FLUID AND ELECTROLYTE

BALANCES

KRISHA LOREN F. FERRER

ICU-CCU STAFF NURSE
WHY IS IT IMPORTANT FOR
NURSES TO KNOW ABOUT
FLUID & ELECTROLYTE
BALANCE
INTRODUCTION
Water is found everywhere on earth
including human body
In an adult 60% of the weight is water
Two third of the body’s water is found in
the cell
 FLUID CONTENT OF THE BODY

Varies with age, sex, adipose tissue

- Females 45-50% TBW
- Males 50-60% TBW
- Infants 77% TBW
- In old age , only about 45% of body weight
is water.
 DISTRIBUTION OF BODY
FLUIDS

Body fluids are distributed in two distinct

compartments:
1.Extracellular fluids[ECF] Which includes
interstitial fliud & intravascular fluid
2.Intracellular fluids[ICF]
 SOLUTES

Non-electrolytes
-dextrose
- urea
- creatinine
Electrolytes
-Anions - negatively charged ions (Chloride, HCO3)
-Cations – positively charged ions (Sodium, potassium, calcium)
*Electrolytes have greater osmotic pressure than non-electrolytes.
*Water moves according to osmotic gradient.
 COMPOSITION OF BODY
FLUIDS
The fluids circulating throughout the body in
extracellular and intracellular fluid spaces
contain
1.Electrolytes
2.Minerals
3.Cells
MOVEMENT OF BODY
FLUIDS
Diffusion
Osmosis
Filtration
Active transport
REGULATION OF BODY
FLUIDS
Fluid intake
Fluid output
Hormonal influence
Lymphatic influences
Neurologic influences
Renal influences
 FLIUD IMBALANCES
The five types of fluid imbalances that may
occur are:
Extracellular fluid imbalances(EVFVD)
Extracellular fluid volume excess(ECFVE)
Extracellular fluid volume shift
Intracellular fluid vloume excess(ICFVE)
Intrcellular fluid volume deficit(ICFVD)
 EXTRACELULLAR FLUID
VOLUME DEFICIT
An ECFVD, commonly called as dehydration , is a
decrease in intravascular and interstitial fluids
An ECFVD can result in cellular fluid loss if it is
sudden or severe

* The goal of treatment is to restore fluid volume,

replace electrolytes as needed, and eliminate the
cause of fluid volume deficit.
 THREE TYPES OF ECFVD
Hyperosmolar fluid volume deficit- water loss is greater than the electrolyte loss
- the clinical problems that occur result from alterations in the concentrations of specific
plasma electrolytes.
- fluid moves the intracellular compartment into the plasma and interstitial fluid spaces,
causing cellular dehydration and shrinkage.
Isosmolar fluid volume deficit (hypovolemia) – equal proportion of fluid and electrolyte loss .
- most common type of dehydration.
- results in decreased circulating blood volume and inadequate tissue perfusion.
Hypotonic fluid volume deficit – electrolyte loss is greater than fluid loss.
- fluid moves from the plasma and interstitial fluid spaces into the cells, causing a plasma
volume deficit and causing cells to swell.
 CAUSES OF FLUID VOLUME DEFICIT

1. ISOTONIC DEHYDRATION
a. Inadequate intake of fluids and solutes.
b. Fluid shifts between compartments
c. Excessive losses of isotonic body fluids
2. Hypertonic dehydration – conditions that increase fluid loss, such as
excessive perspiration, hyperventilation, ketoacidosis, prolonged fevers,
diarrhea, early stage renal failure and diabetes insipidus.
3. Hypotonic dehydration
a. Chronic illness
b. Excessive fluid replacement (hypotonic)
c. Renal failure
d. Chronic malnutrition
 INTERVENTIONS

1. Monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and

gastrointestinal status.
2. Prevent further fluid losses and increase fluid compartment volumes to normal ranges.
3. Provide oral rehydration therapy if possible and intravenous (IV) fluid replacement if
the dehydration is severe; monitor intake and output.
4. Generally, isotonic dehydration is treated with isotonic fluid solutions, hypertonic
dehydration with hypotonic fluid solutions, and hypotonic dehydration with hypertonic
fluid solutions.
5. Administer medications as prescribed such as antidiarrheal, antimicrobial, antiemetic,
and antipyretic medications, to correct the cause and treat the symptoms.
6. Administer oxygen as prescribed.
7. Monitor electrolyte values and prepare to administer medication to treat an imbalance, if
present.
EXTRACELLULAR FLUID
VOLUME EXCESS

ECFVE is increased fluid retention in the intravasular and interstitial

spaces
Flid intake or fluid retention exceeds the fluid needs of the body.
Fluid volume excess is also called OVERHYDRATION or Fluid
overload.
The goal of treatment is to restore fluid balance, correct electrolyte
imbalances if present, and eliminate or control the underlying cause of
the overload.
 TYPES:

1. Isotonic Overhydration
a. known as hypervolemia, isotonic overhydrationresults from excessive fluid in the
ECF compartment.
b. Only the ECF compartment is expanded, and fluid does not shift between the
extracellular and intracellular compartment.
c. Isotonic dehydration causes circulatory overload and interstitial edema; when
severe or when it occurs in a client with poor caediac function, CHF and
pulmonary edema can result.
2. Hypertonic overhydration
a. Occurence of hypertonic overhydration is rare and is caused by an excessive
sodioum intake
b. Fluid is drawn from the intracellular fluid compartment; the extracellular fluid
volume expands; and the intracellular fluid volume.
3. Hypotonic overhydration
a. Hypotonic overhydration is
ETIOLOGY AND RISK FACTORS

Heart failure
Renal disorders
Cirrhosis of liver
Increased ingestion of high sodium foods
Excessive amount of IV fluids containing sodium
Electrolyte free IV fluids
SIADH,Sepsis
decreased colloid osmotic pressure
lymphatic and venous obstruction
Cushing’s syndrome & glucocorticoids
 CLINICAL MANIFESTATION
Constant irritating cough
Dyspnea & crackles in lungs
Cyanosis, pleural fffusion
Neck vein obstruction
Bounding pulse &elevated BP
S3 gallop
Pitting & sacral edema
Weight gain
Increased CVP& PCWP
Change in level of consiousness
LAB INVESTIGATION
serum osmolality <275mOsm/ kg
Low , normal or high sodium
Decreased hematocrit [ < 45%]
Specific gravity below 1.010
Decreased BUN [< 8mg/ dl]
MANAGEMENT
Diuretics [combination of potassium
sparing and potassium depleting diuretics]
In people with CHF, ACE inhibitors and
low dose of beta blockers are used
A low sodium diet
VOLUME SHIFT: THIRD
SPACING
Fluid that shifts into the interstitial spaces
and remain there is called as third space
fluid
Common sites are abdomen , pleural cavity,
peritoneal cavity and pericardial sac
RISK FACTORS
Crushing injuries, major tissue trauma
Major surgery
Extensive burns
Acid –base imbalances and sepsis
Perforated peptic ulcers
Intestinal obstruction
Lymphatic obstruction
Autoimmune disorders
Hypoalbunemia
GI tract malabsorption
CLINICAL MANIFESTATION
skin pallor
Cold extremities
Weak and rapid pulse
Hypotension
Oliguria
Decreased levels of consiousness
LAB INVESTIGATION
Elevated hematocrit & BUN level
 MANAGEMENT
Treat the cause
1. For burns and tissue injuries large volume of
isosmolar IV fluid is administered
2. Albumin is administered for protein deficit
3. IV fluid intake is maintained after major
surgery to maintain kidney perfusion
4. Pericardiocentesis if pericarditis is the result
5. Paracentesis for ascitis
VOULME EXCESS:WATER
INTOXICATION

ICFVE is increase in amount of water

inside the cells
 ETIOLOGY

Administration of excessive amount of

hyposmolar IV fluids[0.45%saline or
5%dextrose in water]
Consumption of excessive amount of tap
water without adequate nutritional intake
SIADH
Schizophrenia[compulsive water
consumption]
CLINICAL
MANIFESTATIONS
Headaches
Behavioral changes
Apprehension
Irritability, disorientation and confusion
Increased ICP – pupillary changes and decreased motor
and sensory function
Bradycardia, elevated BP, widened pulse pressure &
altered respiratory patterns, Babinski’s response flaccidity,
projectile vomiting, Papilledema, delirium, convulsions
&coma
LABORATORY FINDINGS
High serum sodium level- 125 mEq/L
decreased hamatocrit
MANAGEMENT
Early administration of IV fluids containing sodium
chloride cam prevent SIADH
oral fluids such as juices or soft drinks can be given
orally every hour
Perform neurologic checks every hour to see if
cranial changes are present
Monitor fluid intake , IV fluids and fluid output
hourly and weight daily
Administer antiemetics for food and fluid retention
INTRACELLULAR FLUID
VOLUME DEFICIT
Severe hypernatremia and dehydration can cause
ICFVD
Relatively rare in healthy adults
common in elderly people and in those conditions
that result in acute water loss
Symptoms include confusion, coma, and cerebral
hemorrhage
Sodium Definiti Risk factors/ etiology Clinical Laboratory management
imbalances on manifestation findings

Kidney diseases •Weak rapid pulse •Serum sodium •Identify the cause
Hyponatr •Hypotension less than and treat
-aemia It is Adrenal •Dizziness 135mEq/ L
defined insufficiency •Apprehension *Administration of
as a and anxiety • serum sodium orally, by
plasma Gastrointestinal •Abdominal osmolality less NG tube or
sodium losses cramps than parenterally
level •Nausea and 280mOsm/kg
below Use of diuretics vomiting *For patients who
135 (especially with •Diarrhea •urine specific are able to eat &
mEq/ L along with low •Coma and gravity less than drink, sodium is
sodium diet) convulsion 1.010 easily accomplished
•Cold clammy through normal diet
Metabolic acidosis skin
•Finger print *For those unable
impression on the to eat,Ringer’s
sternum after lactate solution or
palpation isotonic saline
•Personality [0.9%Nacl]is given
change
*For very low
sodium 0.3%Nacl
may be indicated
*water restriction in
case of
hypervolaemia
Sodium Definit causes Clinical Lab findings management
imbalan ion manifestation
-ce

Hypernat It is *Ingestion of *high serum *Administration of

-remia defined large amount Low grade sodium hypotonic sodium solution
as of 135mEq/L [0.3 or 0.45%]
plasma concentrated fever
sodium salts *high serum *Rapid lowering of
level *Iatrogenic Postural osmolality295m sodium can cause cerebral
greater administration O sm/kg edema
than of hypertonic hypertension
145mE saline IV *high urine *Slow administration of
q/L *Excess Dry tongue specificity 1.030 IV fluids with the goal of
alderosterone reducing sodium not more
secretion & mucous than 2 mEq/L for the first
48 hrs decreases this risk
membrane
*Diuretics are given in
Agitation case of sodium excess

Convulsions *In case of Diabetes

insipidus desmopressin
Restlessness acetate nasal spray is used

Excitability *Dietary restriction of

sodium in high risk clients
Oliguria or

anuria
Potassium Definitio Causes Clinical Lab findings Management
imbalances n manifestation

Hypokalemia It is *Use of *weak irregular * K – less than Mild hypokalemia[3.3to

defined as potassium pulse 3mEq/L results 3.5] can be managed by
plasma wasting in ST oral potassium
potassium diuretic *shallow depression , replacement
level of respiration flat T wave,
less than *diarrhea, taller U wave
3.0 vomiting or *hypotesion Moderate hypokalemia
mEq/L other GI losses * K – less than *K-3.0to 3.4mEq/L need
*weakness, 2mEq/L cause 100to 200mEq/L of IV
*Alkalosis decreased widened QRS, potassium for the level to
bowel sounds, depressed ST, rise to 1mEq/
*Cushing’s inverted T
syndrome heart blocks , wave
paresthesia,
*Polyuria fatigue,

*Extreme decreased
Severe hypokalemia K- less
sweating muscle tone
than 3.0mEq/L need 200to
400 mEq/L for the level to
*excessive use intestinal
rise to l mEq/L
of potassium obstruction
*Dietary replacement of
free Ivs
potassium helps in
correcting the problem[1875
to 5625 mg/day]
 Definition Causes Clinical Lab findings Management
manifestation

It is Renal failure , Irregular slow *High serum *Dietary restriction of

Hyperkal defined as pulse, potassium potassium for potassium
emia the Hypertonic 5.3mEq/L less than 5.5 mEq/L
elevation dehydration, hypotension, results in
of peaked T wave *Mild hyperkalemia can be
potassium Burns& trauma anxiety, HR 60 to 110 corrected by improving
level output by forcing fluids,
above Large amount of irritability, *serum giving IV saline or
5.0mEq/L IV administration potassium of potassium wasting diuretics
of potassium, paresthesia, 7mEq/L results
in low broad P- *Severe hyperkalemia is
Adrenal weakness wave managed by
insufficiency 1.infusion of calcium
*serum gluconate to decrease the
Use of potassium potassium antagonistic effect of
retaining diuretics levels of potassium excess on
& 8mEq/L results myocardium
rapid infusion of in no arterial 2.infusion of insulin and
stored blood activity[no p- glucose or sodium
wave] bicarbonate to promote
potassium uptake
3.sodium polystyrene
sulfonate [Kayexalate]
given orally or rectally as
retention enema
Calcium Definitio Causes Clinical Lab
imbalan n manifestation findings Management
ces

hypocalc It is a •Rapid •Numbness and Serum 1.Asymtomatic hypocalcemia is

emia plasma administration of tingling calcium treated with oral calcium chloride,
calcium blood containing sensation of less calcium gluconate or calcium
level citrate, fingers, than 4.3 lactate
below mEq/L
8.5 •hypoalbuminemia, •hyperactive and 2.Tetany from acute hypocalcemia
mg/dl reflexes, ECG needs IV calcium chloride or
•Hypothyroidism , • Positve changes calcium gluconate to avoid
Trousseau’s hypotension bradycardia and other
•Vitamin sign, positive dysrythmias
deficiency, chvostek’s sign ,
3.Chronic or mild hypocalcemia
•neoplastic •muscle cramps, can be treated by consumption of
diseases, food high in calcium
•pathological
•pancreatitis fractures,

•prolonged
bleeding time
Calcium Definition Causes Clinical Lab findings Management
imbalance manifestation

It is •Hyperthyro •Decreased •High serum 1.IV normal saline, given

calcium •idism, muscle tone, calcium level rapidly with Lasix
Hypercalc plasma 5.5mEq/L, promotes urinary excretion
emia level over •Metastatic •anorexia, of calcium
5.5 mEq/l bone tumors, • x- ray
or 11mg/dl •nausea, showing 2.Plicamycin an antitumor
•paget’s vomiting, generalized antibiotics decrease the
disease, osteoporosis, plasma calcium level
•weakness ,
lethargy, •widened bone 3.Calcitonin decreases
•osteoporosis , cavitation, serum calcium level
•low back pain
•prolonged from kidney •urinary stones, 4.Corticosteroid drugs
immobalisation stones, compete with vitamin D
•elevated BUN and decreases intestinal
•decreased level 25mg/100ml, absorption of calcium
of
consciousness •elevated 5. If cause is excessive use
& cardiac arrest creatinine1.5mg of calcium or vitamin D
/100ml supplements reduce or
avoid the same
Acid-Base Definition Causes Clinical Lab findings Management
imbalance manifestation

Respiratory It is a COPD, Dyspnea , PH lesser than 1.Treat underlying

acidosis clinical neuromuscular disorientation, 7.35, cause
disorder in disorder, Guillian- coma Paco2 greater
Hypoventilation which the Barre syndrome, than 45mmHg, 2.Support ventilation
& excessive pH is less Myssthenia gravis, Hyperkalemia,
CO2 production than 7.35 Respiratory center Hypoxemia 3.Correct electrolyte
and the depression, Drugs, imbalance
paCO2 is late ARDS,
greater 4.Intravenous
than NaHCO3
42mmHg

Respiratory It is a Hypoxemia, Tachypnea, PH greater than Increase CO2

Alkalosis clinical impaired lung giddiness, 7.35 retention
condition expansion, dizziness, PaCO2 lesser through CO2
Hyperventilation in which thickened alveolar syncope, than 35 mmHg, rebreathing &
the arterial – capillary convulsions, Hypokalemia, sedation and
Ph is membrane, coma, Hypocalcemia mechanical
greater Chemical weakness, hypoventilation
than7.45 stimulation of paresthesia,
and the respiratory center, tetany
paCO2 is traumatic
less than stimulation of
38mmHg respiratory center
 Definition causes Clinical Lab findings Management
manifestation

Metabolic It is a Renal failure, Hyperventilation PH< 7.35, 1.Treat the underlying

Acidosis clinical Diabetic confusion, HCO3< cause
condition in ketoacidosis, drowsiness, 22mEq/L
which the Lactic acidosis, coma, headache 2.Intravenous
HCO3 & pH ingested toxins, NaHCO3
is decreased renal tubular
acidosis 3.correct electrolyte
imbalance

Metabolic It is a Hypokalemia, Hypoventilation PH >7.45 1.Treat the underlying

Alkalosis clinical gatric fluid loss, Dysrythmias Hypokalemia cause
condition in massive Hypocalcemia
which PH is correction of PaCO2 normal 2.Administer KCL
raised whole blood, or increased
Overcorrection of 3.intravenous
acidosis with acidifying
NaCO3 salts[NH4CL]

4.Administer
acetazolamide
CONCLUSION