys decrease ability to
conserve water
• Hormonal changes include a decrease in renin
and aldosterone and increase in ADH and ANP
• Loss of subcutaneous tissue leads to increased
moisture lost
Fluid and Electrolyte Imbalances

• Directly caused by illness or disease (burns or
heart failure)
• Result of therapeutic measures
(colonoscopy preparation, diuretics)
Extracellular Fluid Volume Imbalances

• ECF volume deficit (hypovolemia)
• Abnormal loss of body fluids, inadequate fluid intake, or
plasma to interstitial fluid shift
• Clinical manifestations related to loss of vascular
volume as well as CNS effects

• Interprofessional Care
• Correct the underlying cause and replace water and
electrolytes
• Orally
• Blood products
• Balanced IV solutions

• Fluid volume excess (hypervolemia)
• Excess intake of fluids, abnormal retention of fluids, or
interstitial-to-plasma fluid shift
• Clinical manifestations related to excess volume

• Inter-professional Care
• Remove fluid without changing electrolyte
composition or osmolality of ECF
• Diuretics
• Fluid restriction
• Restriction of sodium intake to treat ascites or
pleural effusion
Nursing Management
Nursing Diagnoses
Hypovolemia Hypervolemia
• Deficient fluid volume • Excess fluid volume
• Decreased cardiac output • Impaired gas exchange
• Risk for impaired oral • Risk for impaired skin
mucous membranes integrity
• Potential complication: • Activity intolerance
Hypovolemic shock • Disturbed body image
• Potential complications:
Pulmonary edema,
ascites
Nursing Management
Nursing Implementation
• Daily weights
•I&O
• Laboratory findings
• Cardiovascular care
Nursing Management
Nursing Implementation
• Respiratory care
• Patient safety
• Skin care
Assessment of Skin Turgor

Sodium
• Imbalances typically associated with parallel
changes in osmolality
• Plays a major role in
• ECF volume and concentration
• Generation and transmission of nerve impulses
• Muscle contractility
• Acid-base balance
Hypernatremia
• Elevated serum sodium occurring with
inadequate water intake, excess water loss or
sodium gain
• Causes hyperosmolality leading to cellular
dehydration
• Primary protection is thirst from hypothalamus
Hypernatremia
• Manifestations
• Thirst
• Alterations in mental status, ranging from agitation,
restlessness, confusion and lethargy to seizures and
coma
• Symptoms of fluid volume deficit
Nursing and Inter-professional

Management
• Nursing Diagnoses
• Risk for electrolyte imbalance
• Risk for fluid volume deficit
• Risk for injury
• Potential complication: Seizures and coma
Nursing and Interprofessional

Management
• Nursing Implementation
• Treat underlying cause
• Primary water deficit—replace fluid orally or IV with
isotonic or hypotonic fluids
• Excess sodium—dilute with sodium-free IV fluids and
promote excretion with diuretics
Case Study
Hyponatremia (©iStockphoto/Thinkstock)
• M.H., a 62-year-old female, was admitted

with confusion and lethargy related to
hyponatremia.
• Her husband tells you that M.H. had c/o
diarrhea over the past week and was
drinking lots of water to prevent
dehydration.
• What caused M.H.’s serum sodium level to
fall?
Case Study
• As you admit M.H. to the nursing unit, you

develop an individualized plan of care.
• Identify appropriate nursing diagnoses for M.H.
Case Study
• Identify appropriate nursing interventions to help

normalize M.H.’s serum sodium levels.
• How would treatment differ if hyponatremia was
more severe?
Potassium
• Major ICF cation
• Necessary for
• Transmission and conduction of nerve and muscle
impulses
• Cellular growth
• Maintenance of cardiac rhythms
• Acid-base balance
Potassium
• Sources
• Fruits and vegetables (bananas and oranges)
• Salt substitutes
• Potassium medications (PO, IV)
• Stored blood
• Regulated by kidneys
Hyperkalemia
• High serum potassium caused by
• Impaired renal excretion
• Shift from ICF to ECF
• Massive intake
• Most common in renal failure
Hyperkalemia
• Manifestations
• Cardiac dysrhythmias
• Cramping leg pain
• Weak or paralyzed skeletal muscles
• Abdominal cramping or diarrhea

Management
• Force K from ECF to ICF by IV insulin and a -
adrenergic agonist or sodium bicarbonate
• Reverse membrane effects of elevated ECF potassium
by administering calcium gluconate IV
Case Study
Hypokalemia (©iStockphoto/Thinkstock)
• T.M., a 76-year-old male, is brought to

emergency department with confusion and
lethargy.
• He has a history of hypertension and type 2
diabetes.
• Patient doubled his furosemide (Lasix) dose
for the last 2 weeks because he felt “puffy.”
Case Study
• T.M.’s lab results include serum

K+ 2.8 and Hct 56%.
• What is the probable cause of T.M.’s
hypokalemia?
• Explain the Hct lab result based on T.M.’s
recent history.
• For what clinical manifestations would you
assess T.M.?
Case Study
• Assessment of T.M. reveals the following:

• Poor skin turgor, c/o leg cramps
• Heart rate 135 and irregular
• Respiratory rate 26
• BP 110/58
• Identify appropriate nursing diagnoses for T.M.
Case Study
• T.M. is started on .45 NaCl and potassium

chloride replacement is ordered.
• How will you administer the potassium chloride?
• Discuss other appropriate nursing interventions
for T.M.
Case Study
• T.M.’s serum electrolytes and fluid volume status

return to normal.
• What important teaching should be done with
T.M. in anticipation of discharge?
Calcium
• Functions
• Formation of teeth and bone
• Blood clotting
• Transmission of nerve impulses
• Myocardial contractions
• Muscle contractions
Hypercalcemia
• High levels of serum calcium
caused by
• Hyperparathyroidism (two thirds
of cases)
• Malignancy
Hypercalcemia
• Manifestations
• Fatigue, lethargy, weakness, confusion
• Hallucinations, seizures, coma
• Bone pain, fractures, nephrolithiasis
• Polyuria, dehydration

Management
• Nursing Diagnoses and Collaborative Problem

• Risk for inactivity intolerance
• Risk for injury
• Potential complication: Dysrhythmias

Management
• Excretion of Ca with loop diuretic
• Hydration with isotonic saline infusion
• Low calcium diet
• Mobilization
• Bisphosphonates
• IM or SC calcitonin
Hypocalcemia
• Low serum Ca levels caused by

• Decreased production of PTH
• Multiple blood transfusions
• Alkalosis
• Increased calcium loss
Hypocalcemia
• Manifestations
• Positive Trousseau’s or Chvostek’s sign
• Laryngeal stridor
• Dysphagia
• Tingling around the mouth or in the extremities

Management
• Nursing Diagnoses and Collaborative Problem
• Ineffective breathing pattern
• Acute pain
• Risk for injury
• Potential complication: Fracture, respiratory arrest

Management
• Treat cause
• Oral or IV calcium supplements
• Rebreathe into paper bag
• Treat pain and anxiety to prevent hyperventilation-
induced respiratory alkalosis
Phosphate
• Primary anion in ICF
• Essential to function of muscle, red blood cells,
and nervous system
• Involved in acid-base buffering system, ATP
production, cellular uptake of glucose, and
metabolism of carbohydrates, proteins, and fats
Phosphate
• Serum levels controlled by parathyroid hormone
• Maintenance requires adequate renal functioning
• Reciprocal relationship with calcium
Hyperphosphatemia
• High serum PO43- caused by
• Acute kidney injury or chronic kidney disease
• Chemotherapy
• Excess intake of phosphate or vitamin D
• Hypoparathyroidism
Hyperphosphatemia
• Manifestations
• Neuromuscular irritability and tetany (hypocalcemia)
• Calcified deposition in soft tissue such as joints,
arteries, skin, kidneys, and corneas (can cause organ
dysfunction)
Hyperphosphatemia
• Management
• Identify and treat underlying cause
• Restrict foods and fluids containing phosphorus
• Oral phosphate-binding agents
• Volume expansion and forced diuresis
• Correct any hypocalcemia
• Hemodialysis
Hypophosphatemia
• Low serum PO43- caused by
• Malnourishment/malabsorption
• Diarrhea
• Use of phosphate-binding antacids
• Inadequate replacement during parenteral nutrition
Hypophosphatemia
• Manifestations
• CNS depression
• Muscle weakness and pain
• Respiratory and heart failure
• Rickets and osteomalacia
Hypophosphatemia
• Management
• Oral supplementation
• Ingestion of foods high in phosphorus
• IV administration of sodium or potassium phosphate
Magnesium
• Coenzyme in metabolism of carbohydrates
• Required for DNA and protein synthesis
• Blood glucose control
• BP regulation
• Necessary for ATP production
Magnesium
• Acts directly on myoneural junction
• Important for normal cardiac function
• 50% to 60% contained in bone
• Absorbed in GI tract
• Excreted by kidneys
Hypermagnesemia
• High serum Mg caused by
• Increased intake or ingestion of products containing
magnesium when renal insufficiency or failure is present
• Excess IV magnesium administration
Hypermagnesemia
• Manifestations
• Lethargy
• Nausea and vomiting
• Impaired reflexes
• Muscle paralysis
• Respiratory and cardiac arrest
Hypermagnesemia
• Management
• Prevention first—restrict magnesium intake in high-
risk patients
• IV CaCl or calcium gluconate if symptomatic
• Fluids and IV furosemide to promote urinary
excretion
• Dialysis
Hypomagnesemia
• Low serum Mg caused by
• Prolonged fasting or starvation
• Chronic alcoholism
• Fluid loss from gastrointestinal tract
• Prolonged parenteral nutrition without supplementation
• Diuretics
• Hyperglycemic osmotic diuresis
Hypomagnesemia
• Manifestations
• Hyperactive deep tendon reflexes
• Muscle cramps
• Tremors
• Seizures
• Corresponding hypocalcemia and hypokalemia
Hypomagnesemia
• Management
• Treat underlying cause
• Oral supplements
• Increase dietary intake
• Parenteral IV or IM magnesium when severe
Oral Fluid Replacement

• Used to correct mild fluid and electrolyte deficits
• Water
• Glucose
• Potassium
• Sodium
IV Fluids
• Purposes
• Maintenance
• When oral intake is not adequate
• Replacement
• When losses have occurred
• Types of fluids categorized by tonicity

IV Fluids
• Hypotonic
• More water than electrolytes
• Pure water lyses RBCs
• Water moves from ECF to ICF by osmosis
• Usually maintenance fluids
• Monitor for changes in mentation
IV Fluids
• Isotonic
• Expands only ECF
• No net loss or gain from ICF
• Ideal to replace ECF volume deficit
D5W
Isotonic
• Free water without electrolytes
• Provides 170 cal/L
• Used to replace water losses, treat
hypernatremia, prevent ketosis
Normal Saline (NS or NSS)

Isotonic
• More NaCl than ECF
• No free water, calories or electrolytes
• Expands IV volume
• Preferred fluid for immediate response
• Compatible with most medications
• Only solution used with blood
Lactated Ringer’s Solution

Isotonic
• Similar in composition to plasma except
contains no magnesium
• Expands ECF—treat burns and
GI losses
• Contraindicated with hyperkalemia and lactic
acidosis
• No free water or calories
IV Fluids
• Hypertonic
• Initially expands and raises the osmolality of ECF
• Require frequent monitoring of
• Blood pressure
• Lung sounds
• Serum sodium levels
D5 ½ NS
Hypertonic
• Common maintenance fluid
• Replaces fluid loss
• KCl added for maintenance or replacement
D10W
Hypertonic
• Provides 340 kcal/L
• Provides free water but no electrolytes
• Limit of dextrose concentration may be
infused peripherally
Colloids
• Stay in vascular space and increase osmotic
pressure
• Include:
• Human plasma products (albumin, fresh frozen plasma,
blood)
• Semisynthetics (dextran and starches, [Hespan])
Fig. 17-12. Differential assessment of extracellular fluid (ECF) volume.

Week 2 For Posting CH 16 Fluid and Electrolytes

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Copyright © 2017, Elsevier Inc. All Rights Reserved.

Mechanisms Controlling Fluid and

Mechanisms Controlling Fluid and

Mechanisms Controlling Fluid and

Mechanisms Controlling Fluid and

Osmotic Movement of Fluids

Mechanisms Controlling Fluid and

• Plasma-to-interstitial fluid shift results in edema

Regulation of Water Balance

Regulation of Water Balance

Regulation of Water Balance

Regulation of Water Balance

Regulation of Water Balance

Fluid and Electrolyte Imbalances

Extracellular Fluid Volume Imbalances

Extracellular Fluid Volume Imbalances

Extracellular Fluid Volume Imbalances

Extracellular Fluid Volume Imbalances

Assessment of Skin Turgor

Nursing and Inter-professional

Nursing and Interprofessional

• M.H., a 62-year-old female, was admitted

• As you admit M.H. to the nursing unit, you

• Identify appropriate nursing interventions to help

Nursing and Interprofessional

• T.M., a 76-year-old male, is brought to

• T.M.’s lab results include serum

• Assessment of T.M. reveals the following:

• T.M. is started on .45 NaCl and potassium

• T.M.’s serum electrolytes and fluid volume status

Nursing and Interprofessional

• Nursing Diagnoses and Collaborative Problem

Nursing and Interprofessional

• Low serum Ca levels caused by

Nursing and Interprofessional

Nursing and Interprofessional

Oral Fluid Replacement

• Types of fluids categorized by tonicity

Normal Saline (NS or NSS)

Lactated Ringer’s Solution

Fig. 17-12. Differential assessment of extracellular fluid (ECF) volume.

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