5.

1 Fluid and Electrolyte Imbalances NCM 112 A

Professor Sandra M. Covarrubias || September 23, 2021 MEDSURG
Transcribed by: Edding, Shaznei Raiyan B.
References: PPT, Books, Internet

TOPIC OUTLINE muscle contractions, acid balance, and fluid

I. General Concepts in Fluid and regulation.
Electrolytes
II. Movement of Fluid and Electrolytes How do you restore fluid and electrolytes
III. Mechanism of Regulating Fluid and normally?
Electrolytes o Fluid and electrolytes can be restored through diet
IV. Fluid Imbalance and fluid intake.
V. Electrolyte Imbalances
VI. Nursing Care FLUIDS
o Body fluid is a solution of water, electrolytes, and
OBJECTIVES non-electrolytes. An average healthy adult is 60%
1. Discuss the different composition of body made up of fluids.
fluids. o Functions of the body fluid:
2. Describe the movement of fluid and ✓ Transport nutrients, hormones, and
electrolytes in the human body. electrolytes
3. Identify the role of different organ system: ✓ Remove waste products in the body
kidney, endocrine, cardiovascular, ✓ Responsible in regulating body temperature
gastrointestinal, lung & integumentary in (Thermoregulation)
regulating fluid and electrolyte balance. ✓ Component of body cavities that protects and
4. Discuss the different fluid and electrolyte cushion joints and organs (e.g., pleural
imbalances. space, peritoneum cavity, pericardial space)
5. Identify appropriate nursing care to patients ✓ Medium for metabolism
with fluid and electrolyte imbalances. o Body fluids are divided into two compartments:
1. Intracellular (ICF) – Fluids within the cell and
Can you identify how your body systems lose fluid is composed of water, electrolytes, nucleic
and electrolytes? acids, lipids, and polysaccharides. These
o Integumentary System cellular contents are enclosed by a
✓ Sensible and insensible fluid loss (e.g., semipermeable membrane.
sweating) 2. Extracellular (ECF) – Fluids outside the cell,
✓ Sensible fluid loss refers to body fluid lost that it is further divided into interstitial,
can be perceived and measured (sweat) intravascular, transcellular fluid. ECF is
✓ Insensible fluid loss refers to body fluid lost that composed of electrolytes, water, proteins,
cannot be perceived and measured (sweat that RBCs, WBCs, and Platelets.
evaporated in the skin)
o Respiratory System
✓ Insensible fluid loss from breathing
✓ When breathing out, the breath has little
amount of water since both the mouth and
lungs are moist. When exhaling, the water
turns into a water vapor. Various factors like
respiratory rate (hyperventilation), humidity
and temperature affect the rate of the
respiratory fluid loss.
o Cardiovascular System
✓ Fluid shift in the blood vessels where there is an
increase in permeability allowing movements of ELECTROLYTES
fluid and electrolytes causing imbalance or fluid o Electrolytes are chemicals that are cations and
loss. anions.
✓ Bleeding or hemorrhage ✓ Cations are positively charged ions.
o Gastrointestinal System ✓ Anions are negatively charged ions.
✓ Sensible fluid losses such as diarrheal stools o Examples:
and vomiting Major electrolytes found in the body that is
o Genitourinary System responsible in the movement of fluid and
electrolytes:
✓ Sensible fluid loss through urination (urine)
✓ Sodium: Na+ a cation, the major ECF
What happens when your body are low in fluid and electrolyte.
electrolytes? Normal Values: 135 – 145 mEq/L
o Body processes are disrupted resulting to ✓ Potassium: K+ a cation, major ICF electrolyte.
homeostatic imbalance. Normal Values: 3.5 – 5.0 mEq/L
o When your body becomes low on electrolytes, it can ✓ Calcium: Ca+
impair your body's functions, such as blood clotting, Normal Values: 4.5 – 5.3 mEq/L

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[NCM 112 A MEDSURG] Fluid and Electrolyte Imbalance – Prof. Sandra M. Covarrubias

✓ Magnesium: Mg+, second abundant ✓ Osmotic pressure is the pressure that needs
electrolyte in the ICF to be applied to a solution to prevent the
Normal Values: 1.3 – 2.1 mEq/L inward flow of water across a semipermeable
membrane.
✓ Chloride: Cl- a major anion of the ECF
o Hydrostatic Pressure
Normal Values: 98 – 106 mEq/L
✓ The outward push from capillary to
✓ Phosphorus: P- major anion of the ICF
extracellular spaces.
Normal Values: 2.5 – 4.5 mEq/L
✓ It is the force of fluid in a compartment
✓ Bicarbonate: HCO3-
pushing against a cell membrane or vessel
Normal Values: 22 – 28 mEq/L
wall.
✓ Sulfate
✓ The blood pressure generated by the heart’s
contraction. It gradually decreases as the
NON-ELECTROLYTES
blood moves through the arteries until it is
o Electrically neutral solutes
about 30 mm Hg in the capillaries.
✓ Vitamins
✓ At the capillary level, it is the major force that
✓ Creatinine
pushes water out of the vascular system and
✓ Protein
into the interstitial space.
✓ Glucose
o Oncotic Pressure
✓ Lipids
✓ The osmotic pressure (colloidal osmotic
pressure) exerted by proteins (plasma
How to maintain electrolyte balance?
colloids) in solution present intravascularly.
o REMEMBER: There should be equal amount of
anion and cation in the ICF and ECF to maintain
balance.

MOVEMENTS OF FLUIDS AND ELECTROLYTES

o Passive Transport is a mechanism that does not

involve expenditure of energy.
1. Diffusion – “Brownian motion” is the
movement of particles from an area of a
greater concentration to an area of lesser
concentration as a part of random activity.
Net movement of molecules stops when the
concentrations are equal in both areas.
2. Osmosis – the passive movement of water
molecule across a semipermeable MECHANISMS OF REGULATING FLUID AND
membrane from an area of higher to lover ELECTROLYTES
concentration until equilibrium is achieved. o Thirst Center
3. Filtration – is a physical process that pushes ✓ Hypothalamic – Pituitary Regulation
fluids through a biologic membrane by ✓ A body fluid deficit or increase in plasma
osmolality activates osmoreceptors in the
unequal pressure exerted by the fluids.
hypothalamus. This stimulates thirst and the
Filtration is another passive process of release of ADH from the posterior pituitary
moving material through a cell membrane. gland.
While diffusion and osmosis rely on ✓ ADH (Antidiuretic Hormone) acts on the
concentration gradients, filtration uses a distal tubules and collecting ducts in the
pressure gradient. Molecules will move from kidney by making them more permeable to
water. The result is increased water
an area of higher pressure to an area of lower
reabsorption from the tubular filtrate into the
pressure. Filtration is non-specific. blood and decreased excretion in the urine.
o Active Transport is the movement of particles ✓ ADH is only able to regulate how much water
across cell membranes against a concentration the body holds onto; an intact thirst
gradient, expends energy to do so. mechanism is our main protection against
✓ An example is the sodium-potassium pump. developing dehydration or hyperosmolality.
Both molecules differ in concentration Thirst causes us to increase the amount of
water we drink.
intracellularly and extracellularly. To
✓ Together these result in increased free water
maintain this concentration difference, the in the body, decreasing plasma osmolality
cell uses active transport to move sodium and restoring fluid volume. Many factors
out of the cell and potassium into the cell. influence ADH secretion and thirst.
This requires energy which is the Decreased BP, nausea, pain, hypoglycemia,
adenosine triphosphate (ATP). and hypoxemia stimulate ADH release.
REMEMBER: Passive and active transport
o Renal Regulation
differentiate in energy expenditure.
✓ Extracellular, renin-angiotensin system and
sodium – potassium pump, ADH, and
PROPERTIES EXERTED BY SOLUTIONS aldosterone.
o Osmotic Pressure ✓ The primary function of the kidneys is to
✓ The semipermeable membrane present regulate fluid and electrolyte balance by
extracellularly.
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[NCM 112 A MEDSURG] Fluid and Electrolyte Imbalance – Prof. Sandra M. Covarrubias

adjusting urine volume and the excretion of ✓ Increases pressure to increase blood
most electrolytes. volume to kidney for urine output. Increased
✓ Renal system is the major regulator of fluid blood volume causes increased in urine
and electrolyte in the body.
output and atrial pressure.
✓ In the average adult, the kidneys reabsorb
99% of this filtrate, producing around 1.5 L ✓ Natriuretic peptides, including atrial
of urine per day. natriuretic peptide (ANP) and b-type
✓ Under the influence of ADH, aldosterone, natriuretic peptide (BNP), are hormones
and other hormones, selective reabsorption made by cardiomyocytes. They are made in
and secretion of water and electrolytes in response to increased atrial pressure
the renal tubules result in urine that is (increased volume, such as occurs in heart
different in composition and concentration failure) and high serum sodium levels. In
from plasma. This process helps maintain the renal tubules, peptides promote
normal plasma osmolality, electrolyte excretion of sodium and water, decreasing
balance, blood volume, and acid-base blood volume and BP.
balance. ✓ ANP works only for a short period of time
✓ Aldosterone is a mineralocorticoid with and on acute stages through positive
strong sodium-retaining and potassium- feedback.
excreting capabilities. Decreased renal o Gastrointestinal Regulation
perfusion or decreased sodium in the distal ✓ In addition to oral intake, the GI tract
part of the renal tubule activates the renin- normally secretes around 8000 mL of
angiotensin-aldosterone system (RAAS), digestive fluids each day.
resulting in aldosterone secretion. ✓ The GI tract normally reabsorbs most of this
✓ Increased serum potassium decreased fluid, with only a small amount eliminated in
serum sodium, and adrenocorticotropic feces. This is why diarrhea and vomiting,
hormone (ACTH) stimulate aldosterone which prevent GI reabsorption of secreted
secretion. Aldosterone increases sodium fluid, can lead to significant fluid and
and water reabsorption in the renal distal electrolyte loss.
tubules, decreasing plasma osmolality and o Pulmonary Regulation
restoring fluid volume. ✓ Regulate fluid and electrolyte through
o Endocrine Regulation breathing. Hyperventilation causes
insensible loss of fluids.
✓ Thirst center (primary regulator), ADH and
NURSING PROCESS
Physical Assessment
o Fluid Assessment Management
✓ Vital Signs
✓ Patterns of intake and output
• Intake – ice cream, oral fluid intake, IV
fluids, blood products, medication
administered through bolus, NGT
feeding, TPN
• Output – urine, profuse sweating
(diaphoresis /+1, +2 ratings), bleeding or
hemorrhage, diarrheal stools (diaper),
tube secretions, drainage from wounds,
vomiting, secretion from GI (GI
irrigation), NGT aspirate
• I&O – Monitor q1 - 2hr postoperatively
(esp. peripheral dialysis or kidney
surgery), depends on the order of
doctor.
✓ Weight loss or gain
• REMEMBER: Weigh patient daily using
the weighing scale, early prior breakfast
aldosterone, parathyroid hormone (calcium every day, on the same time and type of
clothing.
balance)
✓ Edema
o Cardiac Regulation • Assess for the type of edema such as
✓ Consist of pressure center or the generalized, localized, and pitting edema.
baroreceptors that is found in the large ✓ Abdominal Girth
blood vessels which are sensitive to blood • Especially, if there is fluid shift (fluid
pressure changes. retention in peritoneum) causing decrease
✓ Baroreceptors are a type of motility in the GI tract
mechanoreceptor allowing for the relay of ✓ Level of Consciousness
information derived from blood pressure • Monitor orientation and alertness of
within the autonomic nervous system. They patient. Use Glasgow Coma Scale (GCS)
are spray-type nerve endings in the walls of ✓ Cardiac and Respiratory Status
blood vessels and the heart that are • Assess rate, depth, rhythms, and
stimulated by the absolute level of, and regularity.
changes in, arterial pressure. • Oxygen Saturation through pulse
oximeter.
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[NCM 112 A MEDSURG] Fluid and Electrolyte Imbalance – Prof. Sandra M. Covarrubias

o BUN (Blood Urea Nitrogen) – May be decreased administration is within one hour, and the
in fluid volume excess due to plasma dilution. diuresis lasts about 6-8 hours.
Normal values: 10 – 20 mg/dL o Electrolyte Replacement
o Hematocrit (Hct) – Hct levels in fluid volume deficit ✓ Monitor for weight gain and edema.
are greater than normal because there is a
decreased plasma volume NURSING MANAGEMENT
Normal Values: M – 42% - 52% F – 35% - 47% o Fluid Assessment Management
o Serum Electrolyte Levels – Measurement of ✓ Intake and output
electrolyte levels should be performed to check for ✓ Daily weight
presence of imbalance. ✓ Vital signs
o Electrocardiogram (ECG) – ECG changes can ✓ Physical Exam
also contribute to the diagnosis of fluid and o Monitor skin turgor (less than 2 seconds)
electrolyte imbalance. Electrolytes like calcium can o Urine Concentration
alter the cardiac functions. ✓ Determined through specific gravity
o Arterial Blood Gas (ABG) Analysis – ABG Normal Values: 1.003 – 1.010 or 1.005 to
analysis may reveal acid – base imbalance. Shows 1.030
pH level, PaO2, PaCO2, HCO3. o Oral and parenteral fluids
o Oral rehydration solutions
NURSING DIAGNOSIS o Monitor central nervous system changes
o Diet
o Fluid Volume Deficit or Excess
o Altered Mucous Membrane
EVALUATION
o Imbalance Nutrition Less/More than Body
o Maintained fluid volume at a functional level.
Requirements
o Displayed normal laboratory results.
o Demonstrated appropriate changes in lifestyle and
MEDICAL MANAGEMENT
behaviors including eating patterns and food
o Isotonic Electrolyte Solutions
quantity/quality.
✓ These solutions are used to treat the
o Reestablished and maintained normal pattern and
hypotensive patient with fluid volume deficit
GI functioning.
because they expand plasma volume.
✓ Fluid resuscitation through fluid electrolyte
solutions
o Accurate monitoring of Intake and Output
o Dialysis
✓ Indicated when there is fluid overload and
major electrolytes loss
o Nutritional Therapy
✓ Oral rehydration
✓ Diet of fluid and electrolyte-rich foods

PHARMACOLOGICAL TREATMENT
o AVP (Arginine Vasopressin/Antidiuretic
Hormone) receptor antagonists
✓ Vasopressin antagonists are drugs that bind
to vasopressin receptors (V1A, V1B and V2)
and block the action of vasopressin
(antidiuretic hormone, ADH), which is a
hormone released by the pituitary gland.
Vasopressin causes vasoconstriction and
increases reabsorption of water by the
kidneys.
o Diuretics
✓ 3 types of diuretics: Loop-acting, potassium-
sparing, thiazide diuretics.
✓ Furosemide is the most common which is a
loop-acting diuretics. A diuretic makes the
body get rid of extra fluid through the kidneys.
A loop diuretic works on a specific part of the
kidney called the "loop of Henle" to increase
the salt and water excretion.
✓ Furosemide works by blocking the
absorption of sodium, chloride, and water
from the filtered fluid in the kidney tubules,
causing a profound increase in the output of
urine (diuresis). The onset of action after oral

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