FLUID AND ELECTROLYTE (BALANCE & IMBALANCE).pdf

Fluid and electrolyte definition, function of fluid, sources, factor affecting fluid & electrolyte, hypovolemia, terminology, hypervolemia, electrolyte introduction, Extracellular fluid volume deficit (ECFVD), Extracellular fluid volume excess (ECFVE), Intracellular fluid volume excess (IFVE), Intracellular fluid volume deficit (IFVD),

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© R R INSTITUTIONS , BANGALORE
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SUBJECT – MEDICAL AND SURGICAL NURSING
TOPIC – FLUID AND ELECTROLYTE
PREPARED BY DOLISHA WARBI

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© R R INSTITUTIONS , BANGALORE
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FLUID AND ELECTROLYTE IMBALANCE
FLUID:
Fluid help in maintaining body temperature and cell shape.
Helps transport nutrients gases and wastes.
Total body water ( As percentage of body weight ) in relation to age and sex
AGE MALE FEMALE
UNDER 18 65% 55%
18 - 40 60% 50%
40 - 60 50 - 60% 40 - 50%
OVER 60 50% 40%

3. Ø60% of Weight is because of water. It is higher in younger age, about 22% on the body weight is
extracellular water.
ØAbout 38% is intracellular water.
qExtracellular fluid (ECF) =12L (Na+)- cation, (Cl-)- anion - Consists of blood, plasma, lymph, CSF.
qIntracellular fluid (ICF) =28L (<Na,<Cl), (K+)- cation, (PO4-)- anion - Consist of dissolved electrolyte, and
proteins.
FUNCTION:
üFacilitated in the transport [nutrient for more protein and others].
üAid in removal of cellular metabolic wastes
üProvide medium for cellular metabolism.
üRegulate body temperature.
üProvide lubrications of musculoskeletal joints,
üIt assists in digestion of food through hydrolysis.
üIt serves as a medium for excretion of waste products.
ü It plays an important roles in maintenance of blood volume and blood pressure.
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Water Sources: Drinking water, Water contained in food, Metabolism to CO2 & H2O
Water Loses: Urinary loss, Fecal loss, Sweat loss, Pathological Loss,
FACTOR AFFECTING FLUID & ELECTROLYTE IMBALANCE
Age, Stress, Diaphoresis, Renal Disease, Dehydration, Hormones, Lifestyle

5. FLUID BALANCE:
The desirable amount of fluid intake and loss in adults ranges from 1500 to 3500 mL each 24 hours. Ave= 2500
mL
Normally INTAKE = OUTPUT
FLUID IMBALANCE:
It is an abnormal level of fluids in the body.
Changes in ECF volume = alterations in sodium balance.
Change in sodium/water ratio = either hypo osmolarity or hyperosmolarity.
Fluid excess or deficit = loss of fluid balance.
As with all clinical problems, the same pathophysiologic change is not of equal significance to all people.
For example, consider two persons who have the same viral syndrome with associated nausea and vomiting.
It is an abnormally decreased or increased fluid volume or rapid shift from one compartment of body fluid to another:
qHypovolemia
qHypervolemia
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6. Hypovolemia:
Hypovolemia refers to a state of decreased blood volume within the body. This reduction in blood volume can
result from various causes such as excessive fluid loss (through vomiting, diarrhea, excessive sweating),
bleeding (hemorrhage), inadequate fluid intake, or fluid shifts from the bloodstream into the interstitial space
(third-spacing).
Hypovolemia leads to reduced blood pressure, decreased perfusion of organs, and compromised oxygen delivery to
tissues. If severe and left untreated, hypovolemia can lead to shock, a life-threatening condition characterized by
inadequate tissue perfusion.
Signs and symptoms:
Thirst
Decreased urine output
Dry mouth and mucous membranes
Weakness and fatigue
Dizziness or light-headedness
Rapid heartbeat (tachycardia)
Cool, clammy skin
Sunken eyes
Shock
Other signs and symptoms are as follow:
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7. Cardiovascular:
1.Hypotension (Orthostatic hypotension).
2.Tachycardia.
3.Tachypnoea.
4.Weak pulse
Skin:
1.Dry.
2.Decreased skin turgid.
3.Blanching of skin.
Gastrointestinal:
1.Dry mucous membranes.
2.Nausea.
3.Vomiting.
4.Decreased bowel sounds.
5.Diarrhoea.
Extremities:
1.Cold.
2.Decreased capillary refill (> 5 seconds).
3.Muscle cramps.
Central nervous system:
1. Irritability.
2. Thirst.
3. Confusion.
4. Coma.
5. Decreased sensorium.
Renal:
1.Decreased urine output.
2.Concentrated urine.
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8. MANAGEMENT:
üFluid resuscitation.
üIdentify the fluid volume loss and treat the causes
üReplacement of volume deficit.
üPrevention and replacement of ongoing loss.
üRestoration acid – base balance
üElectrolyte replacement
üConsideration of medication e.g.. Antiemetic,
üContinuous monitoring and assessment
üIncase of heart failure - fluid restriction.
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9. May occur as a result of:
oReduced fluid intake
oLoss of body fluids
oMany factors, such as illness, injury, medication, surgery and treatments, can disrupt the patient's fluid and
electrolyte balance.
oEven a patient with a minor illness is at risk for fluid and electrolyte imbalance.
The nurse continuously serves and evaluates patient's progress. Hence, she is most logically accountable for assessing
and reporting real or potential fluid and electrolyte disturbances.
TERMINOLOGY:
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Diffusion:
The process by which solutes move from an area of higher concentration to one
of lower concentration; does not require expenditure of energy

Osmosis:
The process by which fluid moves across a semipermeable membrane from an
area of low solute concentration to an area of high solute concentration.

10. Active transport:
Physiologic pump that moves fluid from an area of lower concentration to
one of higher concentration; active transport requires adenosine
triphosphate (ATP) for energy.
Osmolarity:
The number of osmoles, the standard unit of osmotic pressure per liter of
solution. It is expressed as milliosmoles per liter (mOsm/L).A concentration
of osmoles in a volume of solvent
Osmolality:
The number of osmoles (the standard unit of osmotic pressure) per kilogram
of solution. Expressed as mOsm/kg. Used more often in clinical practice
than the term osmolarity to evaluate serum and urine.
Serum osmolality: 282 – 295 mOsm/kg water
In addition to urea and glucose, sodium contributes the largest number of
particles to osmolality.
Hypertonic solution:
A solution with an osmolality higher than that of serum.
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11. Hypotonic solution:
A solution with an osmolality lower than that of serum.
Isotonic solution:
A solution with the same osmolality as serum and other body fluids.
pH Value:
A concentration of Hydrogen ion in Blood Steam, it shows the potentials
of Hydrogen.
it's regulated by Buffers

Homeostasis:
It is the process through which bodily equilibrium is maintained.
The body is designed to maintain a constant maintenance of internal
environment like body fluid compositions, temperature, blood pressure,
blood glucose level; etc.
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12. Hypervolemia:
Hypervolemia, on the other hand, refers to a state of increased blood volume within the body. It occurs when
there is an excess accumulation of fluid in the blood plasma.
Hypervolemia can result from various factors such as excessive fluid intake, retention of sodium and water (often
seen in conditions like congestive heart failure, kidney disease, liver cirrhosis), certain medications (such as
corticosteroids), or hormonal imbalances.
Signs and symptoms:
Oedema
Shortness of breath
High blood pressure
Weight gain
Fatigue and weakness
Ascites
Jugular vein distension
Decreased urine output
Confusion or altered mental status
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13. MANAGEMENT:
üDiuretics - furosemide (Lasix)
üFluid Restriction
üSodium Restriction
üDialysis (Haemodialysis) - end-stage renal disease or severe kidney dysfunction, dialysis may be necessary to
remove excess fluid and waste products from the blood.
üMonitoring Electrolytes (sodium and potassium)
üTreatment of Underlying Conditions (including heart failure, liver cirrhosis, and nephrotic syndrome)
üRegular Follow-Up
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14. ELECTROLYTES:
qBody fluids contain certain substances which dissociate and carry electrical changes and are known as electrolytes.
qNatural minerals in food become electrolytes or ions in the body through digestion and metabolism.
qElectrolytes are usually measured in milli equivalents per litter (mEq/L) or on milligrams per decilitre (mg/dl).
There is a mainly Two types of ions…
(i)Cations:
Sodium (Na+)
Potassium (K+)
Calcium (Ca2+)
Magnesium (Mg2+)
(ii)Anions:
Chloride (Cl-)
Bicarbonate (HCO3-)
Phosphate (PO)
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15. Sodium:–
ØIs the most abundant cation (90%) in ECF, Normal Value : 135 to 145 mEq/L.
ØSodium particularly in Mustard, Cheese, Bread, Cereal, Table salt. Daily allowance for sodium is 500 mg.
ØDisorder: (>W)Hyponatremia (<135mEq/L), (<W)Hypernatremia(Acute-1mEq/L/hr, Chronic-1mEq/L/hr or 10mEq/L over 24hr).
Potassium:-
ØIs the primary intracellular cation, Potassium plays a vital role in “Sodium - potassium pump.”
ØThe normal potassium serum level is 3.5 to 5.0 mEq/L.
ØPotassium rich diet includes Bananas, Potatoes, Orange, Lentils, Tomatoes etc. Daily requirement : 3400 mg/day.
ØDisorder: Hypokalemia (<3.5mEq/L), Hyperkalemia (>5.0 mEq/L)
Calcium:-
ØIs stored in bone, plasma and body cells. 99% of Calcium is located in Bone and only 1% Calcium is in ECF.
ØApprox. 50% calcium in the plasma is bound to protein and other is free ionized calcium it’s essential for muscle contraction.
ØNormal level of Ca in adult is 8.5 to 10.0 mg/dl.
ØSource of calcium is dairy products. Other sources - green leafy vegetables, Pease, lentils etc. Daily requirement: 2500 mg/day.
ØDisorder: Hypocalcemia (<4.5mEq/L or 8.5mg/dl), Hypercalcemia (>5.5mEq/L or 11mg/dl)
Magnesium:-
ØAbout 50 to 60% of body Mg is contained within ECF compartment and only 1% Mg contained in ICF.
ØIt’s essential ion for neuromuscular transmission and cardiovascular function.
ØThe normal serum Magnesium level is 1.6-2.6 mg/dl.
ØObtained from - Green vegetables, grains, nuts, meat and seafood. Daily requirement: 400-420 mg/day.
ØDisorder: Hypomagnesia (<1.8mg/dl), Hypermagnesemia (>3mg/dl).
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16. Chloride:–
ØIs major anion found in the fluid outside of cells and in the blood.
ØActs with sodium and maintain the osmotic pressure of the blood.
ØVital role in the body acid base balance.
ØEssential for the production of HCL (Hydrochloric acid).
ØThe normal serum range is 98-108 mEq/L.
ØDisorder: Hypochloremia, Hyperchloremia
Phosphate:-
Ø85% is found in bones and about 14% is in ICF and only 1% is in ECF.
ØPO is essential to intracellular processes such as the production of ATP (Adenosine Phosphate).
ØIs vital for RBC function and O2 delivery to tissues. Normal Value 2.5-4.5 mg/dl.
ØIngested in the diet, absorbed in the jejunum and excreted by the kidneys. Daily requirement 700 mg/day.
ØDisorder: Hypophosphatemia, Hyperphosphatemia.
Bicarbonate:-
ØFound in ECF and ICF.
ØBicarbonate working as a buffer and maintain a pH level in body as well as maintain acid base balance.
ØNormal pH level of Blood is 7.35-7.45.
ØIf pH level bellows 7.35, its called Acidosis.
ØIf pH level of blood above 7.45, it’s called Alkalosis.
ØBicarbonate ion Normal level is 22-26 mEq/L.
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17. ABNORMALITIES IN REGULATION OF BODY FLUID:
§Fluid volume deficit (ECFVD) – Dehydration.
§Fluid volume Excess – over hydration
Extra cellular fluid volume deficit (ECFVD)
üA decrease in intravascular and interstitial fluids.
üIt is a common and serious fluid imbalance that results in vascular fluid volume loss (hypovolemia).
RISK FACTORS:
vDiarrhoea, vomiting
vFistula drainage.
vDiabetic ketoacidosis
vHaemorrhage
vDifficulty to swallowing
vAged
vSevere mentally ill patient.
vClimate
vMedication
vDiaphoresis
vBurns.
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ETIOLOGY:
qPatient, who are elderly, confused or debilitated.
qServe vomiting and diarrhea.
qLosing large portion of blood.
qDifficulty in swallowing.
qLoss of sodium containing body fluid.
a)Urine – e.g.. Salt wasting renal disorder, excessive
diuretics therapy, prolonged death rates.
b)GI fluid, e.g.. Vomiting, diarrhea and fistula
drainage.
qDiabetic ketoacidosis.

18. PATHOPHYSIOLOGY:
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This shift causes cells to shrink and cellular
dehydration to occur
Increased serum sodium concentration caused EFVD
by shifting water to vascular space to decrease the
hyperosmolarity which occurs with the loss of water
Concentration of serum sodium is increased with
extracellular fluid volume deficit which is caused by
insufficient water intake or massive water loss
Sodium has major influence on water retention and
water loss
üIncreased thirst
üDecreased skin turgor
üDry mucous membrane, cracked lips or
tongue
üEyeball soft and sunken
üElevated temperature
üPostural systolic blood pressure
fall>15mmHg and diastolic BP
fall>10mmHg
üNarrowed pulse pressure
üWeight loss
üOliguria<30ml per hour
üDecreased central venous pressure.
üRapid thready pulse
üSyncope
CLINICAL MANIFESTATION:

19. DIAGNOSTIC EVALUATION:
•Medical history.
•Physical examination.
•Blood test
•Measuring weight daily.
•First, the pressure measurement in adult and adolescent.
•Burn and hemorrhoids may be increased.
•Serum Osmolality. Less than 275 mOsm/Kg.
•Assess vain filling time.
•Check skin Turgor.
•Assist dryness of opposing mucous membrane example between chick and gum.
MANAGEMENT:
•Medical management
•Replacement of Isotonic sodium containing RL solution, NS, Oral replacement contains sodium
•Dietary management – avoid fatty or fried fluids and milk product, if due to hemorrhage blood replacement is
needed
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20. NURSING MANAGEMENT:
ØAssess the patient physical condition and medical history.
ØMonitor the vital sign every two to four hour.
ØPatient should be assessed for typical clinical manifestation.
ØAs uses for a skin turgor.
ØNurse should assess the patient's ability to participate in treatment plan
ØWeight of the patient should be monitored daily
ØMild fluid volume loss can be corrected with oral fluid replacement
ØPositional blood pressure should be accessed to determine the degree of orthostatic.
ØAssess urine output hourly. If EFVD is served.
ØMonitor serum sodium BUN glucose (6-24 mg/dl or 2.1-8.5 mmol/L) and hematocrit reality.
ØManage the replacement of isotonic sodium containing fluid.
ØA nurse should apply lotion/emollient to the skin to preserve skin integrity.
ØPatient position should be seen every two hours, or more often, if the skin assessment is indicated.
ØOral care should be given every two hour
ØIf fluid loss is moderate or serve, administrations of intravenous flute is indicated.
ØIndicate that cool or hot liquid often satisfies us better than Luke warm water.
ØAdminister medication as order.
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21. EXTRACELLULAR FLUID VOLUME EXCESS (EFVE):
Increase fluid retention in the intravascular and interstitial space is known as Extracellular fluid volume excess
(EFVE).
It is too much isotonic fluid in the extracellular fluid compartment.
CAUSES:
ØDue to heart diseases.
ØExcessive intravenous infusion of sodium containing isotonic solution.
Example, normal saline and RL solution.
ØCorticosteroids therapy
RISK FACTORS:
ØPatient would be hard liver kidney disorder are prone to sodium and water retention.
ØPatient with hyperaldosteronism is advice of EFVE.
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22. PATHOPHYSIOLOGY:
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Congestive heart failure which is not corrected leads to kidney and liver failure which may be
fatal.
Tissue oncotic pressure rises and leads to edema, when the lymphatic channels are obstructed
There is increased in fluid volume and heart compensate for increasing pressure. Due to this,
the result may be heart failure.
Overload fluid results from renal disorders, so that there is decrease in sodium and water
excretion
Fluid is pushed into tissue spaces. Then , the edema of peripheral and pulmonary regions occurs.
With fluid volume excess, fluid pressure is greater than usual at the arterial end of the capillary

23. CLINICAL MANIFESTATION:
qWeight gain.
qRespiratory system involved:
•Constant and irritating cough
•Dyspnea
•Crackle in lungs
•Cyanosis.
qCardio Vascular System involved.
•Bounding pulse, elevated blood pressure.
•Weight gain.
qNeck vein engorgement in semi fowler position.
qNeurologic: change in the level of consciousness.
qEdema in ankle or other dependent area.
DIAGNOSTIC EVALUATION:
üHistory collection
üPhysical examination
üSymptomatic finding
üBlood test
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24. MANAGEMENT:
•Medical management; loop and potassium wasting diuretics (spironolactone)
•Digoxin is prescribed to slow the heart rate
•Dietary management: sodium diet is ordered to reduce a fluid retention.
NURSING MANAGEMENT:
üIntroduce patient and family about extracellular fluid volume excess.
üMonitor the vital sign.
üMonitor 24 hour input and output daily.
üMonitor Patient weight daily.
üFor severe renal diseases perform hemodialysis.
üObserve the side effect of medications.
üPosition patient is semi Fowler to high founder position.
üObserve the set of electrolyte valley.
üMonitors laboratory value for changes.
üManage the prescribed sodium restrictions.
üMeeting a healthy diet.
üProvide skin care to the patient.
üProvide psychological support to patient and family.
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COMPLICATION:
•Delayed wound healing
•Congestive heart failure
•Pulmonary edema

25. INTRACELLULAL FLUID VOLUME EXCESS (IFVE):
WATER INTOXICATION OR WATER TOXEMIA
Intracellular fluid volume excess is the increases in the amount of water inside the cell.
Hypo osmolar disorder result from either water excess or solute deficit, and are mainly due to sodium loss.
In case of water excess, the number of solute is normal, but they are diluted by excessive water.
ETIOLOGY:
•Excessive amount of hypo osmolar intravenous fluid ( 0.45%NS, 5% Dextrose in water).
•Consumption of excessive amount of tap water without inadequate nutritional intake.
•Patient with certain psychiatric disorders such as schizophrenia.
PATHOPHYSIOLOGY:
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Headache, Nausea, Vomiting
Absorption of fluid by cerebral cells more quickly than other cells
Increased ICP
CNS changes
Administration of excessive amount of hypo osmolar intravenous fluid.

26. CLINICAL MANIFESTATION:
1)Vital signs:
üIncreased respiration.
üIncrease systolic blood pressure.
üFlaccidity.
üDelirium.
üPapilledema.
2) Behavioral changes:
üConfusion
üIrritability
üDrowsiness.
üDisorientation.
3)Headache
4)Nausea, vomiting.
5)Decreased muscle strength
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27. MANAGEMENT:
MEDICAL MANAGEMENT –
§Addition of solutes to IVF
§D5%, 0.45% NACL
§Oral fluid, such as juices or soft drinks can given orally every hour.
§Antiemetics such as dexamethasone, ondansetron.
NURSING MANAGEMENT:
§Intravenous therapy should be monitored every hour.
§Nurse should offer fluid containing solute 8 hour
§Monitored the vital sign 1 to 8 hour.
§Monitor the patient weight daily.
§Monitor intake and output 1 to 8 hour.
§Administrator prescribed antiemetic to the patient.
§Prevent patients from injury.
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COMPLICATION:
ØBradycardia
ØWidened pulse pressure
ØSeizure
ØBrain cell damage
ØComa
ØDeath

28. INTRACELLULAR FLUID VOLUME DEFICIT:
A serve hypernatremia and dehydration can cause intracellular fluid volume deficit.
It is most common in elder people and those in condition which result as an acute water loss in human
intracellular compartments contain 28 liters of fluid.
CAUSES:
Vomiting.
Diarrhea.
Polyurea.
Fever.
Blood loss.
Burns.
RISK FACTORS:
Hemorrhage
Adrenal insufficiency.
Liver dysfunction.
Nausea
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CLINICAL MANIFESTATION:
•Confusion,
•Coma
•Cerebral hemorrhage.

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31. NURSING MANAGEMENT:
üMonitor vital sign.
üAssist the skin turgor and oral mucus membrane for sign of dehydration.
üAssess color and amount of urine.
üMonitor fluid status in relation to dietary intake.
üNote the presents of nausea and vomiting.
üIdentify the possible causes of fluid disturbance or imbalance.
üEducate patient and family about the possible causes and effect of loss and decrease from fluid intake.
COMPLICATION:
•Renal diseases.
•Multiple organ failure.
•Death
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32. Degrees of dehydration:
qMild
qModerate
qSevere
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33. COMMON LABORATORY TEST:
oSerum electrolytes
oHaematocrit
oUrine electrolytes and specific gravity serum albumin.
o24 hr urine for Cr clearance
oABG analysis
oBUN
MANAGEMENT OF DEHYDRATION:
•Oral rehydration.
•IV fluids
•Correction of underlying problem.
•Dietary management
•Nursing management.
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34. NURSING MANAGEMENT OF FLUID VOLUME DEFICIT
oMeasure all fluid that enter and leave the body.
oCheck electrolyte CBC and urine specific gravity.
oAssess for hypotension and quick pulse.
oAssess for respiratory system and tissue perfusion.
oCheck orientation vision hearing reflects and muscle strength.
oCheck for weight changes.
oCheck for skin breakdown and good oral care.
oWatch carefully for developing complication.
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35. MANAGEMENT OF OVER HYDRATION:
ØICFVE is treated by the addition of solutes to IV fluids.
ØUse of D5%, 0.45% Nacl will help to correct ICFVE when the causes is water excess.
ØOral fluids such as water and soft drinks should be given in addition to water and ice chips.
ØIV therapy should be monitored every hour.
ØMonitor vital sign in intake output.
ØWe should be checked daily to make sure fluid gain or loss.
ØAdminister prescribed antiemetic as needed to allow food and food to be ingested.
ØSafety measure necessary when the client display behavior changes.
NURSING INTERVENTIONS:
ØMonitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and gastrointestinal status.
ØPrevent for the flute overload and restore normal fluid balance.
ØAdminister diuretics osmotic diuretics typically and prescribe fast to prevent serve electrolyte imbalance.
ØRestrict fluid and sodium intake as prescribed.
ØMonitor intake and output monitor weight.
ØMonitor electrolyte value and prepare to administer medication to treat an imbalance if present.
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36. NURSING CARE FOR FLUID AND ELECTROLYTE IMBALANCE:
ASSESSMENT:
oHistory of recent intake & output.
oBlood pressure
oHeart rate.
oDaily weight.
oSkin turgor.
oMucus membranes.
oMental status.
oLab analysis
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