Fluid & Electrolyte

Assessment and Care of Patients with

Fluid and Electrolyte Imbalances
Dr. Charlotte G. Merrill, DNP, FNP-C
Spring 2014

OBJECTIVES
1. Explain the relationship between weight gain or loss
and fluid imbalances.
2. Use laboratory data and clinical manifestations to
determine the presence of fluid or electrolyte
imbalances.
3. Prioritize interventions for patients who have
dehydration or fluid overload.
4. Plan effective care of patients with the following
imbalances: hypovolemia, hypervolemia,
hyponatremia, hypernatremia, hypokalemia, and
hyperkalemia.

Fluid & Electrolyte

Fluid and electrolyte balance is a dynamic
process that is crucial for life and
homeostasis.

Homeostasis maintenance of relatively

stable internal physiological conditions, i.e.
temp, fluid volume.

Water
Most common substance in the body
55% - 60% of total body weight
Divided into two main compartments

Extracellular Fluid
Fluid outside the cell
1/3 (15L) of the total body water
Includes interstitial fluid
Fluid between the cells third space
Blood
Lymph
Connective tissue water
Transcellular fluids
Cerebrospinal fluid
Synovial fluid
Peritoneal fluid
Pleural fluid

Intracellular Fluid
Two thirds (25L) of total body water
Includes all the water and electrolytes within cells
High concentrations of:
Potassium
Phosphate
Magnesium ions
Lesser amounts of:
Sodium
Chloride
Bicarbonate ions

Regulates Fluid & Electrolytes

Filtration
Movement of fluid through a membrane; usually
occurs from capillaries to the interstitial space
Diffusion
Movement of electrolytes into or out of the cell
Osmosis
Movement of water only through a selectively
permeable (semi-permeable) membrane

Filtration

Diffusion

The Process of Osmosis

Terms to Know
Hydrostatic pressure:
The water-pushing pressure, the force that
pushes water outward from a confined space
through a membrane.
Viscous:
Fluid that is thicker than water
Permeable:
Porous membrane (open to particles)
Impermeable:
Membrane is not open to particles

Terms
Equilibrium:
No pressure difference between two spaces
Disequilibrium:
Two spaces have a graded difference for
hydrostatic pressure
Gradient:
Graded difference b/c of the amount of solutes
in the water.

*****Pearl: Where the fluid is at any moment in time depends on

the balance of hydrostatic pressure (push from the heart and out
through the capillary walls) and the osmotic pressure (push or pull
of the large molecules big boy M&Ms-namely Albumin, which pull
water with them wherever they are located.

Clinical Significance: Blood Pressure

Blood pressure is an example of hydrostatic filtering
forces. It moves whole blood from the heart to capillaries
where filtration can occur to exchange water, nutrients,
and waste products between the blood and the tissues.

Clinical Significance: Edema

Edema develops with changes in normal hydrostatic
pressure differences.

Clinical Significance: Diffusion

Diffusion happens across a permeable membrane from
an area of higher concentration to an area of lower
concentration.
Sodium pumps
Glucose cannot enter most cell membranes without the
help of insulin.

More Terms to know

Particle concentration in body fluids is expressed in:
Milliequivalents per liter (mEq/L)
Millimoles per liter (mmol/L)
Milliosmoles per liter (mOsm/L)
Osmolarity:
The number of milliosmoles in a liter of solution
Normal osmolarity value for plasma and other
body fluids ranges from 270 300 mOsm/L.

Check Your Understanding!

The third space refers to the:
A. vascular area
B. interstitial area
C. intracellular area

Where are most fluids found in the body?

A. blood
B. interstitial space
C. cells

Check Your Understanding!

If a large quantity of fluid had been lost from the vascular
bed, what do you think will happen to the hydrostatic
pressure? It will:
A. increase
B. decrease

If fluid moves from the interstitial space to the blood,

what would you expect to find when assessing the skin?
A. Dry skin with poor turgor

B. Edema

Check Your Understanding!

Which meal option should a nurse choose for a client with
FVE(fluid volume excess) who is placed on a lowsodium?
a. Bologna sandwich on whole wheat bread, potato chips,
sliced cucumbers, and iced tea
b. Spaghetti with meat sauce, salad, hard-crust bread and
milk
c. Baked chicken breast, cor on the cob, dinner roll, and
mild
d. Steak, broccoli with cheese sauce, crackers, and hot
tea.

Clinical Significance: Osmosis and Filtration

The thirst mechanism is an example of how osmosis
helps maintain homeostasis.
The feeling of thirst is caused by the activation of cells in
the brain that respond to changes in ECG osmolarity.

Fluid Balance
Fluid intake
Fluid loss:
Minimum amount of urine needed to excrete
toxic waste products is 400 to 600 mL
Insensible water loss
Skin
Lungs
stools

Hormonal Regulation of Fluid Balance

Aldosterone
Secreted by the adrenal cortex when sodium level in
the ECF is decrease.
Prevents both water and sodium loss
Antidiuretic hormone (ADH)
Secreted by the hypothalamus in response to
changes in blood osmolarity; increase plasma
sodium.
Natriuretic peptides
Hormones secreted by special cells that line the atria
of the heart in response to increased blood volume
and blood pressure diuretic effect

Dehydration
Fluid intake is less than what is needed to meet the
bodys fluid needs, resulting in a fluid volume deficit.
Consideration for older adults.

Collaborative CareDehydration
Assessment
History

Physical assessment/clinical manifestations:

Cardiovascular changes
Respiratory changes
Skin changes
Neurologic changes
Renal changes

Dehydration: Laboratory Assessment

Hemoconcentration

Elevated
Hemoglobin

Hematocrit
Serum osmolarity
Glucose
Protein
BUN
Electrolytes

Dehydration: Interventions
Patient safety
Fluid replacement
Drug therapy

The nurse is caring for a patient with hypovolemia

secondary to severe diarrhea and vomiting. In
evaluating the respiratory system for this patient, what
does the nurse expect to assess?
a. No changes, because the respiratory system is not
involved
b. Hypoventilation, because the respiratory system is
trying to compensate for low pH
c. Increased respiratory rate, because the body perceives
hypovolemia as hypoxia
d. Normal respiratory rate, but a decreased oxygen
saturation.

Fluid Overload
Excess of body fluid.
Most problems caused by
overhydration are related to
fluid volume excess in the
vascular space or to dilution of
specific electrolytes and blood
components.

Collaborative CareFluid Overload

Assessment
Patient safety

Pulmonary edema
Drug therapy

Nutrition therapy
Monitoring of I&O

Sodium (135 to 145 mmol/L)

Sodium level is vital for skeletal muscle contraction,

cardiac contraction, nerve impulse transmission, and
normal osmolarity and volume of the ECF.

Hyponatremia
Sodium level below 136 mEq/L
Cerebral changes
Neuromuscular changes
Intestinal changes
Cardiovascular changes

Hyponatremia Interventions
The priority for nursing care of the patient with
hyponatremia is monitoring the patients response to
therapy and preventing hypernatremia and fluid
overload.

Drug therapy.
Nutrition therapy.

Hypernatremia
Serum sodium level over 145 mEq/L
Nervous system changes

Skeletal muscle changes

Cardiovascular changes

Hypernatremia Interventions
Priorities for nursing care of the patient with
hypernatremia include monitoring the patient's response
to therapy and preventing hyponatremia and
dehydration.

Drug therapy.
Nutrition therapy.

Potassium (3.5 to 5.0 mEq/L)

Major cation of the intracellular fluid (ICF).

Hypokalemia
Serum potassium level below 3.5 mEq/L

Can be life threatening because every body system is

affected
Respiratory changes
Musculoskeletal changes
Cardiovascular changes
Neurologic changes
Intestinal changes

Hypokalemia Interventions
The priorities for nursing care of the patient with
hypokalemia are ensuring adequate oxygenation and
patient safety for falls prevention, preventing injury from
potassium administration, and monitoring the patent's
response to therapy.
Drug therapy.
Nutrition therapy.
Safety measures.
Respiratory monitoring.

Hyperkalemia
Serum potassium greater than 5.0 mEq/L.
Cardiovascular changes are the most severe problems
from hyperkalemia and are the most common cause of
death in patients with hyperkalemia.
Neuromuscular changes.
Intestinal changes.

Hyperkalemia Interventions
Drug therapyKayexalate, insulin
Cardiac monitoring

Health teaching

Calcium (9.0 to 10.5 mg/dL)

Calcium is a mineral with functions closely related
to those of phosphorus and magnesium.
Absorption of dietary calcium requires the active
form of vitamin D.
Calcium is stored in the bones.
Parathyroid hormone.
Thyrocalcitonin.

Hypocalcemia
Total serum calcium level below 9.0 mg/dL
Womens health considerations
Neuromuscular changes
Cardiovascular changes
Intestinal changes
Skeletal changes

Hypocalcemia Interventions
Drug therapy
Nutritional therapy

Environmental managementseizure precautions

Injury prevention strategies

Hypercalcemia
Total serum calcium level above 10.5 mg/dL.
Effects of hypercalcemia occur first in excitable tissues.
All systems are affected.
Cardiovascular changes are the most serious and lifethreatening problems of hypercalcemia.

Neuromuscular changes.
Intestinal changes.

Hypercalcemia Interventions
Drug therapyIV 0.9% sodium chloride, furosemide,
calcium chelators, phosphorus, calcitonin,
bisphosphonates, and prostaglandin synthesis
inhibitors

Dialysis
Cardiac monitoring

Phosphorus (3.0 to 4.5 mg/dL)

Most phosphorus can be found in the bones.
Phosphorus is needed for activating vitamins and
enzymes

Food sources include meats, fish, dairy products, and

nuts.
Plasma levels of calcium and phosphorus exist in a
balanced reciprocal relationship.

Hypophosphatemia
Serum phosphorus level below 3.0 mEq/L.
Most of the effects of hypophosphatemia are related to
decreased energy metabolism and imbalances of other
electrolytes and body fluids.

Hypophosphatemia (Contd)
Manifestations are most apparent in the cardiac,
musculoskeletal, and hematologic systems and the
CNS.
Cardiac changes.
Musculoskeletal changesrhabdomyolysis.
CNS changes.

Hypophosphatemia Interventions
Oral replacement of phosphorus
Vitamin D supplements

IV phosphorus
Nutrition therapyincreasing the intake of phosphorusrich foods while decreasing the intake of calcium-rich
foods

Hyperphosphatemia
Serum phosphorus level above 4.5 mEq/L.
Problems caused by hyperphosphatemia center on the
hypocalcemia that results when serum phosphorus
levels increase.
Does not cause many direct problems with body
function.

Causes include renal insufficiency, certain cancer

treatments, increased phosphorus intake, and
hypoparathyroidism.

Hyperphosphatemia Interventions
Because calcium and phosphorus ions exist in the blood
in a balanced reciprocal relationship, management of
hyperphosphatemia entails the management of
hypocalcemia.

Magnesium (1.3 to 2.1 mg/dL)

Magnesium is critical for skeletal muscle contraction,
carbohydrate metabolism, vitamin activation, and cell
growth.

Hypomagnesemia
Serum magnesium level below 1.3 mEq/L.
Effects of hypomagnesemia are caused by increased
membrane excitability and the accompanying serum
calcium and potassium imbalances.

Hypomagnesemia (Contd)
Neuromuscular changes.
CNS changes.
Intestinal changes.
Interventions for hypomagnesemia:
DrugsIV magnesium sulfate

Hypermagnesemia
Serum magnesium level above 2.1 mEq/L.
When magnesium excess occurs, excitable membranes
are less excitable and need a stronger-than-normal
stimulus to respond.
Cardiac changes.
CNS changes.
Neuromuscular changes.
Respiratory changes.

Hypermagnesemia Interventions
Magnesium-free IV fluids
Furosemide
Calcium

Chloride (98 to 106 mEq/L)

Imbalances of chloride usually occur as a result of other
electrolyte imbalances.

Usually corrected by interventions for correcting other

electrolyte or acid-base problems.

I DID IT !!!!