Fluid and Electrolytes

Homeostasis

• State of equilibrium in internal environment of body, naturally maintained by adaptive

responses that promote healthy survival
• Body fluids and electrolytes play an important role

Water Content of the Body

• Accounts for 60% of body weight in adult

• 70-80% of body weight in infant

• Varies with gender, body mass, and age

Compartments

• Intracellular fluid (ICF)

• Extracellular fluid (ECF)
• Intravascular (plasma)
• Interstitial
• Transcellular

Intracellular Fluid (ICF)

• Fluid located within cells

• 42% of body weight
• Most prevalent cation is potassium (K+)

• Most prevalent anion is phosphate (PO4-)

Extracellular Fluid (ECF)

• Fluid spaces between cells (interstitial fluid) and the plasma space
• Interstitial
• Most prevalent anion is chloride (Cl-)
• Most prevalent cation is sodium (Na+)
• Expands and contracts
• 2/3 of ECF in interstitium
• Extracellular Fluid (ECF)

Intravascular (IV)

• Within vascular space

• Measured with blood tests
• 1/3 of ECF

Transcellular Fluid

• Small but important fluid compartment

• Approximately 1L
• Includes fluid in
 Cerebrospinal fluid
 Gastrointestinal (GI) tract
 Pleural spaces
 Synovial spaces

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  Peritoneal fluid spaces

Mechanisms Controlling Fluid and Electrolyte Movement

 Diffusion

 Facilitated diffusion

 Active transport

 Osmosis

 Hydrostatic pressure

 Oncotic pressure

Diffusion

• Movement of molecules from an area of high concentration to low concentration

• Occurs in liquids, solids, and gases
• Membrane separating two areas must be permeable to substance for diffusion to occur

Facilitated Diffusion

• Very similar to diffusion

• Specific carrier molecules involved to accelerate diffusion

• Active Transport

• Process in which molecules move against concentration gradient

• Example: sodium-potassium pump

• ATP is energy source

Osmosis

• Movement of water between two compartments by a membrane permeable to water

but not to a solute

• Water moves from area of low solute concentration to area of high solute
concentration

• Requires no energy

Osmotic Pressure

• Amount of pressure required to stop osmotic flow of water

• Water will move from less concentrated to more concentrated side
• Determined by concentration of solutes in solution

Hydrostatic Pressure

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 • Force within a fluid compartment

• Major force that pushes water out of vascular system at capillary level

Oncotic Pressure

• Osmotic pressure exerted by colloids in solution

• Protein is major colloid in vascular system

Fluid Movement in Capillaries

• Amount and direction of movement determined by

 Capillary hydrostatic pressure
 Plasma oncotic pressure
 Interstitial hydrostatic pressure
 Interstitial oncotic pressure

Fluid Shifts

• Plasma to interstitial fluid shift results in edema

 Elevation of hydrostatic pressure
 Decrease in plasma oncotic pressure
 Elevation of interstitial oncotic pressure

Fluid Shifts

• Interstitial fluid to plasma

• Fluid drawn into plasma space whenever there is increase in plasma osmotic or
oncotic pressure
• Wearing of compression stockings or hose is a therapeutic action on this effect

Fluid Movement between Extracellular and Intracellular

• Water deficit (increased ECF) is associated with symptoms that result from cell
shrinkage as water is pulled into vascular system

• Water excess (decreased ECF) develops from gain or retention of excess water

Fluid Spacing

• First spacing
 Normal distribution of fluid in ICF and ECF
• Second spacing

 Abnormal accumulation of interstitial fluid

• Third spacing
 Fluid accumulation in part of body where it is not easily exchanged with ECF

Electrolytes

• Cations (+) and anions (-) are paired

• Most powerful cation is H+

• If one electrolyte is disturbed, others are likely disturbed

Regulation of Water Balance

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  Hypothalamic regulation
 Pituitary regulation
 Adrenal cortical regulation
 Renal regulation
 Cardiac regulation
 Gastrointestinal regulation
 Insensible water loss

Hypothalamic Regulation

• Osmoreceptors in hypothalamus sense fluid deficit or increase in plasma osmolality

• Stimulates thirst and antidiuretic hormone (ADH) release
• Result in increased free water and decreased plasma osmolarity

Pituitary Regulation

• Under control of hypothalamus, posterior pituitary releases ADH

• Stress, nausea, nicotine, and morphine also stimulate ADH release

Adrenal Cortical Regulation

• Adrenal cortex releases hormones to regulate both water and electrolytes

 Glucocorticoids
 Mineralcorticoids
• Aldosterone is a mineralocorticoid with potent sodium-retaining and potassium
excreting capability
 Factors Affecting Aldosterone Secretion
 Effects of Stress on F&E Balance

Renal Regulation

• Kidneys are primary organs for regulating fluid and electrolyte balance
• Selective reabsorption of water and electrolytes
• Excretion of electrolytes occurs
• Renal tubules are sites of action of ADH and aldosterone

Cardiac Regulation

• Atrial natriuretic factor (ANF) is released by the cardiac atria in response to increased
atrial pressure
• ANF causes vasodilation and increased urinary excretion of sodium and water

Gastrointestinal Regulation

• Gastrointestinal tract accounts for most of the water intake

• Small amounts of water are eliminated by GI tract in feces

Insensible Water Loss

• Invisible vaporization from lungs and skin

• Approximately 900 ml per day is lost
• No electrolytes are lost with insensible water loss
 Excessive sweating, not insensible loss, leads to loss of water and electrolytes

[Sodium]

• Imbalances typically associated with parallel changes in osmolality

• Plays a major role in
 ECF volume and concentration
 Generation and transmission of nerve impulses
 Acid-base balance

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Hypernatremia

• Elevated serum sodium occurring with water loss or sodium gain

• Causes hyperosmolality leading to cellular dehydration

• Primary protection is thirst from hypothalamus

Differential Assessment of ECF Volume

 Imbalances in ECF Volume

 Hypernatremia

• Manifestations include thirst, lethargy, agitation, seizures, and coma

• If secondary to water deficiency, it often results of impaired LOC

• Can be produced by clinical states such as central or nephrogenic diabetes insipidus
• Management includes

 Treat underlying cause

 If oral fluids cannot be ingested, IV solution of 5% dextrose in water or
hypotonic saline
 Diuretics
• Serum sodium levels must be reduced gradually to avoid cerebral edema

Nursing Management
Nursing Diagnosis

• Risk for injury

Hyponatremia

• Results from loss of sodium-containing fluids or from water excess

• Clinical manifestations include confusion, nausea, vomiting, seizures, and coma

Hyponatremia

• If caused by water excess, fluid restriction is needed

• If severe symptoms (seizures) occur, small amount of intravenous hypertonic saline
solution (3% NaCl) is given

Hyponatremia

• If associated with abnormal fluid loss, fluid replacement with sodium-containing

solution is needed

Nursing Management
Nursing Diagnosis

• Risk for injury

Extracellular Fluid Volume Imbalances

• Hypovolemia can occur with loss of normal body fluids (diarrhea, fistula drainage,
hemorrhage), decreased intake, or plasma-to-interstitial fluid shift

• Hypervolemia may result from excessive intake of fluids, abnormal retention of fluids
(CHF), or interstitial-to-plasma fluid shift
• Extracellular Fluid Volume Imbalances

• Treatment for hypovolemia is balanced IV solutions, isotonic chloride, or blood

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 • Treatment for hypervolemia is use of diuretics, fluid restriction, and sodium
restriction

Nursing Management
Nursing Diagnoses

• Hypovolemia:
 Excess fluid volume
 Ineffective airway clearance
 Risk for impaired skin integrity
 Disturbed body image
 Potential complications: pulmonary edema, ascites

Nursing Management
Nursing Diagnoses

• Hypovolemia
 Deficient fluid volume
 Decreased cardiac output
 Potential complication: hypovolemic shock

Nursing Management
Nursing Implementation

• I&O
• Monitor cardiovascular changes
• Assess respiratory status and monitor changes
• Daily weights
• Skin assessment

Nursing Management
Nursing Implementation

• Neurologic function
 LOC
 PERLA
 Voluntary movement of extremities
 Muscle strength
 Reflexes

[Potassium]

• Potassium major ICF cation

• Potassium is necessary for
 Transmission and conduction of nerve impulses
 Maintenance of normal cardiac rhythms
 Skeletal muscle contraction
 Acid-base balance

Potassium

• Critical to action membrane potential

 Sources
 Fruits and vegetables (bananas and oranges)
 Salt substitutes
 Potassium medications (PO, IV)
 Stored blood

Hyperkalemia

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 • Causes
 Increased retention

 Renal failure
 Potassium sparing diuretics
 Increased intake
 Mobilization from ICF
 Tissue destruction
 Acidosis

Hyperkalemia
Clinical Manifestations

• Skeletal muscles weak or paralyzed

• Ventricular fibrillation or cardiac standstill
• Cardiac depolarization is impaired
• Repolarization occurs more quickly
• Abdominal cramping or diarrhea

Nursing Management
Nursing Diagnoses

• Risk for injury

• Potential complication: arrhythmias

Nursing Management
Nursing Implementation

• Eliminate oral and parenteral K intake

• Increase elimination of K (diuretics, dialysis, Kayexalate)
• Force K from ECF to ICF by IV insulin or sodium bicarbonate
• Reverse membrane effects of elevated ECF potassium by administering calcium
gluconate IV

Hypokalemia

• Causes
 Increased loss
 Aldosterone
 Loop diuretics
 GI losses
 Associated with Mg deficiency
 Movement into cells

Hypokalemia
Clinical Manifestations

• Potentially lethal ventricular arrhythmias

• Impaired repolarization
• Increased digoxin toxicity in those taking the drug
• Skeletal muscle weakness and paralysis
• Muscle cell breakdown
 Leads to myoglobin in plasma and urine

Hypokalemia
Clinical Manifestations

• Decreased GI motility
• Altered airway responsiveness
• Impaired regulation of arterial blood flow
• Diuresis
• Hyperglycemia

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Nursing Management
Nursing Diagnoses

• Risk for injury

• Potential complication: arrhythmias

Nursing Management
Nursing Implementation

• Replacement PO or IV
 Never push IV
 Painful in peripheral veins
 Never give with anuric renal failure
• Teach prevention methods

[Calcium]

• Obtained from ingested foods

• More than 99% combined with phosphorus and concentrated in skeletal system
• Inverse relationship with phosphorus
• Bones readily available store of calcium

Calcium

• Calcium blocks sodium transport and stabilizes cell membrane

• Functions include transmission of nerve impulses, myocardial contractions, blood
clotting, formation of teeth and bone, and muscle contractions
• Only ionized form of calcium is biologically active

Calcium

• t Controlled by
 Parathyroid hormone
 Calcitonin
 Vitamin D

Hypercalcemia

• High serum calcium levels

• Causes include
 Hyperparathyroidism
 Malignancy
 Vitamin D overdose
 Prolonged immobilization

Hypercalcemia

• Clinical manifestations include

 decreased memory
 confusion
 disorientation
 fatigue

Hypercalcemia

• Management includes
 loop diuretic
 hydration with isotonic saline infusion

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  synthetic calcitonin
 mobilization

Nursing Management
Nursing Diagnosis

• Risk for injury

• Potential complication: arrhythmias

Hypocalcemia

• Low serum calcium levels

• Causes include
 Decreased production of PTH
 Acute pancreatitis
 Multiple drug transfusions
 Alkalosis
 Decreased intake

Hypocalcemia

• Clinical manifestations include positive Trousseau’s sign and Chvostek’s sign

• Others include laryngeal stridor, dysphagia, numbness, and tingling around the mouth
or in the extremities

Hypocalcemia

• Management
 Treat cause
 Oral or IV calcium supplements
 Treatment of pain and anxiety to prevent hyperventilation-induced respiratory
alkalosis

[Phosphate]

• Phosphorus is primary anion in ICF

• Essential to function of muscle, red blood cells, and nervous system
• Deposited with calcium for bone and tooth structure

Phosphate

• Involved in acid-base buffering system, ATP production, and cellular uptake of glucose
• Maintenance requires adequate renal functioning
• Essential to function muscle, RBCs, and nervous system

Hyperphosphatemia

• Causes include
 Acute or chronic renal failure
 Chemotherapy
 Excessive ingestion of milk or phosphate
 Containing laxatives
 Large intakes of vitamin D

Hyperphosphatemia
Clinical Manifestations

• Hypocalcemia
• Muscle problems (tetany)

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 • Deposition of calcium-phosphate precipitates in skin, soft tissue, cornea, viscera, and
blood vessels

Hyperphosphatemia

• Management
 Identifying and treating underlying cause
 Restricting foods and fluids containing phosphorus
 Adequate hydration and correction of hypocalcemic conditions
 Sevelamer (Renagel)

Hypophosphatemia

• Causes include
 Malnourishment/malabsorption
 Alcohol withdrawal
 Use of phosphate-binding antacids
 During parenteral nutrition with inadequate replacement

Hypophosphatemia
Clinical Manifestations

• CNS depression
• Confusion
• Muscle weakness and pain
• Arrhythmias
• Cardiomyopathy

Hypophosphatemia

• Management
 Oral supplementation
 Ingestion of foods high in phosphorus
 May require IV administration of sodium or potassium phosphate

[Magnesium]

• 50-60% contained in bone

• A coenzyme in metabolism of protein and carbohydrates
• Factors that regulate calcium balance appear to influence magnesium balance

Magnesium

• Acts directly on myoneural junction

• Important for normal cardiac function

Hypermagnesemia

• Causes include
 Increased intake or ingestion of products containing magnesium when renal
insufficiency or failure is present

Hypermagnesemia
Clinical Manifestations

• Lethargy
• Drowsiness
• N/V
• Reflexes impaired
• Somnolence
• Respiratory and cardiac arrest can occur

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Hypermagnesemia

• Management
 Prevention
 IV CaCl or calcium gluconate
 Fluids

Hypomagnesemia

• Causes include
 Prolonged fasting or starvation
 Chronic alcoholism
 Fluid loss

Hypomagnesemia

 Prolonged parenteral nutrition without supplementation

 Diuretics
 Osmotic diuretics from high glucose levels

Hypomagnesemia
Clinical Manifestations

• Hyperactive deep tendon reflexes

• Tremors
• Seizures
• Cardiac arrhythmias
• Confusion

Hypomagnesemia

• Management
 Oral supplements
 Increase dietary intake
 If severe, parenteral IV or IM magnesium

[Protein] Imbalances

• Plasma proteins, particularly albumin, are significant determinants of plasma volume

• Hyperproteinemia is rare, but occurs with dehydration-induced hemoconcentration

Hypoproteinemia

• Caused by
 Anorexia
 Malnutrition
 Starvation
 Fad dieting
 Poorly balanced vegetarian diets

Hypoproteinemia

• Poor absorption can occur in certain GI malabsorptive diseases

• Protein can shift out of intravascular space with inflammation
• Hemorrhage
• Nephrotic syndrome

Hypoproteinemia
Clinical Manifestations

• Edema
• Slow healing

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 • Anorexia
• Fatigue
• Anemia
• Muscle loss
• Ascites

Hypoproteinemia
Management

 High-carbohydrate, high-protein diet

 Dietary protein supplements
 Enteral nutrition or total parenteral nutrition

IV Fluids

Purposes

 Maintenance
 When oral intake is not adequate
 Replacement
 When losses have occurred

IV Fluids

• IV fluids will cause electrolyte imbalances if not corrected

• Imbalances classified as deficits or excesses
• Sodium plays major role in homeostasis of ECF

D5W

• Isotonic
• Provides 170 kcal/L
• Free water
 Moves into ICF
 Increases renal solute excretion

D5W

• Prevents ketosis
• Supports edema formation
• Decreased chance of IV fluid overload
• Usually compatible with medications

Normal Saline (NS)

• Isotonic
• No calories
• More NaCl than ECF
• 30% stays in IV (most)
 70% moves out of IV

Normal Saline (NS)

• Expands IV volume
 Preferred fluid for immediate response
 Risk for fluid overload higher
• Does not change ICF Volume
• Blood products
• Compatible with most medications

Lactated Ringer’s

• Isotonic

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 • More similar to plasma than NS
 l Has less Na Cl
 l Has K, Ca, PO4, lactate (metabolized to HCO3)
• Expands ECF, IV
• Common replacement fluid

D5 ½ NS

• Hypertonic
• Common maintenance fluid
• KCl added for maintenance or replacement

D5 ½ NS

• Provides calories
 Prevents ketosis

• Moves into ICF

• Usually compatible with medications

D10W

 Hypertonic
 Provides 340 kcal/L
 Free water
 Limit of dextrose concentration may be infused peripherally

Plasma Expanders

• Pull fluid into IV from interstitium

• Colloids
 Packed RBCs
 Albumin
 Plasma

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