FLUID AND ELECTROLYTE IMBALANCES

INTRODUCTION

Health and normal body functioning depend on fluid ,electrolyte and acid-
base balance. Physiologic homeostasis ,depends on multiple physiological process that
regulate fluid intake and output and the movement of water and the substances
dissolved in it between the body compartments. Almost every illness has the potential to
threaten this balance eg.diarrhoea,vomiting,cardiac diseases etc. Nurses play a vital
role in promoting ,normal fluid electrolyteand acid base balance and in preventing life
threatening imbalances.

NORMAL FLUID AND ELECTROLYTE BALANCE.

Body fluid is composed primarily of water, which contains chemical compounds

called electrolytes. About 46% to 60% of the average adult’s weight is water, the
primary body fluid. Water is vital to health and serves some cellular functions,such as:

 A medium for metabolic reactions withins cells.

 A transporter for nutrients,waste products,and other substances.

 A lubricant

 An insulator and shock absorber

 Regulating and maintaining body temperature.

FLUID COMPARTMENTS.

The body fluid is divided into two compartments. Intracellular, which

constitutes two- third of the body weight and extracellular fluid constitutes one- third
of the body weight. ECF constitutes intravascular or plasma, interstitial , lymph
and trancellular fluid such as CSF,Peritoneal, pleural. Many salts dissociate in water,
that is, break up into electrically charged ions called electrolytes.
Composition of body fluids.: Extracellular and intracellular fluids contain
oxygen from the lungs, dissolved nutrients, excretory products and charged particles
called ions.

Many salts dissociates in water,that is ,break up into electrically charged ions.these

charged particles are called electrolytes because they are capable of conducting
electricity.Ions that carry a positive charge are called cations,like sodium
,potassium,calcium etc and ions carrying a negative charge are called anions, eg.
Chloride, bicarbonate, phosphate and sulphate.

Electrolytes are generally measured in milliequivalents per liter of water. The term
milliequivalent refers to the combining power of the ion. In extra cellular fluid the
principal electrolytes are sodium, chloride and bicarbonate. Other electrolytes such
as potassium, calcium, and magnesium are also present in smaller quantities.
Plasma is a protien rich fluid. ICF contains Potassium, magnesium, phosphate and
sulphate.

Movement of body fluids and electrolytes.

The body fluid compartments are separated from one another by cell membrane and
the capillary membrane. These are selectively permeable.The methods by which
fluids move are osmosis,diffusion, filtration, and active transport.

Osmosis : is the movement of water across cell membranes, from the less
concentrated solution to the more concentrated solution.The concentration of the
solutes in the body fluids is usually expressed as the osmolality. Osmotic pressure
is the power of a solution to draw water across a semi permeable membrane. In the
body plasma protiens exerts an osmotic draw called oncotic pressure.

Diffusion : is the random movement of the molecules. In the body, diffusion of water
occurs through the split pores of capillary membranes.

Filtration: is a process whereby fluid and solutes move together across

a membrane from one compartment to another. The movement is from an area of
higher pressure to one of lower pressure. Hydrostatic pressure is the pressure
exerted by a fluid within a closed system on the walls of a container in which it is
contained.

Active transport: substances can move across cell membranes from a less
concentrated to a more concentrated by active transport.a specific carrier is required
for each substance.

REGULATION OF BODY FLUIDS

 In a healthy person, normally fluid intake and fluid loss are balanced.

Fluid intake: the thirst mechanism is the primary regulator of fluid intake. The thirst
center is located in the hypothalamus of the brain.

Fluid output: fluid losses from the body counterbalance the adult’s 2500 ml average
daily intake of fluid. Fluid losses as urine, insensible losses through skin ,and
expired air and loss through feces.

Maintaining homeostasis: the volume and composition of body fluids is regulated

through several homeostatic mechanisms including

1. kidneys: are the primary regulator and is maintained by selective retention

and excretion by the kidneys.

2. ADH. : it is synthesized in the anterior portion of the hypothalamus and acts

on the collecting ducts of the nephrons and regulates the water excretion from
the kidney. When serum osmolality rises ,ADH is produced,causing the
collecting ducts to become more permeable.

3. Renin-Angiotensin Aldosterone system.:renin causes the conversion of

angiotensinogen to angiotensin 1, which is then converted to angiotensin 2.
this acts directly on the nephrons to promote sodium and water retention.

4. Atrial Natriuretic factor. :ANF is released from the cells in the atrium of the
heart in response to exess blood volume. This acts as a potent diuretic and it
also inhibits thirst ,reducing the fluid intake.

REGULATION OF ELECTROLYTES

Electrolytes are minerals in your body that have an electric charge. They are in your
blood, urine and body fluids. Maintaining the right balance of electrolytes helps your
body's blood chemistry, muscle action and other processes. Sodium, calcium,
potassium, chlorine, phosphate,magnesium ,bicarbonate are all electrolytes.
Electrolytes are important for ,

 Maintaining fluid balance

 Contributing to acid base regulation.

 Facilitating enzyme reactions

 Transmitting neuromuscular reactions.

Factors affecting the balance are:

Age : infants and growing children have much greater fluid turn over than adults. Infants
lose more water through kidneys. And increased levels of ANF seen in older contributes
to impaired ability to conserve water.

Gender and body size: total body water is also affected by gender and body size.
Women have more body fat and less water than men.

Environmental temperature: ther is an high risk for fluid imbalances when tem. Is high
and fluid loses through sweating

Life style: other factors such as diet,exercise,and stress affect fluid imbalances. Heavy
alcohol consumption affects electrolyte balance.

Fluid electrolyte imbalances:

A number of factors such as illness,trauma, surgery and medications can affect the
normal balances. Fluid imbalances are of two types. Isotonic, when water and
electrolytes are lost or gained in equal proportions; and osmolar involve the loss or gain
of only water.

1. fluid volume deficit (hypovolemia).

This occurs when the body loses both water and electrolytes from ECF in similar
proportions.

Isotonic Fluid Volume Deficit

Risk Factors
Loss of water and electrolytes from
•Vomiting
• Diarrhea
• Excessive sweating
• Polyuria
• Fever
• Nasogastric suction
♦ Abnormal drainage or wound losses
Insufficient intake due to
• Anorexia
• Nausea
• Inability to access fluids
• Impaired swallowing
• Confusion, depression
Clinical Manifestations Nursing Interventions
Complaints of weakness and thirst Assess for clinical manifestations of
Weight loss FVD.
Monitor weight and vital signs,
• 2% loss = mild FVD Temperature.
• 5% loss = moderate Assess tissue turgor.
• 8% loss = severe Assess breath sounds.
Fluid intake less than output
Decreased tissue turgor Monitor fluid intake and
output. Monitor laboratory
Dry mucous membranes, sunken findings. Administer oral and intravenous fluids
eyeballs, decreased tearing as
indicated.
Subnormal temperature Provide frequent mouth care.
Weak, rapid pulse Implement measures to prevent skin
Decreased blood pressure breakdown.
Postural (orthostatic) hypotension Provide for safety, e.g., provide
(significant drop in BP when moving forassistance
a client rising from bed.
from
lying to sitting or standing position)
Flat neck veins; decreased capillary
refill
Decreased central venous pressure
Decreased urine volume (<30 mL/h)
 Increased specific gravity of urine (<
1.030)
Increased hematocrit
Increased blood urea nitrogen (BUN)

THIRD SPACE SYNDROME. In third space syndrome, Quid shifts from the vascular space into an
area where it is not readily accessible as extracellular fluid. This lluid remains in the body but is
essentially unavailable for use, causing an isotonic fluid volume deficit. Fluid may be
sequestered in the bowel, in the interstitial space as edema, in inflamed tissue, or in potential
spaces such as the peritoneal or pleural cavities.

The client with third space syndrome has an isotonic fluid deficit but may not manifest
apparent fluid loss or weight loss. Careful nursing assessment is vital to effectively identify and
intervene for clients experiencing third-spacing. Because the fluid shifts back into the vascular
compartment after time, assessment for manifestations of fluid volume excess or hypervolemia
is also vital.

2.Fluid Volume Excess

Fluid volume excess (FVE) occurs when the body retains both water and sodium in similar
proportions to normal ECF. This is commonly referred to as hypervolemia (increased blood
volume). Because both water and sodium are retained, the serum sodium concentration
remains essentially normal. FVE is always secondary to an increase in the total body sodium
content. Specific causes of FVE include (a) excessive intake of sodium chloride; (b)
administering sodium-containing infusions too rapidly, particularly to clients with impaired
regulatory mechanisms; and (c) disease processes that alter regulatory mechanisms, such as
heart failure, renal failure, cirrhosis of the liver, and Cushing's syndrome

EDEMA. In fluid volume excess, both intravascular and interstitial spaces have an
increased water and sodium content. Excess interstitial fluid is known as edema.
Edema typically is I most apparent in areas where the tissue pressure is low. such as
around the eyes, and in dependent tissues (known as dependent edema), where
hydrostatic capillary pressure is high.

Edema can be caused by several different mechanisms. The three main

mechanisms are increased capillary hydrostatic pressure, decreased plasma oncotic
pressure, and increased capillary permeability. It may be due to FVE that increases
capillary hydrostatic pressures, pushing fluid into the interstitial tissues. This type of
edema is often seen in dependent tissues such as the feet, ankles, and sacrum
because of the effects of gravity. Low levels o\' plasma proteins from malnutrition or
liver or kidney diseases can reduce the plasma oncotic pressure so that fluid is not
drawn into the capillaries from interstitial tissues, causing edema. With tissue trauma
and some disorders such as allergic reactions, capillaries become more permeable,
allowing fluid to escape into interstitial tissues. Obstructed lymph flow impairs the
movement of fluid from interstitial tissues back into the vascular compartment, resulting
in edema.
 Pitting edema is edema that leaves a small depression or pit after finger pressure is
applied to the swollen area. The pit is caused by movement of fluid to adjacent tissue,
away from the point of pressure Within 10 to 30 seconds the pit normally disappears.

Fluid Volume Excess

Risk Factors Clinical Manifestations Nursing Interventions
Excess intake of sodium- Weight gain Assess for clinical manifestations of
containing
intravenous fluids • 2% gain = mild FVE FVE.
Monitor weight and vital signs.
Excess ingestion of sodium in diet • 5% gain = moderate Assess for edema.
or
medications (e.g., sodium •8% gain = severe Assess breath sounds.
bicarbonate Fluid intake greater than output Monitor fluid intake and
antacids such as Alka-Seltzer or
hypertonic enema solutions such Moist mucous membranes output. Monitor laboratory
as Full, bounding pulse;tachycardia findings. Place in Fowler's
Fleet's) Increased blood pressure and position. Administer diuretics
Impaired fluid balance regulation central as ordered.
• Renal failure Restrict fluid intake as indicated.
•Cirrhosis of the Restrict dietary sodium as
liver
Moist crackles (rales) in lungs; ordered.
Implement measures to prevent
dyspnea, shortness of breath skin breakdown.
Mental confusion

Dehydration
Dehydration occurs when you lose more fluid than you take in, and your body
doesn't have enough water and other fluids to carry out its normal functions. If you don't
replenish lost fluids, you may suffer serious consequences. Dehydration is a leading
cause of death in children worldwide. Dehydration

Dehydration, or hyperosmolar imbalance, occurs when water is lost from the body without
significant loss of electrolytes. Because water is lost while electrolytes, particularly sodium,
are retained, the serum osmolality and serum sodium levels increase. Water is drawn into
the vascular compartment from the interstitial space and cells, resulting in cellular
dehydration. Older adults are at particular risk for dehydration because of decreased thirst
sensation. This type of water deficit also can affect clients who are hyperventilating or have
prolonged fever or in diabetic ketoacidosis and those receiving enteral feedings with
insufficient water intake.

Etiology:

 Diarrhea, vomiting. Children and infants are especially at risk

 Fever. In general, the higher your fever, the more dehydrated you may become.

 Excessive sweating
 Increased urination. This is most often the result of undiagnosed or
uncontrolled diabetes mellitus, diabetes insipidus,Certain medications — diuretics,
antihistamines, blood pressure medications and some psychiatric drugs — as well as
alcohol also cause to urinate or perspire more than normal.

 Inadequate intake of water during hot weather or exercise also may cause
dehydration.

 Burns

Risk factors

 Infants and children. Worldwide, dehydration caused by diarrhea is a leading

cause of death in children. Infants and children are especially vulnerable because of
their relatively small body weights and high turnover of water and electrolytes.

 Older adults

 People with chronic illnesses.

 Endurance athletes..

 People living at high altitudes

Symptoms
Mild to moderate dehydration is likely to cause:

 Dry, sticky mouth

 Sleepiness or tiredness—children are likely to be less active than usual

 Thirst

 Decreased urine output — fewer than six wet diapers a day for infants and eight
hours or more without urination for older children and teens

 Few or no tears when crying

 Muscle weakness

 Headache
 Dizziness or lightheadedness

Severe dehydration, a medical emergency, can cause:

 Extreme thirst

 Extreme fussiness or sleepiness in infants and children; irritability and confusion

in adults

 Very dry mouth, skin and mucous membranes

 Lack of sweating

 Little or no urination — any urine that is produced will be dark yellow or amber

 Sunken eyes

 Shriveled and dry skin that lacks elasticity and doesn't "bounce back" when
pinched into a fold

 In infants, sunken fontanels — the soft spots on the top of a baby's head

 Low blood pressure

 Rapid heartbeat

 Fever

 In the most serious cases, delirium or unconsciousness

A better barometer is the color of your urine: Clear or light-colored urine means you're
well hydrated, whereas a dark yellow or amber color usually signals dehydration.

Complications

Dehydration can lead to serious complications, including:

 Heat injury. Inadequate fluid intake combined with vigorous exercise and heavy
perspiration can lead to heat injury.
 Swelling of the brain (cerebral edema). Most often, the fluid lose when
dehydrated contains the same amount of sodium the blood does (isotonic dehydration).
In some instances, though, client may lose more sodium than fluid (hypotonic
dehydration). To compensate for this loss, the body produces particles that pull water
back into the cells. As a result, cells may absorb too much water during the rehydration
process, causing them to swell and rupture. The consequences are especially grave
when brain cells are affected.

 Seizures. These occur when the normal electrical discharges in brain become
disorganized, leading to involuntary muscle contractions and sometimes to a loss of
consciousness.

 Hypovolemic shock. This is one of the most serious complications of

dehydration. It occurs when low blood volume causes a drop in blood pressure and a
corresponding reduction in the amount of oxygen reaching tissues.

 Kidney failure. This potentially life-threatening problem occurs when kidneys are
no longer able to remove excess fluids and waste from blood.

 Coma and death. When not treated promptly and appropriately, severe
dehydration can be fatal.

Tests and diagnosis

To help confirm the diagnosis and pinpoint the degree of dehydration,there are other
tests, such as:

1. Blood tests. These may be used to check electrolytes, especially sodium

and potassium; to look for signs of concentrated blood; and to evaluate how
well kidneys are working.

2. Urinalysis.

 The color and clarity of urine

 the presence of carbon compounds (ketones)

 anurine's specific gravity — that is, the mass of the urine as compared with equal
amounts of distilled water. A high specific gravity, for example, indicates
significant dehydration.
 If it's not obvious , additional tests to check for diabetes and for liver or kidney problems.

Treatments and drugs

The only effective treatment for dehydration is to replace lost fluids and lost electrolytes.
The best approach to dehydration treatment depends on age, the severity and its
cause. Treating dehydration in sick children:
There are specific suggestions for treating dehydration in child, but some general
guidelines include the following:

 Use an oral rehydration solution. oral rehydration solution such as Pedialyte

contain water and salts in specific proportions to replenish both fluids and electrolytes.In
an emergency situation where a pre-formulated solution is unavailable, you can make
your own oral rehydration solution by mixing 1/2 teaspoon salt, 1/2 teaspoon baking
soda, 3 tablespoons sugar and 1 liter (about 1 quart) of safe drinking water.When your
child is vomiting, try giving small amounts of solution at frequent intervals — 1 teaspoon
every minute, for instance. If your child can't keep this down, wait 30 to 60 minutes and
try again. Room temperature fluids are best.

 Continue to breast-feed. Don't stop breast-feeding when your baby is sick, but
add an oral rehydration solution as well. If you give your baby formula, try switching to
one that's lactose-free until diarrhea improves — lactose can make diarrhea worse.

 Avoid certain foods and drinks. The best liquid for a sick child is an oral
rehydration solution — plain water doesn't provide essential electrolytes. Avoid giving
your child salty broths, milk — especially boiled milk — sodas, fruit juices or gelatins,
which don't relieve dehydration and which may make symptoms worse.

Treatingdehydrationinsickadults
Most adults with mild to moderate dehydration from diarrhea, vomiting or fever can improve
their condition by drinking more water. Water is best because other liquids, such as fruit
juices, carbonated beverages or coffee, can make diarrhea worse.

Treating severe dehydration

Children and adults who are severely dehydrated should be treated intravenously.
Intravenous hydration provides the body with water and essential nutrients much more
quickly than oral solutions do.
 Prevention
To prevent dehydration, consume plenty of fluids and foods high in water such as fruits
and vegetables. The safest approach is prevention of dehydration. Monitor your fluid
loss during hot weather, illness or exerciseUnder certain circumstances,there is need to
take in more fluids than usual:

 Illness. Start giving extra water or an oral rehydration solution at the first signs of
illness — don't wait until dehydration occurs.

 Exercise. In general, it's best to start hydrating the day before strenuous
exercise. s too low (hyponatremia).

 Environment. You need to drink additional water in hot or humid weather to help
lower your body temperature and to replace what you lose through sweating.

Overhydration

Overhydration, also known as hypo-osmolar imbalance or water intoxication, occurs

when water is gained in excess of electrolytes, resulting in low serum osmolality and
low serum sodium levels. Water is drawn into the cells, causing them to swell. In the
brain this can lead to cerebral edema and impaired neurologic function. Water
intoxication often occurs when both fluid and electrolytes are lost, for example, through
excessive sweating, but only water is replaced. It can also result from the syndrome of
inappropriate antidiuretic hormone (SIADH), a disorder that can occur with some
malignant tumors, AIDS, head injury, or administration of certain drugs such as barbitu-
rates or anesthetics.

Overhydration is an excess of water in the body.

 People can have overhydration if they drink too much or if they have a disorder
that decreases the body's ability to excrete water.
 Often, no symptoms occur, but people may become confused or have seizures.
 Fluid intake is restricted and diuretics may be given.

Overhydration occurs when the body takes in more water than
it loses. Overhydration can occur, for example, when athletes drink excessive amounts
of water or sports drinks to avoid dehydration, or when people drink much more water
than their body needs because of a psychiatric disorder called psychogenic polydipsia.
The result is too much water and not enough sodium.
 Thus, overhydration generally results in low
sodium levels in the blood (hyponatremia—see Minerals and Electrolytes:
Hyponatremia), which can be dangerous. However, drinking large amounts of water
usually does not cause overhydration if the pituitary gland, kidneys, liver, and heart are
functioning normally. To exceed the body's ability to excrete water, a young adult with
normal kidney function would have to drink more than 6 gallons of water a day on a
regular basis.

Overhydration is much more common among people whose kidneys do not excrete
urine normally—for example, among people with a disorder of the heart, kidneys, or
liver. Overhydration may also result from the inappropriate secretion of antidiuretic
hormone (see Minerals and Electrolytes: Syndrome of Inappropriate Secretion of
Antidiuretic Hormone). In this syndrome, the pituitary gland secretes too much
antidiuretic hormone, stimulating the kidneys to conserve water when that is not
needed. Premature infants may become overhydrated if they receive too large an
amount of intravenous fluids.

Brain cells are particularly susceptible to overhydration and to low sodium levels in the
blood. When overhydration occurs slowly, brain cells have time to adapt, so few
symptoms occur. When overhydration occurs quickly, confusion, seizures, or coma may
develop.

Doctors try to distinguish between overhydration and excess blood volume. With
overhydration and normal blood volume, the excess water usually moves into the cells,
and tissue swelling (edema) does not occur. With overhydration and excess blood
volume, an excess amount of sodium prevents the excess water from moving into the
cells. Instead, the excess water accumulates around the cells, resulting in edema in the
chest, abdomen, and lower legs.

Treatment
Regardless of the cause of overhydration, fluid intake usually must be restricted (but
only as advised by doctors). Drinking less than a quart of fluids a day usually results in
improvement over several days. If overhydration occurs because of heart, liver, or
kidney disease, restricting the intake of sodium (sodium causes the body to retain
water) is also helpful.
Sometimes, doctors prescribe a drug to increase sodium and water excretion in the
urine (diuretic). In general, diuretics are more useful when overhydration is
accompanied by excess blood volume

Electrolyte Imbalances

The most common and most significant electrolyte imbalances involve sodium,
potassium, calcium, magnesium, chloride, and phosphate.

Common risk factors include chronic diseases, acute conditions,medications,

treatments, and other factors such as age.

Sodium

Sodium (Na+), the most abundant cation in the extracellular fluid, not only moves into
and out of the body but also moves in careful balance among the three fluid
compartments. It is found in most body secretions, for example, saliva, gastric and
intestinal secretions, bile, and pancreatic fluid. Therefore, continuous excretion of any of
these fluids, such as via intestinal suction, can result in a sodium deficit. Because of its
role in regulating water balance, sodium imbalances usually are accompanied by water
imbalance.

Hyponatremia is a sodium deficit, or serum sodium level of less than 135 mEq/L.
Because of sodium's role in determining the osmolality of ECF, hyponatremia typically
results in a low serum osmolality. Water is drawn out of the vascular compartment into
interstitial tissues and the cells causing the clinical manifestations associated with this
disorder.

Hypernatremia is excess sodium in ECF, or a serum sodium of greater than 145

mEq/L. Because the osmotic pressure of extracellular fluid is increased, fluid moves out
of the cells into the ECF. As a result, the cells become dehydrated.

Potassium

Although the amount of potassium (K +) in extracellular fluid is small, it is vital to normal

neuromuscular and cardiac function. Potassium is usually excreted by the kidneys.
However, the kidneys do not regulate potassium excretion as effectively as they do
sodium excretion. Therefore, an acute potassium deficiency can develop rapidly. Of the
body's secretions, the gastrointestinal secretions are high in potassium.

Hypokalemia is a potassium deficit or a serum potassium level of less than 3.5

mEq/L. Gastrointestinal losses of potassium through vomiting and gastric suction are
common causes of hypokalemia,as are the use of potassium-wasting diuretics.
 Hyperkalemia is a potassium excess or a serum potassium level greater than 5.0
mEq/L. Hyperkalemia is less common than hypokalemia and rarely occurs in clients
with normal renal function. It is, however, more dangerous than hypokalemia, and can
lead to cardiac arrest.

CLINICAL ALERT Potassium may be given intravenously for severe

hypokalemia. It must ALWAYS be diluted appropriately and NEVER given IV push.
Potassium that is to be given IV should be mixed in the pharmacy and double
checked prior to administration by two nurses. T

he usual concentration of IVpotassium is 20 to 40 mEq/L.

Calcium

Regulating levels of calcium (Ca2+) in the body is more complex than the other major
electrolytes so calcium balance can be affected by many factors. Imbalances of this
electrolyte are relatively common.

Hypocalcemia is a calcium deficit, or a total serum calcium level of less than 8.5
mg/dL and an ionized calcium level of less than 4.0 mg/dL. Severe depletion of calcium
can cause tetany with muscle spasms and paresthesias and can lead to convul sions.
Clients at greatest risk for hypocalcemia are those whose parathyroid glands have been
removed. This is frequently as sociated with total thyroidectomy or bilateral neck
surgery for cancer. Low serum magnesium levels (hypomagnesemia) and chronic
alcoholism also increase the risk of hypocalcemia.

Hypercalcemia, or serum calcium levels greater than 10.5 mg/dL, most often
occurs when calcium is mobilized from the bony skeleton. This may be due to
malignancy or prolonged immobilization.

Magnesium

Magnesium (Mg +) imbalances are relatively common in hospitalized clients, although

they may be unrecognized. Hypomagnesemia occurs more frequently than
hypermagnesemia. Chronic alcoholism is the most common cause of hypo-
magnesemia. Magnesium deficiency also may aggravate the manifestations of
alcohol withdrawal, such as delirium tremens (DTs). Hypermagnesemia is present
when the serum magnesium level rises. It is due to increased intake or decreased ex-
cretion. It is often iatrogenic, that is, a result of overzealous magnesium therapy.

Chloride

Because of the relationship between sodium ions and chloride ions (CI ), imbalances of
chloride commonly occur in conjunction with sodium imbalances. Hypochloremia is
a decreased Serum chloride level. Conditions that can cause sodium retention also can
lead to hyperchloremia.

Phosphate:

Hypophosphatemia occurs when phosphate shifts into cells from extracellular

compartments and hyper occus when they shifts out of the cells into extracellular fluid.
Nursing management

Assessing the clients for fluid ,electrolyte imbalances is an important

nursing care function.components of the assessment include The nursing
history, Physical assessment of the client,Clinical measurements and
review of laboratory test results.

Nursing history.

The nursing history is particularly important for identifying clients who are
at risk. The current and past medical history reveals conditions such as
diabetes,lung diseases ,medications, socio economic conditions etc. the
nurse needs to elicite food and fluid intake, fluid output, and the presence of
signs and symptoms.

Physical assessment

Physical assessment to evaluate a clients status focuses on the skin, the

oral cavity, mucous membranes, the eyes, the cardiovascular and
respiratory systems ,neurologic and muscular status. Data from this are
used to expand and verify information obtained in the nursing history.

Clinical measurements

Three simple Clinical measurements that the nurse can initiate without a
physician’s order are daily weights, vital signs, and fluid intake and output.

Daily weights.: Daily weight measurements provide a relatively accurate

assessment of a client’s fluid status. Significant changes in weight over a
short time are indicative of acute fluid changes. The nurse should weigh the
client at the same time,wearing the same or minimal clothing and on the
same scale.

Vital signs: changes in the vitals may indicate fluid imbalance. Elevated
body temperature may be a result of dehydration.tachycardia is an early
sign of hypovolemia. Pulse volume will decrease in FVD and increase in
FVE. Blood pressure , a sensitive measure to detect blood volume
changes.

Fluid intake and output: the measurement and recording of all fluid intake
and output during a 24-hour period provides important data about the
clients fluid and electrolyte balance. To measure fluid intake , the nurse
records on the I & O form each fluid item taken specifying the time and
type of fluid. When there is significant discrepancy between intake and
output it should br reported.

Laboratory tests

Many laboratory studies are conducted to determine the status.

Serum electrolytes.: the most common serum tests are for sodium,
potassium, chloride, magnesium and bicarbonate ions.

Complete blood count

Osmolality: an increase in serum osmolality indicates a fluid volume

deficit; a decrease reflects a fluid volume excess..the normal osmolality
ranges between 280-300. urine osmolality is a measure of the solute
concentration of urine. Normal values are 500-800.

Urine p H : normally the urine pH of the urine is relatively acidic, aveaging

about 6, but a range of 4.6 to 8 is considered normal.

Urine specific gravity and ABGs.

Nursing diagnosis:

 Deficient fluid volume related to excess fluid loss as evidenced by

decreased heartrate and decreased blood pressure.
 Excess fluid volume related to fluid retention as evidenced by edema

 Risk for imbalanced fluid volume

 Risk for deficient fluid volume

 Impaired gas exchange

 Impaired oral mucous membrane

 Impaired skin integrity

 Decreased cardiac output

 Ineffective tissue perfusion.activity intolerance

 Risk for injury

 Acute confusion

General interventions include:

maintain or restore fluid balance

 Maintain oxygenation and prevent associated risks.

 Promoting wellness

 Enteralfluid and electrolyte replacement

  Fluid intake modifications.dietary changes

 Oral electrolyte supplements

 Parenteral fluid and electrolyte replacement

Conlusion

Most people rarely think about their fluid electrolyte balances.in good health
a delicate balance of fluids should be maintained in the body . people know it
is important to drink adequate fluid and consume a balanced diet, but they
may not understand the potential effectsof imbalances. So nurses can
promote clients health by providing teaching that will help them to maitain fluid
and electrolyte balance

Journal abstract

1. Caffeine, Fluid-Electrolyte Balance, Temperature Regulation, and

Exercise-Heat Tolerance

Armstrong, Lawrence E.; Casa, Douglas J.; Maresh, Carl M.; Ganio,
Matthew S.
Dietitians, exercise physiologists, athletic trainers, and other sports medicine
personnel commonly recommend that exercising adults and athletes refrain
from caffeine use because it is a diuretic, and it may exacerbate dehydration
and hyperthermia. This review, contrary to popular beliefs, proposes that
caffeine consumption does not result in the following: (a) water-electrolyte
imbalances or hyperthermia and (b) reduced exercise-heat tolerance.

2. Electrolytes in the aging.

The elderly population in the United States continues to grow and is expected
to double by 2050. With aging, there are degenerative changes in many
organs and the kidney is no exception. After 40 years of age, there is an
increase in cortical glomerulosclerosis and a decline in both glomerular
filtration rate and renal plasma flow. These changes may be associated with
an inability to excrete a concentrated or a dilute urine, ammonium, sodium, or
potassium. Hypernatremia and hyponatremia are the most common
electrolyte abnormalities found in the elderly and both are associated with a
high mortality. Under normal conditions, the elderly are able to maintain water
and electrolyte balance, but this may be jeopardized by an illness, a decline in
cognitive ability, and with certain medications. Therefore, it is important to be
aware of the potential electrolyte abnormalities in the elderly that can arise
under these various conditions to prevent adverse outcomes.
Research abstract
Shibata H
Department of Clinical Oncology, Graduate School of Medicine, Akita
University.

The electrolyte imbalance in advanced cancer patients, including

hyperkalemia, hypercalcemia and hyponatremia, can be induced by various
factors. Hyperkalemia is occasionally induced by chemotherapy for very large
malignant tumors, due to tumor lysis syndrome. hyponatremia are often
observed in patients with breast cancer, renal cancer, prostate cancer,
and the like, as a paraneoplastic syndrome. Some part of hypercalcemia
results from osteolysis, but the majority is induced by hormonal factors, such
as parathyroid hormone-related protein. One of the paraneoplastic causes of
hyponatremia is antidiuretic hormone-producing tumor. These disorders could
be morbid or even motile, resulting from encephalopathy or arrhythmia in
some cases. However, it should be kept in mind that they could be improved
or cured by prompt treatment. Recently, after approval of the molecular
targeted drugs for epidermal growth factor receptors, such as cetuximab and
panitumumab, the incidence of hypomagnesia with use of these monoclonal
antibodies, is relatively frequent. In addition, small molecular targeted drugs,
such as m-TORinhibitors and ABL kinase inhibitors, also exert adverse
reactions including hypomagnesia and hypophosphatemia. Careful monitoring
of the serum concentration of magnesium and phosphate ions, to which little
attention was paid previously, is a key issue in these cases.
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[2010, 17(4):308-19Gan to Kagaku Ryoho. Cancer & Chemotherapy [2010,
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