1

LINCOLN MEMORIAL UNIVERSITY

Caylor School of Nursing
Nursing 124/125
Fall 2010

LESSON PLAN: Fluid and Electrolytes

1. Explain the distribution of fluid and electrolytes in the body.

2. Identify the compartments for water in the body.
3. Identify ways adult human persons lose fluids and nursing measures to replace fluid
loss.
4. Recognize the mechanism and routes by which fluid is transported in the body.
5. Identify the major electrolytes of the body and the primary function and purpose of
the electrolytes.
6. Identify common electrolytes and water imbalances, signs and symptoms of these
imbalances and nursing interventions to prevent and correct such imbalances.
7. Accurately calculate intake and output.
8. Describe the relationship between normal fluid intake and output.
9. Identify common diagnostic tests regarding fluid and electrolyte balance.
10. Identify stimuli which may affect fluid and electrolyte balance in different the
young adult and older adult.
11. Utilize the Roy Adaptation Model (RAM) nursing process to develop a plan of care
for the adult with fluid and/or electrolyte imbalance.
12. Identify the physiologic action, use, side effects, and nursing implications of
medications utilized in the pharmacologic management of fluid balance needs.
13. Identify appropriate interventions for the adult receiving parenteral fluid therapy.
14. Correctly calculate medication dosage and administration.
15. Identify the various acid base disorders, causes and interventions.
16. Describe the process of administering blood, assessing and evaluating
complications.

TOPICAL OUTLINE
I. Review of Fluid and Electrolyte Balance
• Homeostasis- maintenance of this constant environment in the face of continual
change.
• Fluid imbalance manifests as:
o Excesses
o Deficits
o Abnormal shifts among body compartments

Nurses’ Functions related to F&E Balance

• Daily weight is a major indicator of fluid status
• Recognize situations causing imbalances
• Intervene to prevent imbalances
• Carry out preventive/therapeutic measures prescribed and monitor response
• Monitor to prevent and recognize imbalances
• Alleviate effects of disturbances in comfort and safety
Rev 07/16/10
 2

• Prevent imbalances in people at risk

Fluid
• Approximately 60% of the typical adult is fluid
• Varies with age, body size, and gender
o 80% or greater in infants; decreases with age
o Less in elderly
o Less with obesity- fat cells contain little water

Adequate body water is necessary in:

• Maintenance of normal body temperature
• Elimination of waste products
• Making transportation within the body possible
• Acts as tissue lubricant

A. Distribution of Body Fluids

Distribution of Body fluid
• Intracellular fluid (ICF)
o Found within body cells
o 60-70% total body
o Major electrolytes in ICF
 Potassium
 Magnesium
 Phosphate
• Extracellular Fluid (ECF)
o Found outside the cell
o 30-40% total body fluid
o In constant motion
 Interstitial fluid (between cells)
 Intravascular (plasma)
 Cerebrospinal fluid
 GI secretions

Extracellular Fluid (ECF)

• Highly determined by Na+ concentration
• Contains large amounts of Na+, Cl-, and HCO3-
• Normal movement occurs between capillaries and interstitial spaces
• If capillary of interstitial pressures are altered, fluid can shift abnormally

Fluid spacing
• Third spacing- occurs when fluid accumulates in areas that normally have little or
no fluid (peritoneum, edema with burns, etc)
o It is lost- body is not able to use = imbalance
o What clinical manifestations will be seen?

Rev 07/16/10
 3

 Low BP
 Tachycardia
 Cold, clammy skin
 Decreased urine output
 Give albumin to pull out trapped fluid

B. Electrolytes
1. Major Cations (Na+, K+, Ca+, Mg+)
Sodium
• Main electrolyte in ECF
• Controls and regulates volume of body fluids
• Maintains water balance
• Primary regulator of ECF volume
• Important for nerve impulse generation and transmission
• Regulated by antidiuretic hormone, thirst, and angiotensin-aldosterone system

Potassium
• Major cation in ICF
• Vital in transmission of electrical impulses in the heart, nervous system, skeletal
system, intestinal and lung tissues
• Chief regulator of cellular enzyme activity
• 80% of potassium is lost through kidneys, if kidneys are not functioning properly
could cause increase in potassium

Calcium
• Plays a major role in transmitting nerve impulses, and helps regulate muscle
contraction and relaxation, including cardiac muscle.
• Plays a role in blood coagulation
• Excreted mostly through feces
• Serum calcium level is controlled by PTH and calcitonin, which is released from the
thyroid.

Magnesium
• 2nd most abundant cation in ICF
• Plays a role in carbohydrate and protein metabolism
• Important for neuromuscular function
• Also acts peripherally to produce vasodilation
• Predominantly found in bone and soft tissues
• Primarily excreted by kidneys
• Mostly absorbed through GI tract

Rev 07/16/10
 4

2. Major Anions (Cl-, HCO3-, PO4-)

C. Movement of body fluid and electrolytes

1. Osmosis
Movement of fluid from an area of lower solute concentration to an area of higher
solute concentration

2. Diffusion
Movement of molecules and ions from an area of higher concentration to an area of
lower concentration

3. Active transport
• Physiologic pump that moves fluid from an area of lower concentration to one of
higher concentration
• Movement against the concentration gradient
• Sodium-potassium pump maintains the higher concentration of extracellular
sodium and intracellular potassium
• Requires adenosine (ATP) for energy

• Sodium-potassium pump
o Sodium concentration greater in ECF
o Diffusion allows sodium to enter the cell
o Once inside the cell, the sodium-potassium pump actively moves the Na
back to the ECF
o Energy must be expended for Na+ and K+ to change places rapidly through
the system
o Sodium-potassium pump maintains the higher concentrations

4. Filtration
• Movement of water and solutes from an area of higher hydrostatic pressure to an
area of lower hydrostatic pressure
• Capillaries filter fluid from intravascular space to interstitial space
• Kidneys filter plasma allowing excretion of water and waste products
• Must have two factors present
o Hydrostatic pressure = BP
o Osmotic pressure

D. Routes of gains and losses

1. Gains – dietary, enteral, parenteral
o Dietary intake of fluid and food or enteral feeding
o Parenteral fluids

Rev 07/16/10
 5

2. Losses - Sensible vs. insensible, kidneys, skin, lungs, GI

tract, other
• Loss: sensible (measurable) and insensible (unmeasurable)
o Kidney: urine output
o Skin loss-sweating
o Lungs
o GI tract
o Other- hemorrhaging

3. Intake and output

Intake
• Intake primarily regulated by thirst mechanism
• Adult daily fluid intake is approximately 2600ml
o 1300 ml from liquids
o 1000 ml from foods
o 300 ml from metabolism

Output
• Kidneys- approximately 1500ml each day, at least 30 ml/hr
• Skin
o Loss through sweat/perspiration, increased temperature or metabolism
o Evaporation through skin/lungs with respiration
• Lungs- approximately 300 ml/day (average adult)
• GI Tract- approximately 200 ml/day

4. Daily weights
Daily weights
• Provide estimate of fluid volume status
• Best indicator of fluid balance
• What principles should be remembered?
o Same time of the day, everyday
o Same scale, make sure scales are properly zeroed
o Same amount of clothes

E. Regulation of body fluid and electrolytes

1. Kidneys
• Adjustments made in urine volume to balance fluid
• Excretion of metabolic waste and toxic substances
• Filters plasma
• Responds to ADH and aldosterone to regulate levels

2. Cardiac
• Increase HR and CO
• Atrial natriuretic factor (ANF)- lab test to identify BNP
Rev 07/16/10
 6

• Released when left atrium of heart is stretched from volume overload

• Vasodilates and increases urinary excretion of Na+ and H20

3. Lungs
• Through exhalation, the lungs remove about 300ml of fluid daily

4. Hormones
Regulation of Fluid
• Renin-Angiotensin-Aldosterone System (RAAS)
o A complex series of events triggered by decrease B/P and decreased
perfusion to kidneys
o Decrease BP = secretion of renin from kidneys
o Renin combines with angiotensinogen to form Angiotensin I
o Angiotensin I is converted in the lungs to Angiotensin II
o Angiotensin II stimulates the adrenal cortex to release aldosterone
o Aldosterone results in Na+ and H2O retention = also causes increase
in BP

Hormonal Effects on Fluid Balance

• ADH regulation – anti-diuretic hormone secreted from posterior pituitary gland
when increased serum osmolality (concentration) is increased.
o Promotes water reabsorption

Atrial Natriuretic Peptide

• Hormone that is released by the atrium of the heart when it is stretched from
fluid overload.
o Hormone blocks effects and excretion of aldosterone and renin

5. Thirst mechanism
Thirst mechanism- located in the hypothalamus
• Activated by increased ECF osmolality (concentration)

II. Diagnosis

A. Common tests
1. CBC (complete blood count)
• Hematocrit- measures the percentage of red blood cells in whole blood
o Male Normal Range: 42-52
o Female Normal Range: 35-47

2. Serum electrolytes
• Sodium 135-145 mEq/L
• Potassium 3.5-5.0 mEq/L

Rev 07/16/10
 7

• Calcium 8.6-10.2 mg/dL

• Magnesium 1.3-2.5 mEq/L
• Phosphorus 2.5-4.5 mg/dL
• Chloride 97-107 mEq/L
• Carbon Dioxide 24-32 mEq/L
• Glucose 60-110 mg/dL
• Albumin 3.5-5.0 g/dL

3. Blood urea nitrogen (BUN)

• BUN- is made up of urea, the end product of metabolism of protein by the liver
o Normal BUN- 10-20mg/dL

4. Creatinine
• Creatinine- the end product of muscle metabolism. Indicator of renal function
o Normal creatinine- 0.7-1.4mg/dL

5. Osmolarity/osmolality
• Osmolality- measures the solute concentration per kilogram in blood and urine
o Normal serum osmolality- 275 – 300 mOsm/kg
o Normal urine osmolality- 250 – 900 mOsm/kg

6. Urine pH & specific gravity

• Specific Gravity- measures the kidney’s ability to excrete or conserve water
o Less reliable indicator of concentration than osmolality
o Normal urine specific gravity- 1.003 – 1.030
• Urinary Sodium 75-200 mEq/day
• Urinary Potassium 26-123 mEq/day
• Urinary Chloride 110-250 mEq/day
• Urinary pH 4.5-8.0

III. General Risk Factors

A. Age related differences

1. Gerontological
• Reduced homeostatic mechanisms: cardiac, renal, and respiratory function
• Decreased body fluid percentage
• Medication use
• Presence of concomitant (History of other diseases) conditions

2. Pediatric
• Children are also at greater risk for fluid and electrolyte imbalance due to higher
proportion of water in the body.

Rev 07/16/10
 8

IV. Utilize the RAM nursing process for fluid volume imbalances,
which includes risk factors, assessment, analysis/nursing
diagnosis and evaluation/expected outcomes.

A. Fluid volume deficit (FVD): hypovolemia/dehydration

Fluid Volume Deficit
• Dehydration- a decrease volume of water, but not a change in electrolytes
• Hypovolemia- deficiency in both water and electrolytes in the ECF. (more severe)

• Causes
o Abnormal fluid losses
 Vomiting, diarrhea, and GI suctioning
 Diaphoresis, prolonged fever
 Diuretics, Diabetes Insipidus, Renal disease, Adrenal Insufficiency,
ketoacidosis
 Hemorrhage
o Decreased intake of fluid
 Anorexia, nausea, inability to gain access to fluid
o Third Spacing
 Peritonitis, intestinal obstruction, ascites, burns
o Risk Factors: diabetes insipidus, adrenal insufficiency, osmotic diuresis,
hemorrhage, coma, and third space shifts
• Assessment findings
o Thirst, weight loss, dry mucus membranes
o Decreased skin turgor, edema
o Decreases UOP, oliguria
o Increased HR, rapid and weak pulse, increased temperature
o Decreased B/P, postural hypotension
o Confusion, dizziness, fatigue
o Cool, clammy skin
o Muscle weakness and cramps
o Flattened neck veins
• Labs
o Na- elevated
o Serum osmolality- elevated
o BUN- elevated
o Urine specific gravity- elevated
o HCT- elevated
• Nursing interventions for FVD
o Assess for presence or worsening of FVD (Always think why?)
o Administer oral fluids as tolerated
o Provide TPN, IVF’s (isotonic or hypotonic)
o Tube feedings PRN
o Monitor patient response, mental status
o Monitor for signs of fluid volume overload, monitor I&O
Rev 07/16/10
 9

o Skin and oral care

o Evaluate interventions

B. Fluid volume excess (FVE): hypervolemia

Fluid Volume Excess (FVE)
• Hypervolemia- excess retention of water and Na+ (Examples)
• Due to fluid overload or diminished homeostatic mechanisms
• Risk factors: heart failure, renal failure, and cirrhosis of the liver
• Contributing factors: excessive dietary sodium or sodium-containing IV solutions

• Causes
o Fluid shift- burns, protein administration
o Water intoxication- caused by excess water ingestion or from excess ADH
secretions (heart failure, cirrhosis, glucocorticosteroids)
o Excessive sodium intake
• Assessment
o Weight gain, edema, skin pale and cool
o Increased BP and pulse
o SOB, crackles, increased RR (tachycardia), Pulmonary edema
o Distended neck veins
o Headache, altered LOC, weakness
o Polyuria
o Third spacing
• Labs
o Decreased BUN, Na, hematocrit, and specific gravity
• Nursing Interventions
o Assess for presence or worsening of FVE
o I&O
o Daily weights
o Na+ restricted and/or fluid-restricted diet as ordered
o Teaching/learning regarding adherence to fluid restrictions
o Short term goals and offer fluids every 1-2 hours
o Oral hygiene
o Avoid salty, dry, sweet foods
o Evaluate if goals met and interventions useful
o Administering diuretics

FVE/Diuretics
• Diet- increase K for all except Aldactone
• Intake & Output, daily weight
• Undesirable effects: fluid and electrolyte imbalances
• Review BP and electrolytes
• Elderly- careful and evening does not recommended
• Take with or after meals in AM
• Increase risk of orthostatic hypotension
Rev 07/16/10
 10

• Cancel alcohol and cigarettes

*See diuretics handout

General Nursing Interventions for F&E Imbalances

• 24 hour I & O
• Monitoring of VS
• Monitor for Neurologic changes
• Daily weights
• Monitor rates/types of IVF’s
• Provide supplementary water if receiving tube feedings
• Irrigate NG tube with saline not water

V. IV Therapy
IV Catheter

PICC Line
• Line is entered peripherally (usually through the A.C.) to the heart (subclavian
artery)
• Has to be done by physician or specially trained nurse
• Can have 1-2 ports, needs to be flushed with 10ml saline, Hep-lock 5ml
• Has to be flushed once per shift or before and after medication
• Always use a 10ml syringe

Central Line
• Usually entered through jugular artery or subclavian
• Has 3 ports, has to be flushed with 5 ml saline, hep-lock 2 ml
• Always use a 10ml syringe (because of amount of pressure)

A. Site selection and initiation

B. Complications
• Fluid overload
• Air embolism
• Septicemia and other infections
• Infiltration and extravasation
• Phlebitis
• Thrombophlebitis
• Hematoma
• Clotting and obstruction

C. Isotonic, hypertonic and hypotonic fluids

4 Classifications of IV fluids
• Crystalloids
o IV Fluids- D5W, lactated ringers
• Colloids
Rev 07/16/10
 11

o Volume expanders
 Hetastarch (can decrease HCT and PLT)
 Plasmanate (protein)
• Blood
o Whole or PRBC (packed red blood cells)
• Lipids

Types of Fluids
• Isotonic fluid- concentration of dissolved particles equal to ICF
o D5W- 5% dextrose in water
 Hypernatremia, fluid loss, and dehydration
o 0.9% NaCl- normal saline
 Hypovolemia, metabolic alkalosis, hypercalcemia
o Lactated Ringers- contains potassium and calcium in addition to sodium
chloride
 Hypovolemia, burns, fluid lost as bile or diarrhea, and acute blood loss
replacement
• Hypotonic fluids- concentration less than ICF
o 0.45 NaCl- half-strength normal saline
 Hypertonic dehydration, Na and Cl depletion, and gastric fluid loss
o 0.25 NaCl-
o D5 ½ NS
• Hypertonic fluids- concentration greater than ICF
o 3% NaCl

o 10% Dextrose (D10)
o 50% Dextrose (D50)

D. Blood transfusions
Blood Transfusions (Pg. 1107-1113)
• Patient History
o History of transfusions and reactions
• Physical assessment
o Respiratory
o Cardiac
o Integumentary
• Patient teaching
• Obtain consent
• Equipment: IV (20 gauge or greater for PRBCs), appropriate tubing, and normal saline solution
• Procedure to identify patient and blood product

Transfusion Reaction Types

• Febrile nonhemolytic reaction
o Most common
o Chills followed by fever

Rev 07/16/10
 12

o Often begins 2 hours after transfusion starts- not life-threatening

• Acute hemolytic reaction
o Most dangerous
o Fever, chills, low back pain, nausea, chest tightness, dyspnea, anxiety, acute
renal failure, DIC, death
• Allergic reaction
o Urticaria, itching, flushing

Nursing management of transfusion reactions

• Immediately stop transfusion
• Assess patient
• Notify physician of assessment findings
• Notify blood bank
• Return blood container and tubing to the blood bank
• If hemolytic transfusion reaction or bacterial infection- obtain blood and urine
specimens. Document according to facility protocol.

VI. Utilize the RAM nursing process for electrolyte imbalances,

which includes risk factors, assessment, analysis/nursing diagnosis
and evaluation/expected outcomes.

A. Hyponatremia
Hyponatremia (sodium <135)
• Stimuli/causes
o Vomiting/diarrhea, NG tube suction, diuretics
o Adrenal insufficiency, burns, wound drainage
o CHF
o Administration of hypotonic IVF (too much)
o Excessive water intake
• Behaviors/effects
o With water excess-rapid weight gain, headache, confusion, nausea, vomiting
o With Na+ loss- irritability, apprehension, confusion, tachycardia
o =decrease serum osmolarity (blood concentration)
o Fluid shift can cause cerebral edema (swelling of cells) and cause confusion
• Nursing Interventions
o Water restriction may be the only necessary treatment
o If neuro changes, small amounts of hypertonic solutions (if sodium is
dangerously low <120). Listen for breath sounds when giving hypertonic, fluid
shift will occur and need to monitor for fluid overload.
o Possibly Lasix administration
o Thorough nursing assessment
o PREVENTION- teach pt. about dehydration

B. Hypernatremia
Hypernatremia (> 145)
Rev 07/16/10
 13

• Stimuli/causes
o May occur with water loss or sodium gain
o Primary protection- thirst
o Usually doesn’t happen in the alert person
o Can occur with hypertonic IVF’s or near drowning in salt water
o Diabetes insipidus and heat stroke
• Behaviors/effects
o Intense thirst (may be impaired in elderly or ill)
o Elevated temperature
o Dry, sticky mucus membranes
o Firm rubbery turgor
o Restlessness and weakness (moderate)
o Confusion and hallucinations (severe)
o SALT
 S – skin flushed
 A – agitation (altered LOC)
 L - low grade temp
 T – thirst
• Treatment
o Depends on cause
o I&O
o VS
o Daily weight
o Increase fluids – to help decrease the concentration, hypotonic solution or D5W
o Seizure precautions

C. Hypokalemia
Hypokalemia (<3.5)
• Stimuli/causes
o Vomiting and Diarrhea
o Diuretics
o Dialysis
o Hyperaldosteronism
o Poor dietary intake
o Increased insulin- causes potassium to go back into cell
• Behaviors/effects
o Neurologic- fatigue, lethargy, confusion
o Cardiovascular- dysrhythmias, vertigo, hypotension, slow weak pulse, increased
risk of digoxin toxicity
o EKG- flat T wave, U wave, & or ST depression
o GI- anorexia, N/V, constipation, ileus
o Respiratory- shallow respirations
o Renal- polyuria, polydipsia
o Fatigue, muscle weakness and cramping
o Deep tendon reflexes

Rev 07/16/10
 14

• Nursing Interventions
o Oral or IV administration of KCL
 Don’t give if UOP <0.5ml/kg/hr
 IV- has to be mix in with at least 100 ml/fluid
 Cardiac monitoring
 Never exceed 20mEq/hour through peripheral line, no more
than 40mEq/hr through central line
 Never give IV push or IM!!!
 Best to give through PICC or central line, potassium is irritating to
veins, may help to slow infusion to decreases burning or put ice pack over IV
site if patient complains
o Increase dietary intake K+
o Oral supplements- may taste bad, mix with juice for liquid form
o Teach s/s hypokalemia and digoxin toxicity

D. Hyperkalemia
Hyperkalemia (>5.0)
• Hemolysis of blood specimen or drawing of blood above IV site may result in false
laboratory result
• Salt substitutes and medications may contain potassium
• Potassium-sparing diuretics may cause elevation of potassium and should not be
used in patients with renal dysfunction

• Stimuli/causes
o Massive intake of K+, usually treatment related
o Decreased renal excretion
o Renal failure
o Hypoaldosteronism
o Tissue trauma- forces potassium out of cell
o Hyperglycemia and uncontrolled DM
o Meds such as K+ sparing diuretics and Ace inhibitors
• Behaviors/effects
o Cardiac- increased HR then decreased HR, arrhythmias (V-tach or V-fib),
hypotension
o EKG- peaked T wave, wide QRS
o GI- anorexia, nausea, diarrhea
o Neuromuscular- muscle weakness, cramps
• Interventions
o Eliminate oral and parenteral K+
o Increase elimination of K+ (diuretics, dialysis, or Kayexalate)
o Increase fluid intake
o Force K+ from ECF to ICF by giving insulin IV along with glucose or by giving
IV NaHCO3(sodium bi-carbonate)
o Calcium gluconate IV (emergent situation)
o Monitor cardiac rhythm, VS, UOP, I & O, and fluid status

Rev 07/16/10
 15

• Potassium and Sodium supplements

o Monitor for adverse side effects
o Administer meds according to manufacturer’s guidelines
 Dilute K+ in juice or water
 Most patients receiving diuretics will need K+ supplement unless K+
sparing diuretic (Aldactone)
o Know risks associated with IV K+
o Check for drug-drug interactions

E. Hypocalcemia
• Serum level less than 8.5 mg/dL must be considered in conjunction with serum
albumin level
• Causes: hypoparathyroidism, malabsorption, pancreatitis, alkalosis, massive
transfusion of citrated blood, renal failure, medications, other
• Manifestations: tetany, circumoral numbness, paresthesias, hyperactive DTRs,
Trousseau’s sign, Chovstek's sign, seizures, respiratory symptoms of dyspnea and
laryngospasm, abnormal clotting, and anxiety
• Medical management: IV of calcium gluconate; calcium and vitamin D
supplements; diet
• Nursing management: assessment as severe hypocalcemia is life-threatening,
weight-bearing exercises to decrease bone calcium loss, patient teaching related
to diet and medications, and nursing care related to IV calcium administration

F. Hypercalcemia
• Serum level above 10.5 mg/dL
• Causes: malignancy and hyperparathyroidism, bone loss related to immobility
• Manifestations: muscle weakness, incoordination, anorexia, constipation, nausea
and vomiting, abdominal and bone pain, polyuria, thirst, ECG changes, and
dysrhythmias
• Medical management: treat underlying cause, administer fluids, furosemide,
phosphates, calcitonin, and biphosphonates
• Nursing management: assessment as hypercalcemic crisis has high mortality,
encourage ambulation, fluids of 3 to 4 L/d, provide fluids containing sodium unless
contraindicated and fiber for constipation, and ensure safety

G. Hypomagnesemia
• Serum level less than 1.8 mg/dL; evaluate in conjunction with serum albumin
• Causes: alcoholism, GI losses, enteral or parenteral feeding deficient in
magnesium, medications, rapid administration of citrated blood; contributing
causes include diabetic ketoacidosis, sepsis, burns, and hypothermia
• Manifestations: neuromuscular irritability, muscle weakness, tremors, athetoid
movements, ECG changes and dysrhythmias, and alterations in mood and level of
consciousness
• Medical management: diet, oral magnesium, and magnesium sulfate IV
Rev 07/16/10
 16

• Nursing management: assessment, ensure safety, patient teaching related to diet,

medications, alcohol use, and nursing care related to IV magnesium sulfate
• Hypomagnesemia is often accompanied by hypocalcemia
• Monitor and treat potential hypocalcemia
• Dysphagia is common in magnesium-depleted patients; assess ability to
swallow with water before administering food or medications

H. Hypermagnesemia
• Serum level more than 2.7 mg/dL
• Causes: renal failure, diabetic ketoacidosis, and excessive administration of
magnesium
• Manifestations: flushing, lowered BP, nausea, vomiting, hypoactive reflexes,
drowsiness, muscle weakness, depressed respirations, ECG changes, and
dysrhythmias
• Medical management: IV calcium gluconate, loop diuretics, IV NS of RL,
hemodialysis
• Nursing management: assessment, avoid administering medications containing
magnesium, and provide patient teaching regarding magnesium-containing OTC
medications

VII. Utilize the RAM nursing process for acid base imbalances,
which includes risk factors, assessment, analysis/nursing diagnosis
and evaluation/expected outcomes.
Maintaining acid-base balance
• Normal plasma ph is 7.35 to 7.45: hydrogen ion concentration
• Major ECF buffer system; bicarbonate-carbonic acid buffer system
• Kidneys regulate bicarbonate in the ECF
• Lungs under the control of the medulla regulate CO2 and , therefore, carbonic acid
in the ECF
• Other buffer systems
o ECF: inorganic phosphates and plasma proteins
o ICF: proteins, organic and inorganic phosphates
o Hemoglobin

Bicarbonate
• Major chemical base buffer
• Found in both ECF and ICF
• Essential for acid-base balance
• Alkalosis- ph over 7.4
• Acidosis- ph under

Rev 07/16/10
 17

Arterial Blood Gases

• pH 7.35 (7.4) to 7.45
• PaCO2 35 (40) to 45 mm Hg
• HCO3ˉ 22 (24) to 26 mEq/L (assumed average values for ABG interpretation)
• PaO2 80 to 100 mm Hg
• Oxygen saturation >94%
• Base excess/deficit ±2 mEq/L

Acid Base (ROME)

R- respiratory
O- opposite

pH PCO2 alkalosis

pH PCO2 acidosis

M- metabolic
E- equal

pH HCO3 alkalosis

pH HCO3 acidosis

A. Metabolic acidosis
Metabolic Acidosis
• Low ph <7.35
• Low bicarbonate <22 meq/l
• Most commonly due to renal failure
• Manifestations: headache, confusion, drowsiness, increased respiratory rate and
depth, decreased blood pressure, decreased cardiac output, dysrhythmias, shock; if
decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less
• Correct the underlying problem and correct the imbalance; bicarbonate may be
administered
• With acidosis, hyperkalemia may occur as potassium shifts out of the cell
• As acidosis is corrected, potassium shifts back into the cell and potassium levels
decrease
• Monitor potassium levels
• Serum calcium levels may be low with chronic metabolic acidosis and must be
corrected before treating the acidosis

B. Metabolic alkalosis
Metabolic Alkalosis
• High pH >7.45
Rev 07/16/10
 18

• High bicarbonate >26 mEq/L

• Most commonly due to vomiting or gastric suction; may also be caused by
medications, especially long-term diuretic use
• Hypokalemia will produce alkalosis
• Manifestations: symptoms related to decreased calcium, respiratory depression,
tachycardia, and symptoms of hypokalemia
• Correct underlying disorder, supply chloride to allow excretion of excess bicarbonate,
and restore fluid volume with sodium chloride solutions

C. Respiratory acidosis
Respiratory Acidosis
• Low pH <7.35
• PaCO2 >42 mm Hg (mostly higher than 45)
• Always due to a respiratory problem with inadequate excretion of CO2
• With chronic respiratory acidosis, the body may compensate and may be
asymptomatic; symptoms may include a suddenly increased pulse, respiratory rate,
and BP; mental changes; feeling of fullness in the head
• Potential increased intracranial pressure
• Treatment is aimed at improving ventilation

D. Respiratory alkalosis
Respiratory Alkalosis
• High pH >7.45
• PaCO2 <35 mm Hg
• Always due to hyperventilation
• Manifestations: lightheadedness, inability to concentrate, numbness and tingling, and
sometimes loss of consciousness
• Correct cause of hyperventilation

REQUIRED READINGS:
Kee, J., Hayes, E., & McCuistion, L. (2009). Pharmacology a nursing process approach
(6th
ed.). St. Louis, MO: Mosby. Ch. 15.

Smeltzer, S., Bare, B., Hinkle, J. & Cheever, K. (2008). Brunner and Suddarth’s textbook
of medical – surgical nursing (11th ed.). Philadelphia: Lippincott Williams
& Wilkins.
Ch. 14 & Ch. 33 pp. 1103-1113.

Silvestri, L. A. (2005). Saunders comprehensive review for NCLEX-RN (4th

ed.). Philadelphia, PA: W.B. Saunders Company.
Chapter 9 Fluid and Electrolytes p. 87, Questions 1-20
Chapter 10 Acid-Base Balance p. 107, Questions 1-10
Chapter 14 Intravenous Therapy p. 158, Questions 1-15
Chapter 15 Administration of Blood products p. 173, Questions 1-12
Rev 07/16/10
 19

Wissmann, J. (2000-2007). Adult medical-surgical nursing RN edition 7.1. Current

mastery
series review module. Assessment Technologies Institute. Unit 3 (pp. 233-240) &
Unit 4.

Wissman, J. (2000-2007). Fundamentals of nursing edition 6.1. Current mastery series

review
module. Assessment Technologies Institute. Unit 5 (Ch. 73 & 74).

CLINICAL OBJECTIVES:
1. Assess hydration status.
2. Accurately calculate intake and output on an adult with compromised or ineffective
responses to fluid and electrolyte balance.
3. Correctly calculate IV flow rate.
4. Identify signs and symptoms of fluid and/or electrolyte imbalance.
5. Develop teaching/learning strategies for the adult with fluid and/or electrolyte
imbalance to promote adaptation.
6. Using the Roy Adaptation Model nursing process, develop a plan of care for the
adult with fluid/electrolyte imbalance and acid base imbalance.
7. Participate in administering blood.

Rev 07/16/10
 20

Rev 07/16/10
 21

Diuretics
Used for treatment of hypertension (HTN), edema, congestive heart failure (CHF), renal dysfunction
Diuretic class Mechanism of General Contraindications Side effects/adverse Nursing
action information effects considerations
Thiazide diuretics Inhibit • Orally • Allergy and allergy • Dizziness, • Administer early
reabsorption of • Generally to sulfonamides vertigo, AM to decrease
salt (Na+ and mild side • F/E imbalance weakness sleep disturbance.
Cl-) in the distal effects • Gout • Nausea, • Give with food or
• Hydrochlorothiazide renal tubule • Effective for • Diabetes vomiting, milk to decrease
o Esidrix thereby long-term use • Renal disease anorexia GI disturbance
o HydroDIURIL increasing • Can be • Dry mouth • Stand slowly –
• Liver disease
excretion of salt primary • Orthostatic safety precautions
and water • Pregnancy/lactatio
treatment for n hypotension • Monitor
• Chlorothiazide HTN • Polyuria, nocturia electrolyte levels
o Diuril • Photosensitivity (esp. K+)
o Chlorthalidone • Muscle weakness • Add K+ rich foods
o Quinethazone or cramps or supplement
• Monitor I & O,
daily weight, and
hydration
• Home care -
Patient report
weight change of
more than 3lb/day
• Photosensitivity –
wear sunscreen,
sunglasses, and
protective
clothing
• Increased risk of
dig toxicity with
hypokalemia
Loop Diuretics Inhibits • Potent, rapid- • Same as thiazides • Same as • Same as thiazides
reabsorption of acting thiazides • IV administration
salt in the diuretic • Glycosuria o Slow IV
• Furosemide (Lasix) proximal and • Can be given • Thrombophlebitis push (10 –
o Usual dose 20 – 80 distal renal PO, IM, or IV • Blood dyscrasias 20mg/min)
mg tubules and the • Used often • Check
• Ototoxic (can
• Bumetanide (Bumex) loop of Henle with thiazides compatibility with
cause irreversible
• Ethacrynic acid (Edecrin) fail or patient hearing loss – other meds and
• Torsemide (Demadex) needs rapid especially when IVF
Rev 07/16/10
 22

diuresis given rapid IV • Protect from light

push) • Use within 24
• Rash hours after
dilution
• Assess patient
frequently for s/s
of F/E imbalance
Potassium-Sparing Blocks the effects • Used • Allergy • dizziness, • similar to
Diuretics of aldosterone in especially if • hyperK+ drowsiness, thiazides
the renal tubule, hypokalemia • renal disease headache • avoid high K+
causing loss of is a problem • lactation • diarrhea, foods
Na+ and H2O • Also used to cramping • avoid salt
• use cautiously with
• Spironolactone and retention of treat patient • rash substitutes
ACE inhibitors
(Aldactone) K+ with high • for GI problems,
• Triamterene (Dyrenium) aldosterone administer after
levels meals
Osmotic Diuretics Hinders • • renal disease • Dizziness • Given IV only
reabsorption of • intracranial • Nausea, anorexia • Do not refrigerate
water in the bleeding • Dry mouth, thirst – causes
• Mannitol (Osmitrol) kidneys leading • dehydration • Diuresis crystallization
to loss of water • CHF • Use IV filter with
• Dizziness
and sodium tubing
chloride) • Foley catheter
(F/C) may be
inserted to
manage and
monitor diuresis
• Monitor patient’s
hydration status,

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., Cheever, K. H. (2008). Brunner & Suddarth’s Textbook of medical-surgical
nursing.
(11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Rev 07/16/10
 23

Rev 07/16/10