Chapter 39

Chapter 39
Fluid, Electrolyte, and

Acid-Base Balance
Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
Functions of Water in the Body
Transporting nutrients to cells and wastes from cells

Transporting hormones, enzymes, blood platelets, and
red and white blood cells
Facilitating cellular metabolism and proper cellular
chemical functioning
Acting as a solvent for electrolytes and nonelectrolytes
Helping maintain normal body temperature
Facilitating digestion and promoting elimination
Acting as a tissue lubricant
Copyright 2015 Wolters Kluwer All Rights Reserved
Two Compartments of Fluid in the Body

Intracellular fluid (ICF): fluid within cells (70%)
Extracellular fluid (ECF): fluid outside cells (30%)
Intravascular fluid- plasma, serum
Interstitial fluids- fluid between cells
Variations in Fluid Content
Healthy person: total body water is 50% to 60% of body

weight
An infant has considerably more body fluid and ECF than
an adult; more prone to fluid volume deficits
Gender and amount of fat cells affect body water; women
and obese people have less body water
Fluid Balance
Solvents:
liquids that hold a substance in solution (water)
Solutes:
substances dissolved in a solution (electrolytes and
nonelectrolytes), solids
Source of Fluids for the Body
Ingested liquids
Food
Metabolism
Fluid regulation takes place through thirst mechanism,
food and fluid ingestion, fluid losses
Transporting Body Fluids
Osmosis: water passes from an area of lesser solute

concentration to greater concentration until equilibrium is
established
Diffusion: tendency of solutes to move freely throughout
a solvent (downhill)
Active transport: requires energy for movement of
substances through the cell membrane from the lesser
solute concentration to the higher solute concentration
Filtration: passage of fluid through a permeable
membrane from the area of higher to lower pressure
Osmolarity of a Solution
Isotonic: same concentration of particles as plasma

Hypertonic: greater concentration of particles than
plasma
Hypotonic: lesser concentration of particles than plasma
Capillary Filtration
Hydrostatic pressure
Results from the force of blood pushing against the
walls of capillaries
The pressure inside the capillaries is greater than the
interstitial pressure
Colloid osmotic pressure (oncotic pressure)
Pressure inside the capillary is less than the
interstitial fluid
Fluid is pulled back into the vascular space
Primary Organs of Homeostasis

Kidneys normally filter 170 L of plasma and excrete 15 L
of urine. Electrolytes are excreted.
The cardiovascular system pumps and carries nutrients
and water in body. Blood pressure helps control fluid
volume.
Lungs regulate oxygen and carbon dioxide levels of the
blood.
Adrenal glands produce aldosterone which helps the body
conserve sodium, save chloride and water, and excrete
potassium.
The pituitary gland stores and releases ADH.
Primary Organs of Homeostasis (cont.)
The thyroid gland increases the blood flow in the body

and increases renal circulation.
The nervous system inhibits and stimulates mechanisms
influencing fluid balance.
Parathyroid glands regulate the level of calcium in ECF.
The GI tract absorbs water and nutrients that enter the
body through this route.
Fluid Losses
Kidneys: urine
Intestinal tract: feces
Skin: perspiration
Insensible water loss
Fluid Volume Defecit
Involve either volume or distribution of water or

electrolytes
Hypovolemia: deficiency in amount of water and
electrolytes in ECF with near-normal water/electrolyte
proportions. Fluid is forced into intravascular space.
Dehydration: decreased volume of water and electrolyte
change
Third-space fluid shift: distributional shift of body fluids
into potential body spaces
Fluid Volume Excess
Hypervolemia: excessive retention of water and sodium

in ECF
Overhydration: above-normal amounts of water in
extracellular spaces
Edema: excessive ECF accumulates in tissue spaces
Interstitial-to-plasma shift: movement of fluid from space
surrounding cells to blood
Electrolytes
Dissolved particles which have an electrical charge

Ions
Cations: positive charge
Anions: negative charge
Homeostasis: total cations equal to total anions
Major Electrolytes/Chief Function

Sodium: ECF, controls and regulates volume of body
fluids
Potassium: ICF, chief regulator of cellular enzyme activity
and water content
Calcium: bone and ICF, nerve impulse, blood clotting,
muscle contraction, B12 absorption
Magnesium: ICF, metabolism of carbohydrates and
proteins, vital actions involving enzymes
Chloride: ECF, maintains osmotic pressure in blood,
produces hydrochloric acid
Bicarbonate: bodys primary buffer system
Phosphate: involved in important chemical reactions in
the body, cell division, and hereditary traits
Electrolyte Imbalances
Hyponatremia and hypernatremia

Hypokalemia and hyperkalemia
Hypocalcemia and hypercalcemia
Hypomagnesemia and hypermagnesemia
Hypophosphatemia and hyperphosphatemia
Hypochloremia and hyperchloremia
Electrolyte Imbalances: Hyponatremia
Na+ <135 mEq/L

Caused by active losses or by dilutional hyponatremia
Loss of Na from vomiting, diarrhea, diuretics
Excess fluid volume from CHF, SIADH
Clinical manifestations depend on the cause, magnitude,
and speed of the deficit
Fluid volume deficit or excess
Increased or decreased ICP
Edema or dry mucous membranes
Electrolyte Imbalances: Hypernatremia

Na+ exceeding 145 mEq/L caused by a gain of sodium in
excess of water or by a loss of water
Causes include dehydration, enteral feedings, diarrhea,
burns, diabetes insipidus
Clinical manifestations are primarily neurologic
(weakness, confusion, coma) also dry mucous
membranes, decreased B/P, concentrated urine
Treatment is usually a hypotonic electrolyte solution or
isotonic solution (D5W)
Nursing management:
Prevention of hypernatremia
Monitoring of fluid I&O
Electrolyte Imbalances - Hypokalemia
K+ level of <3.5 mEq/L from active losses of potassium or

insufficient intake
Causes may include NGT, vomiting, diarrhea, diuretics,
adrenal disorders
Signs and symptoms may include cardiac arrhythmias,
muscular weakness and cramping, parasthesia
EKG changes may include flattened or inverted T waves,
and/or an elevated U wave
Hypokalemia
Treatment is oral or IV replacement therapy
Dietary intake should average 50 to 100 meq daily
Usual supplementation should be 40 to 80 meq daily
Potassium rich foods include fruits, vegetables, grains,
meats
Nursing treatment includes:
IV K at a rate no greater than 20 meq per hour
Assessment of cardiac and motor signs and
symptoms
Prevention of hypokalemia
Hypocalcemia
Requires IV administration of calcium mixed in D5W
Keep a trache cut down tray and ambu bag at bedside
Prevention of hypocalcemia with adequate dietary
intake, supplements, weight bearing exercise, reduce
alcohol and caffeine, smoking cessation,
bisphosphates (Fosamex), avoid OTC antacids and
laxatives with phosphorous
Electrolyte Imbalance: Hypercalcemia

Calcium level of >10.5 mg/dL
Usually results from malignancy or hyperparathyroidism
Results in muscle weakness; lack of coordination;
hypertension and cardiovascular effects; nausea;
vomiting; constipation; cognitive effects (severe); cardiac
arrest
Treatment:
Administration of NS and lasix to dilute serum Ca and
promote excretion via the kidneys
Calcitonin administration prevents bone breakdown
Management of the underlying cause
Hypomagnesemia
Serum magnesium below 1.3 meq/L
Hypomagnesemia results from alcoholism, GI losses
(NGT, diarrhea, fistula), administration of specific
medications
Signs and symptoms include hyper-excitabilty, muscle
weakness, tremors, athetoid motions, disphagia, tetany,
seizures, stridor, mood alterations
Labs: serum albumin, K and Ca, EKG changes,
arrhythmias, PVCs, digitalis toxicity
Neuromuscular symptoms are treated with magnesium
salts (oral or IV), dietary changes- green leafy
vegetables, whole grains, nuts, legumes, seafood
Nursing care: monitor labs, observe for symptoms,
patient teaching, alcohol cessation
Hypermagnesemia
Serum magnesium above 2.3 meq/L
Rare and usually caused by renal failure, may also occur
in diabetic ketoacidosis, Addisons, antacids, and certain
medications
Signs and symptoms: peripheral vasodilation, nausea,
muscle weakness, dysarthria, loss of deep tendon
reflexes, possible paralysis, AV heart block, and cardiac
arrest
Labs: K, Ca, EKG changes
Treatment may include dialysis, loop diuretics, isotonic
IVs, calcium gluconate to counteract cardiac and
neuromuscular symptoms
Prevention is essential in renal failure patients
Phosphorus Imbalances
Hypophosphatemia
May result from use of nutritional supplements,
malnourishment, and various other causes
Results in neurologic and muscular symptoms which
are treated with phosphorus supplementation
Hyperphosphatemia
Usually results from renal failure and is often
asymptomatic
Excess phosphorous may cause hypocalcemia and
tetany; also soft tissue calcification
Treatment focuses on the underlying disorder, vitamin
D, dietary changes
Chloride Imbalances
Hypochloremia
Rarely occurs in the absence of other abnormalities; signs
and symptoms are associated with hyponatremia,
hypokalemia, and metabolic alkalosis
Treatment involves correcting the cause, IV normal saline,
dietary replacement
Hyperchloremia
Related to related to hypernatremia, bicarbonate loss, and
metabolic acidosis
Symptoms include cardiac, muscular, and cognitive issues,
tachypnea, lethargy
Treatment focuses on correcting the cause and restoring
electrolyte, fluid, and acidbase balance; hypotonic IV
solutions; IV sodium bicarbonate
Maintaining Acid-Base Balance

Homeostatic mechanisms keep pH within a normal range
(7.35 to 7.45)
Buffer systems prevent major changes in the pH of body
fluids by removing or releasing H +
The major extracellular buffer system is the bicarbonate
carbonic acid buffer system
The kidneys regulate the bicarbonate level in the ECF
The lungs, under the control of the medulla, regulate the
CO2 and the carbonic acid content of the ECF
CO2 + H2O= carbonic acid
Other buffer systems
ECF: inorganic phosphates, plasma proteins
ICF: proteins, organic, inorganic phosphates
AcidBase Imbalances
Occur when carbonic acid or bicarbonate levels become

disproportionate
Respiratory acidosis: primary excess of carbonic acid
in ECF
Respiratory alkalosis: primary deficit of carbonic acid
in ECF
Metabolic acidosis: proportionate deficit of
bicarbonate in ECF
Metabolic alkalosis: primary excess of bicarbonate in
ECF
Administering Medications
Mineralelectrolyte preparations
To treat electrolyte imbalances
Diuretics
Monitor for fluid deficit and electrolyte imbalance
Intravenous therapy
Intravenous Therapy
Peripheral venous catheters

Midline peripheral catheter
Central venous access devices
PICC
Non-tunneled central venous
Tunneled central venous
Implanted ports
Vein Site Selection
Accessibility of a vein
Condition of vein
Type of fluid to be infused
Anticipated duration of infusion
Complications of IV Therapy
Fluid overload
Air embolism
Septicemia, other infections
Infiltration, extravasation
Phlebitis
Thrombophlebitis
Hematoma
Clotting, obstruction
Nursing Process: Assessments
Identify patients at risk for imbalances.

Determine that a specific imbalance is present and its
severity, etiology, and characteristics.
Determine the plan of care, nursing diagnoses or
collaborative problems.
Identify specific outcomes and associated interventions.
Determine effectiveness of the plan of care.
Nursing Process: Parameters of

Assessment
Nursing history and physical assessment
Fluid intake and output
Daily weights
Laboratory studies
Nursing Process: Lab Studies to Assess for

Imbalances
Complete blood count
Serum electrolytes, blood urea nitrogen, and creatinine
levels
Urine pH and specific gravity
Arterial blood gases
Nursing Process: Risk Factors for

Imbalances
Pathophysiology underlying acute and chronic illnesses
Abnormal losses of body fluids
Burns
Trauma
Surgery
Therapies that disrupt fluid and electrolyte balance
Nursing Process: Nursing Diagnoses

Related to Imbalances
Excess fluid volume
Deficient fluid volume
Risk for imbalanced fluid volume
Nursing Process: Implementing
Dietary modifications
Modifications of fluid intake
Medication administration
IV therapy
Blood and blood products replacement
TPN
Allaying patient anxiety as needed
Appropriate patient and family teaching
Nursing Process: Expected Outcomes
Maintain approximate fluid intake and output balance

(2,500-mL intake and output over 3 days).
Maintain urine specific gravity within normal range
(1,0101,025).
Practice self-care behaviors to promote balance.
Administering Blood and Blood Products
Typing and cross-matching

A, B, AB, and O type blood
Rh factor
Selecting blood donors
Initiating transfusion
Transfusion reactions

Chapter 39 - Fluid, Electrolyte, and Acid-Base Balance

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Chapter 39 - Fluid, Electrolyte, and Acid-Base Balance

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Fluid, Electrolyte, and

Copyright 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Functions of Water in the Body

Transporting nutrients to cells and wastes from cells

Copyright 2015 Wolters Kluwer All Rights Reserved

Two Compartments of Fluid in the Body

Copyright 2015 Wolters Kluwer All Rights Reserved

Variations in Fluid Content

Healthy person: total body water is 50% to 60% of body

Copyright 2015 Wolters Kluwer All Rights Reserved

Copyright 2015 Wolters Kluwer All Rights Reserved

Source of Fluids for the Body

Copyright 2015 Wolters Kluwer All Rights Reserved

Transporting Body Fluids

Osmosis: water passes from an area of lesser solute

Copyright 2015 Wolters Kluwer All Rights Reserved

Isotonic: same concentration of particles as plasma

Copyright 2015 Wolters Kluwer All Rights Reserved

Copyright 2015 Wolters Kluwer All Rights Reserved

Primary Organs of Homeostasis

Copyright 2015 Wolters Kluwer All Rights Reserved

Primary Organs of Homeostasis (cont.)

The thyroid gland increases the blood flow in the body

Copyright 2015 Wolters Kluwer All Rights Reserved

Copyright 2015 Wolters Kluwer All Rights Reserved

Fluid Volume Defecit

Involve either volume or distribution of water or

Copyright 2015 Wolters Kluwer All Rights Reserved

Fluid Volume Excess

Hypervolemia: excessive retention of water and sodium

Copyright 2015 Wolters Kluwer All Rights Reserved

Dissolved particles which have an electrical charge

Copyright 2015 Wolters Kluwer All Rights Reserved

Major Electrolytes/Chief Function

Hyponatremia and hypernatremia

Copyright 2015 Wolters Kluwer All Rights Reserved

Electrolyte Imbalances: Hyponatremia

Na+ <135 mEq/L

Electrolyte Imbalances: Hypernatremia

Electrolyte Imbalances - Hypokalemia

K+ level of <3.5 mEq/L from active losses of potassium or

Copyright 2015 Wolters Kluwer All Rights Reserved

Copyright 2015 Wolters Kluwer All Rights Reserved

Copyright 2015 Wolters Kluwer All Rights Reserved

Electrolyte Imbalance: Hypercalcemia

Maintaining Acid-Base Balance

Occur when carbonic acid or bicarbonate levels become

Copyright 2015 Wolters Kluwer All Rights Reserved

Copyright 2015 Wolters Kluwer All Rights Reserved

Peripheral venous catheters

Copyright 2015 Wolters Kluwer All Rights Reserved

Vein Site Selection

Copyright 2015 Wolters Kluwer All Rights Reserved

Copyright 2015 Wolters Kluwer All Rights Reserved

Nursing Process: Assessments

Identify patients at risk for imbalances.

Copyright 2015 Wolters Kluwer All Rights Reserved

Nursing Process: Parameters of

Copyright 2015 Wolters Kluwer All Rights Reserved

Nursing Process: Lab Studies to Assess for

Copyright 2015 Wolters Kluwer All Rights Reserved

Nursing Process: Risk Factors for