Fluids & Electrolytes

Body Fluids
Fluid surrounds all cells in the body
and is also inside cells
Fluid, electrolyte and acid-base
balances within the body maintain the
health and function of all body
system

Body Fluids
Fluid amount (volume), concentration
(osmolality) and composition
(electrolyte concentration) and
degree of acidity (pH) effects the
function of the cells

Water & Cellular Function

Medium for metabolic reactions
Transport of nutrients, waste
products
Lubrication
Insulation
Regulation & maintenance body
temperature

Fluids and Electrolytes:

Body Fluids
Body fluids are located in two distinct
compartments: extracellular fluids
(ECF) outside the cells and
intracellular (ICF) inside the cells

Fluids and Electrolytes:

Body Fluids
Intracellular Fluids (ICF)
Extracellular fluids (ECF)
INTRAVASCULAR - plasma
TRANSCELLULAR cerebrospinal,
synovial, biliary, lymph, pleural
INTERSTITIAL beteween the
cells and outside vessels.

Fluids and Electrolytes:

Body Fluids
In adults:
ICF is approximately two thirds of total
body water
ECF is approximately one thirds of total
body water

Fluids and Electrolytes:

Composition
Electrolytes - elements or compounds
able to carry an electric charge when
dissolved or melted.
These electrical charges are called
ions

Fluids and Electrolytes:

Composition
Cations
Positively charged ions

Anions
Negatively charged ions

Milliequivalents
Unit of measure for electrolytes

Fluids and Electrolytes:

Composition
Major cations within the body fluids
include:
Sodium - Na+
Potassium - K+
Calcium - Ca++
Magnesium - Mg++

Fluids and Electrolytes:

Composition
Major anions within the body fluids
include:
Chloride
Bicarbonate
Phosphorus/Phosphate

Movement of Water and

Electrolytes
Fluids in different body compartments
have different concentrations of
electrolytes that are necessary for
normal function
Cells maintain their high intracellular
electrolyte concentration by active
transport

Movement of Water and

Electrolytes
Active transport requires energy in
the form of adenosine triphosphate
(ATP) to move electrolyte across the
cell membrane against a
concentration gradient, from an area
of low concentration to an area of
higher concentration

Movement of Body Fluids: Osmosis

Balance of Body Fluids: Diffusion

Movement of Body Fluids: Filtration

Movement of Body Fluids: Active

Transport

Fluids and Electrolytes: Movement

of Body Fluids
Hydrostatic pressure exerted by fluids
Osmotic pressure stop osmotic flow
Oncotic Pressure by colloids
Osmolarity /Osmolality measurement
concentration
Tonicity balanced tension/concentration

Fluids and Electrolytes:

Concentration of Body Fluids
TONICITY
Isotonic solution 0.9% NaCl, D5W
Hypotonic solution 0.45% NaCl
Hypertonic solution 3% NaCl, D5NS

ISOTONIC SOLUTIONS
Isotonic = same osmolality as blood (0.9% NaCl /
NS, D5W, LR)

Hypertonic = osmolality (less H2O) than blood,

H2O from cells & interstitial spaces plasma
(50% glucose, 3% NaCI)

HYPOTONIC SOLUTIONS
Hypotonic = osmolality (more H2O) than
blood, H2O moves from plasma cells
(.45% NaCl, 1/2 NS)

Regulation of Extracellular Fluid

Decreased ECF Osmolality
(hypotonicity)
cells swell (hemolysed)
Increased ECF Osmolality (hypertonicity)
cells shrivel (crenated)

Lab Assessment of Fluid,

Electrolyte & Acid Base Balance
Serum osmolality 280-300 mOsm/kg
Serum concentration the number of
dissolved particles per unit of fluid.
Decreases in hydrated conditions,
increases in dehydration.

Hematocrit: Males 40-54%

Females 38-47%
Percentage of RBCs to blood volume
in relation to plasma.
Increase with dehydration
Decrease with overhydration

Regulation of Fluid Balance

Kidneys
Endocrine system
Cardiovascular system
Lungs
GI system

Body Homeostasis
Lungs - exhalation
Kidneys Regulation of ECF by retention & excretion of
fluids & electrolytes (Na+ & K+)
Regulation of pH of ECF by retention &
excretion of H+ ions
Excretion of waste
Heart & Blood vessels - pumping action

Fluid Gains:
Metabolism 250-300 mL
Oral fluids 1100 1400 mL
Solid food 800 1000 mL
Fluid therapy

Fluid Losses:
Kidneys 1500 mL
Skin 500-600 mL:
Insensible/Sensible fluid loss
Lungs 400 mL
GI Tract 100-200 mL (3-6L re-absorbed)
Additional: Wounds, external bleeding,
third space loss

Disorders of Fluid
Balance:
Hypovolemia depletion of ECF
volume, abnormally low circulating
blood volume.
Causes: abnormal skin, GI, renal
losses, bleeding, decreased intake,
movement of fluid to third space
S&S: weakness, fatigue, syncope,
confusion, oliguria, low B/P, weight
loss, tachycardia, sunken eyeballs.

Disorders of Fluid Balance:

Hypervolemia expansion of ECF volume,
increase amount intravascular fluid.
Causes: chronic stimulus kidney or abnormal
kidney function to conserve Na & water,
excessive IV fluids, interstitial to plasma
fluid shift
S&S: Edema, weight gain, increased B/P,
bounding pulses, SOB, rales, tachypnea,
distended neck veins, ascites.

Fluid Volume Alterations

Fluid Volume Deficits FVD:
Fluid & Electrolytes lost in = proportion
Ratio of H2O/electrolytes remains the same
Not DEHYDRATION - Causes:
Fistulas
GI suction
Third space shifts
Anorexia, intake (nausea)
Inability to obtain fluids

Dehydration
Excessive, rapid loss of H2O from
body tissues, disturbance in the
balance of Na, K+, Cl
Causes: Prolonged fever, diarrhea,
vomiting

Acid Base Balance: Regulation

Arterial pH an indirect
measurement hydrogen ion (H+)
concentration
Values: normal range 7.35-7.45
acid below 7.35
alkalosis above 7.45

Acid-Base Balance: Function

Why a normal pH?

Maintain cell membrane integrity

Speeds enzymatic reactions

Acid-Base Balance
pH is maintained by the utilization of a
buffer.
Buffer - a substance that can absorb
or release H+ to correct an acid-base
imbalance: HCO-3, Phosphate,
Ammonium, Protein, CO2.

Acid Base Balance

Acid base balance is based on the
Hydrogen ion (H+) concentration.
Increased H+ leads to decreased pH
(acidosis)
Decreased H+ leads to increased pH
(alkalosis)

Buffer Systems:
Renal/Respiratory
Lungs eliminate or retain CO2 in
direct relation to arterial pH.
Kidneys increase or decrease
HCO-3 concentration in body
fluids.

Acid Base Imbalances:

ABGs
pH
PaCO2
PaO2
O2 saturation
Base excess
HCO3

7.35-7.45
35-45mm
80-95
95-99%
+- 2
22-26 mEq/L

Alterations: Laboratory Values Arterial Blood Gas

If pH is outside of the parameter 7.35 - 7.45,
ABG is labeled uncompensated
If pH is within the parameter 7.35 - 7.45,
ABG is labeled compensated
If all parameters are within their specified
limits, the ABG is labeled normal.

ABG: Interpretation
pH 7.24
Uncompensated
Acidosis

pH 7.47
Uncompensated
Alkalosis

pH 7.51
Uncompensated
Alkalosis

pH 6.88
Uncompensated
Acidosis

pH 7.42
Compensated

pH 7.49
Uncompensated
Alkalosis

Acid Base Imbalance: Types

1. Respiratory acidosis

Increased PaCO2
Decreased pH = increased H+
Respiratory depression leads to
hypoxemia (COPD).

Acid Base Imbalance: Types

2. Respiratory Alkalosis
Decreased PaCO2
Increased pH = Decreased H+
Seen in anxiety with
hyperventilation,
Initial phase of asthma attack.

Acid Base Imbalance: Types

3. Metabolic Acidosis

High acid blood content leading to

loss of NaHCO3 (alkaline buffer)
Seen in Diabetic ketoacidosis,
diarrhea.

Acid Base Imbalance: Types

4.

Metabolic Alkalosis

Heavy loss of acid from body or

from increased levels of
bicarbonate.
Most common cause: Vomiting, NG
suctioning.

ABG: Interpretation
Baby Andy

pH 7.22
PaO2 76
BE -4

PaCO2 80
HCO3 27
SaO2 93%

Uncompensated
Uncompensated
Acidosis
Uncompensated Respiratory Acidosis

ABG: Interpretation
Baby Betty
pH 7.49
PaCO2 21
PaO2 145
HCO3 21
BE -2
SaO2 93%
Uncompensated
Uncompensated
Alkalosis
Uncompensated Respiratory Alkalosis

ABG: Interpretation
Baby Chuck
pH 7.31
PaCO2 49
PaO2 90
HCO3 26
BE -1.4
SaO2 97%
Uncompensated
Uncompensated
Acidosis
Uncompensated Respiratory Acidosis

ABG: Interpretation
Baby Daisy
pH 7.18
PaCO2 36
PaO2 146
HCO3 8
BE -17
SaO2 98%
Uncompensated
Uncompensated
Acidosis
Uncompensated Metabolic Acidosis

ABG: Interpretation
Baby Joan
pH 7.37
PaCO2 36
PaO2 85
HCO3 17
BE 3
SaO2 98%
Compensated
Compensated
Acidosis
Compensated Metabolic Acidosis

ABG: Interpretation
Baby Isis
pH 7.36
PaCO2 38
PaO2 86
HCO3 28
BE 3.6
SaO2 96%
Compensated
Compensated
Alkalosis
Compensated Metabolic Alkalosis

Alterations: Assessment
Inspection

General appearance

Labored respiration (Kussmaul)

Chest movement symmetrical?
Overall skin color, turgor, and appearance
Facial expression
Ability to speak complete words or complete
sentences
Tracheal position

Alterations: Laboratory Values

- Electrolytes Na+
Hyponatremia

Hypernatremia

Serum level ^145 mEq/l

Serum level
<135 mEq/l
Thirst
Dry mouth
Muscular twitching
Severe hypernatremia:
seizure
Hallucinations
Muscle cramps
Disorientation
Lethargy
Irritable
Confusion
Focal or grand mal
seizures
Coma

Alterations: Laboratory Values Electrolytes K+

Hypokalemia

Serum level
<3.5 mEq/L
Cardiac
arrhythmias
Increased
sensitivity to
Digoxin
Fatigue

Hyperkalemia
Serum level > 5.0
mEq/L
EKG changes
Vague muscle
weakness (Usually
the 1st sign)

Alterations: Laboratory Values Electrolytes Ca+

Hypocalcemia

Serum level
< 8.5 mg/dl
Chvosteks sign &
Trousseaus sign
Confusion
Altered mood or
memory
Abdominal spasms

Hypercalcemia

Serum level
> 10.5mg/dl
Muscle weakness
Tenderness
Anorexia
Constipation
Cardiac Arrest

Alterations: Laboratory Values Electrolytes Mg+

Hypomagnesemia

Serum level
<1.3 mEq/l
Neuromuscular
irritability
Cardiac
manifestations
Mental changes

Hypermagnesemia

Serum level
> 3 mEq/l
Flushing (Due to
peripheral
vasodilation)
Hypotension
Depressed
respiration

Nursing Process
Assessment
Nursing History

Risk factors that may cause or contribute

to fluid, electrolyte and acid-base
imbalance

Age
Environment
Dietary Intake
Lifestyle

Nursing Process
Assessment

Medication
Recent Surgery
Gastrointestinal Output
Acute Illness or Trauma
Respiratory disorders
Burns
Chronic Illness

Nursing Diagnosis: Electrolyte and

Acid/Base Balance
Ineffective breathing
pattern
Decreased Cardiac
Output
Fluid Volume Deficit
(Risk)
Fluid Volume Excess
Alteration in Gas
Exchange

Altered Oral Mucous

Membrane
Impaired Skin
Integrity (Risk for)
Alteration in
Perfusion
(Peripheral, Cardiac,
generalized)

Nursing Process
Planning
The patients clinical condition
determines the priority nursing
diagnosis
Goals need to be individualized and
realistic with measurable outcomes
Consultations with the healthcare
team helps to set realistic time
frames for the goals

Nursing Process
Implementation
Health Promotion

Patient and caregivers education to

recognize risk factors for developing
imbalances and implement appropriate
preventive measures

Vomiting or diarrhea in infants

People with chronic diseases

Nursing Process
Implementation
Acute care

Enteral replacement of fluids

Restriction of fluids
Parenteral Replacement of fluids and
electrolytes

Parenteral Nutrition
Intravenous Therapy (Crystalloids)

Vascular Access Devices

Nursing Process
Evaluation
Evaluate the effectiveness of
interventions using the goals and
outcomes established for the
patients nursing diagnosis
Modifications maybe needed if
outcomes are nor achieved

Nursing Diagnosis:
Plan of Care
Nursing Diagnosis - Impaired gas
exchange
R/T excessive pulmonary secretions
AEB:
Obj: positive productive cough,
SaO2 < 95%, tachyapnea and cyanosis.
Subj: Its hard to breathe.

Nursing Diagnosis:
Plan of Care
Long-Term Goal

Patient will maintain SaO2 > 95%

throughout hospitalization.

Short-Term Goal

Patients excessive pulmonary secretions

will return to baseline levels within 2 days.

Nursing Diagnosis:
Plan of Care
Nursing Interventions

Suction q2hrs and PRN

Maintain O2 per DO and monitor s/s of
medications effectiveness

SaO2
Rate, depth and pattern of respiration

Instruct patient to turn q2hrs

Encourage patient to C&DB q2hrs W/A
Increase fluid intake to 1500ml po qd

Nursing Diagnosis:
Plan of Care
Nursing Evaluation

Auscultate clients lungs

Observe clients cough
Observe color, consistency and amount of
secretions
Observe clients respirations

Nursing Diagnosis:
Plan of Care
Expected Outcomes

Patients sputum will be clear, white within

48 hours.
Patients adventitious lung sounds will
disappear within 48 hours.
Patients respiratory rate will be between 20
and 28 within 24 hours Client will be able to
clear airway by coughing in 24 hours

Medical /Nursing Management

Dietary

Impaired Renal
Function
HTN

Sodium Deficit
Head Trauma (IVF)

Impaired Renal
Function
Elevated Serum K+

High Potassium

High Sodium

Low Potassium

Low
Sodium/Potassium

Deficit Serum K+
Diuretics

Low Protein

Impaired Hepatic
Function

Medical /Nursing Management

Oxygen
Medical

Non-Rebreather
Ventimask
NC
Partial Non-Rebreather
Intubation

ETT or NTT

Bag Valve Mask

Medications

Oxygen
Nursing

Positioning
Suctioning
Patient Education
Encourage C&DB
Increase po Fluid Intake
Assess VS, Mental Status,
Hydration, I&O, and
laboratory values

Blood Component Therapy

Whole Blood
Blood Component

Packed Red Blood Cells

Platelets
Plasma

Blood Component Therapy

Blood Groups and Types

A, B, O and AB

Rh factor

Positive
Negative

Autologous Transfusion

Collection and transfusion of patients

own blood

Transfusing Blood
Two RNs or one RN and a LPN must
check the label on the blood against
the medical record and against the
patients identification number, blood
group and complete name before the
blood is administered

Transfusing Blood
Adults require a large IV catheter
Blood is administered in a special
blood administration tubing
Tubing is primed with 0.9% sodium
chloride to prevent hemolysis or
breakdown of the RBCs

Transfusing Blood
Stay with the patient during the first
15 minutes to observe for a reaction
A unit of blood should be infused
between 2-4 hours
Vital signs are monitored at the
beginning of the transfusion, 15
minute. into the transfusion, at 1 hour
and at the end of the transfusion

Transfusion Reaction
Range from mild to severe reaction
both of which are life threatening
Stop the transfusion
Replace the IV tubing and infuse
0.9% NS
Notify the MD and follow the
institution protocol for transfusion
reaction