LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE

Rebecca De Asis, MAN, RN

Description
OUTLINE • ECF fluid that contains colloids, proteins, and is
I. Review of Common Terms related to Fluid,
the liquid part of the blood along with the RBC.
Electrolyte, and Acid-Base
II. Terms related to Fluid and Electrolyte Movement • It maintains blood volume, which makes 5% of
III. Hormones that regulate Fluid and Electrolyte the body water.
Balance
IV. Terms related to Hydrogen Ions ELECTROLYTE
V. Basic Concepts about Body Description
VI. Basic Concepts about Fluid and Electrolyte • A substance when placed in solvent like water
Imbalance breaks up into separately charged particles called
VII. Alterations in Fluid Balance ions.
VIII. Electrolyte Imbalance • Electrolytes contain ions that may be positive or
IX. Acid-Base Imbalance negative electrical charges.
X. Defense Mechanism against Imbalances
XI. Four Major Acid-Base Imbalances ION
XII. Nursing Experiencing Burns Description
Link: • Atom having positive or negative electrical
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Book: CATION
Kozier & Erb's Fundamentals of Nursing: Concepts, Description
Process, and Practice.
• Is positively charged ion like sodium (Na+),
potassium (K+), magnesium (Mg2+), calcium
(Ca2+), hydrogen (H2).
REVIEW OF COMMON TERMS RELATED TO
FLUID, ELECTROLYTE, AND ACID-BASE ANION
Description

BODY WATER • Is negatively charged particles like chloride (Cl-),

Description
phosphate (PO43-), sulfate (SO42-), bicarbonate
(HCO3-).
• The aqueous medium of the body minus the
electrolytes, the major component in the body. COLLOIDS
Description
BODY FLUID
Description
• Macronutrients of protein, that are located within
the plasma.
• Body fluid in which electrolytes are dissolved.
• Colloids maintain the intravascular pressure. A
• e.g. ECF, ICF, Interstitial Fluid
decrease in colloids like albumin would allow
• Other fluids include cerebrospinal, pericardial,
movement of fluids from the intravascular space
pancreatic, pleural, intraocular, biliary, peritoneal,
into the interstitial spaces.
and synovial fluids.
MILLIEQUIVALENT (mEq)
INTRACELLULAR FLUID
Description
Description
• The measure of the combining power of an ion.
• Body fluid located within the cells.
• The capacity of cations to combine with anions to
• 70% of total body weight is normally within the
form molecules.
cells.
• It constitutes approximately two third of the total
body fluids in adults. TERMS RELATED TO FLUID AND
ELECTROLYTE MOVEMENT
EXTRACELLULAR FLUID
Description
• Body fluid located outside the cells. OSMOLALITY
Description
• 30% of the total body weight.
• It accounts for about one third of total body • The total number of dissolved particles/ liter of
fluids. solvent.
• Two main compartments of ECF are intravascular • Osmolality increases when you are
and interstitial. dehydrated and decreases when you have too
much fluid in your blood.
• Other components of ECF include the lymph and
transcellular fluids. • It would decrease because a solvent is a solution
that would dilute the particles that are dissolved
• Example of transcellular fluid include
in it.
cerebrospinal, pericardial, pancreatic, pleural,
intraocular, biliary, peritoneal, and synovial fluids. HYPEROSMOLALITY
Description
INTERSTITIAL FLUID
Description • Decrease in water in relative to solvent.
• Fluid found in between the cells. • Kun hyperomolar, mas damo an imo solute
compared to your water.
• 25% of total body water in the interstitial space.

PLASMA or INTRAVASCULAR FLUID HYPO-OSMOLAR

Description

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

• Increase in water relative to solute concentration. • Factors that stimulate ADH release:
• Kun hypo-osmolar, guruguti an solute kaysa han o Hyperosmolality of body fluid.
water. Conditions such as high blood sugar
levels cause hyperosmolality because
ACTIVE TRANSPORT the blood is within the extracellular
Description compartment. Another condition is
• An energy requiring process that transport ions hypernatremia or too much sodium in the
across cell membrane. intracellular space.
• Example of active transport that takes place in the o Reduced circulating blood volume.
body is the sodium-potassium pump wherein the
sodium may be transported from one ALDOSTERONE
compartment to another in exchange of Description
potassium. • Hormone secreted by adrenal cortex.
• It increases renal absorption of sodium and
BLOOD HYDROSTATIC PRESSURE water, thus regulates fluid volume in the ECF.
Description • Since sodium goes with water, as sodium is
• Pressure of the blood within the capillaries. reabsorb, water is also reabsorb.
• It depends on the:
o Level of arterial BP. An increase in PARATHYROID HORMONE (PTH)
arterial blood pressure will allow Description
movement of fluids from the intravascular • Secreted by the parathyroid gland to maintain
into the interstitial space. serum calcium level.
o Rate of blood flow through the
capillaries THYROID HORMONE
o Venous pressure Description
• Thyroxine (T4)
COLLOID OSMOTIC PRESSURE • Triiodothyronine (T3)
Description • Patients who undergone thyroidectomy should be
• Also called oncotic pressure. monitored for signs and symptoms of
• There is movement of fluids towards or inside. hypocalcemia since the parathyroid gland may
• Pressure exerted by the plasma proteins which have been damaged.
hold water within the vessels and draws back
water that escapes from the vessels. CALCITONIN
Description
• If there is a decrease in osmotic pressure, fluid
will move into the interstitial space because it • Secreted by the thyroid gland, enhance calcium
lacks large proteins to hold water within the blood shift to the bones.
vessels. • If there is increased in serum calcium levels,
• It also allows to push back water that escapes calcitonin is released by the thyroid gland to
from the vessels to maintain the oncotic pressure increase movement or shifting of calcium into the
within the intravascular space. bones. Calcitonin will then antagonize the effects
of parathormone.
FILTRATION PRESSURE
Description
• The net pressure that forces fluid out of vessels. TERMS RELATED TO HYDROGEN IONS
• For example, in the glomerulus, only small
solutes could pass through the intact membrane ACID
of the glomerulus. Some solutes are filtered and Description
they could not pass through the membrane. • A hydrogen ion donor.
• An acid gives ions to a base, thereby neutralizing
the base.
HORMONES THAT REGULATE FLUID AND • Hydrogen is an acid. To prevent acidosis, excess
ELECTROLYTE BALANCE hydrogen ion should be donated and be accepted
by an alkali or base.
ANTIDIURETIC HORMONE (ADH)
Description BASE
Description
• Hormone released from the posterior pituitary
gland which controls water reabsorption by the • A hydrogen ion acceptor.
kidneys and regulates fluid osmolality. • A base accepts hydrogen ion from an acid,
• Water is reabsorb by the kidney tubules. thereby neutralizing the acid.
• If ADH is released due to the hyperosmolality of • To maintain acid-base balance, they should
the fluid, the urine output will decrease. accept the excess hydrogen from an acid.
• Conditions where ADH is stimulated to be release pH
is when there is low blood pressure or a decrease Description
in intravascular volume.
• Signifies the chemical concentration of hydrogen
• An increase in the osmolality of the intracellular ion, describes the alkalinity or acidity of a
fluid will stimulate the ADH to be released which solution.
will result to water reabsorption until it would
• Its normal value is 7.35 to 7.45.
normalize the osmolality.
• Below 7.35 is acidic. Above 7.45 is alkali.
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

• If there is a decreased in pH, the hydrogen ion • Osmosis occurs in the body when the
concentration will increase. This is because a concentration of solutes is higher on one side of
hydrogen ion is acid and blood pH is below 7.35. a selectively permeable membrane, such as the
• If the blood pH is above 7.45, there is a decrease capillary membrane, than on the other side.
in hydrogen ion. 2. Diffusion
• Movement of solute particles from a higher
BUFFERS concentration to a lower concentration.
Description • For example, an increase in blood glucose will
• Pair of chemicals that donate or accept hydrogen make the blood hyperosmolar so glucose should
ions. be transported into the cell with the help of insulin.
• They are buffer system wherein they could • Fluids will diffuse into the semipermeable
correct acidosis or alkalosis. membrane of the glomerulus as long as it is intact
and smaller particles could pass through except
the large particles including protein.
BODY WATER: BASIC CONCEPTS
• The rate of diffusion of a solute varies according
to the size of the molecules, the concentration of
A. VOLUME OF BODY WATER
the solution, and the temperature of the solution.
• The normal human body consists of 47% to 87%
• Larger molecules move less quickly than smaller
water, varies with age, sex, and individual body
ones,
physical characteristics.
• Molecules move from a solution of higher
• Body water as a percentage of body weight
concentration to a solution of lower concentration,
declines with age.
and
• Infant’s body is 77% to 80% water.
• Increases in temperature increase the rate of
• Elder adult’s body is 47% water.
motion of molecules and therefore the rate of
• Based on sex, male has greater percentage of diffusion.
water (60% to 70% of their body weight) 3. Hydrostatic Pressure
compared to females which has 50 to 54% of • There is pressure that is exerted to move fluid
their body weight is water.
pushing outward against the boundaries.
• A decrease in regulatory mechanisms may be a • Hydrostatic pressure is exerted by the pumping
factor as to why elderlies have lower percentage action of the heart so that blood will be pumped
of body water. into the blood vessels.
• In both women and older adults, this is due to • The hydrostatic pressure of blood is the force
lower levels of muscle mass and a greater exerted by blood against blood vessel walls.
percentage of fat tissue. Fat tissue is essentially 4. Filtration Pressure
free of water, whereas lean tissue contains a
• Fluid achieve its equilibrium by moving from the
significant amount of water.
space with higher pressure across a semi-
• Therefore, water makes up a greater percentage
permeable membrane.
of a lean individual’s body weight than of an
• Smaller electrolytes move along with H2O, larger
individual who is obese.
solutes remain on the other side of the
B. DISTRIBUTION OF BODY WATER membrane.
• 70% of total body water is located in the • Filtration pressure is the difference between the
intracellular compartment. hydrostatic pressure and the osmotic pressure.
• 30% is distributed in the extracellular E. BALANCE AND IMBALANCE OF WATER
compartment.
• Balance of water depends on balance between I
• 24% is in the interstitial space. & O at normal environment and at normal activity
• 6% is in the intravascular space, as plasma. of an individual.
C. FUNCTIONS OF WATER • Normally, a person must have balance of intake
• Provides aqueous medium for cellular and output of 2600 ml/day.
metabolism. • Average sources of water intake:
• Acts as solvent for solutes for cell function. o 1200 ml water in beverages
• Transports substances to and from cells. o 1100 ml hidden water in foods
o 300 ml water from oxidation
• Aids in regulation of body temperature and
o 2600 ml/day total
digestion.
• Average water losses:
D. FLUID TRANSPORT OR MOVEMENT o 1500 ml losses from urine output
1. Osmosis o 1000 ml from skin and lungs
• The movement of fluid from lower to a higher o 100 ml from GIT or feces
concentration. o 2600 ml/day total
• e.g. Administration of hypotonic solutions • Insensible fluid losses occur through the skin and
• Hypotonic solutions have a lower concentration the lungs. They are called insensible because it
compared to plasma. If infused in large amounts, is usually not noticeable and cannot be measured.
it would allow movement of fluid from the • Insensible fluid loss through the skin occurs in
intravascular into the intracellular compartment two ways, diffusion and perspiration.
causing the cell to swell. With the administration • Another type of insensible loss is the water in
of hypotonic solution, it makes the extracellular exhaled air. When respiratory rate accelerates,
fluid hypoosmolar.

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

for example, due to exercise or an elevated body B. CAUSES OF FLUID AND ELECTROLYTE
temperature, this loss can increase. IMBALANCES
• Deficiency of F & E due to insufficient dietary
F. NORMAL BODY REQUIREMENT FOR WATER intake.
• Normally, an adult person needs 2600 ml o Prolonged starvation
fluid/day to meet body’s fluid requirements. o Prolonged dieting
• Adults can live 10 days without water, while in • Increased excretion or loss.
children 5 days, provided weather conditions are o Diarrhea
moderate. o High fever through insensible fluid loss
o Diabetes Mellitus due to polyuria
G. HOMEOSTATIC REGULATION OF WATER
o Liver Cirrhosis manifested by ascites,
1. ADH
which is related to the increase of
• Increase water reabsorption.
pressure in the portal vein
• ADH is released by the posterior pituitary gland.
• Compartmental shifts or electrolytes.
As water is reabsorbed in the kidney tubules, it
o Ascites where fluid accumulate in
would result to a decreased osmolality in the
spaces within the abdomen
extracellular fluid.
o Edema due to increase in capillary
• The main hormone of water regulation is ADH. permeability which allows movement of
2. Kidneys fluid into the interstitial spaces. (i.e.
• Maintain concentration and volume of urine. congestive heart failure, right or left-sided
• Aldosterone is released in the proximal heart failure)
convoluted tubules of the kidneys though the
adrenal cortex of the adrenal glands. As sodium C. EXCESS OF FLUID AND ELECTROLYTES
is reabsorbed, water is also reabsorbed, and • Intake is greater than excretion.
potassium is excreted. • Decreased excretion due to kidney disease or
• The main hormone that regulates sodium impaired homeostatic regulation.
reabsorption is aldosterone. • Sequestration of fluid and/or electrolytes in one
3. Thirst Mechanism compartment,
• The hypothalamus is activated by an increased in • e.g. Ascites, Anasarca or the general swelling of
body fluid osmolality results to increase water the whole body seen in patients with ESRD
intake.
• The initial response of the body towards the need D. PERSONS SUSCEPTIBLE TO FLUID AND
ELECTROLYTES IMBALANCES
of water.
1. Conditions contributing to imbalances
• The main regulator of water intake is the thirst
• Vomiting. It contains food particles and the liquid
mechanism.
part of vomitus which is hydrochloric acid. Patient
become at risk for metabolic alkalosis.
FLUID AND ELECTROLYTE IMBALANCES: • Diarrhea, renal or cardiac disease. Potassium is
BASIC CONCEPTS loss through diarrhea as well as alkali from the
intestinal secretions. Patient become at risk for
A. DISORDERS OF FLUID AND ELECTROLYTE metabolic acidosis.
IMBALANCES • Burns.
• Disorders that can be caused by a deficit or • Hormonal disorders like DM.
excess of essential body substances. • Cirrhosis of the liver. Normally, if a liver disorder
• Disorders caused by protein deficiency. is present, the liver would inactivate aldosterone.
o Kwashiorkor, a severe protein In cases of liver cirrhosis, liver fails to inactivate
deficiency, causes fluid retention and a aldosterone resulting in sodium excretion.
protruding abdomen. • Severe insensible fluid losses and
o Marasmus, which results from severe hyperventilation. This is due to the loss of water
calorie deficiency, leads to wasting and vapor through exhalation.
significant fat and muscle loss. • Patients who will undergo surgery. This is
o Cachexia, occurs through increased rate because of the blood loss during surgery.
of skeletal muscle protein breakdown • Patients who needs blood transfusion.
and a reduction in the rate of muscle o Patients who are anemic. This can be
protein synthesis. corrected through administration of
o Nephrotic Syndrome, where there is packed RBCs.
loss of protein in the urine. o Patients with bleeding disorders or
o Liver Dysfunction, in which the liver hematemesis. This can be corrected
fails to synthesize proteins leading to through administration of whole blood.
protein deficiency. 2. Interventions contributing to imbalances
• Fluid shifts to the interstitial and/or fluids shifts • IVF therapy
into the plasma. o Isotonic solutions has the same
o Third spacing or movement of body osmolality as ECF (e.g. normal saline
fluids from the blood into the spaces [NSS], 0.9% sodium chloride, lactated
between the cells or body cavities that ringer’s solution [PLR], 5% dextrose in
normally contain little fluid. (e.g. edema, water [D5W]). Because the IV fluid is
ascites, pleural effusion) similar to the blood, the fluid stays in the
intravascular space and osmosis does

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

not cause fluid movement between o Paracentesis in which ascitic fluid is

compartments. drained from the patient’s abdomen
o Hypotonic solutions have a lower through a hollow needle.
osmolality than ECF (e.g. 0.45% sodium o Lumbar puncture to obtain CSF for
chloride). It causes osmotic movement of examination.
water from the intravascular o Thoracentesis to treat pleural effusion
compartment into the intracellular space or presence of fluid in the lungs.
resulting for the cell to swell. • Medications to treat main causes of imbalances
o Hypertonic solutions have a higher o Sodium chloride is used to treat
osmolality than ECF (e.g. 3% sodium hyponatremia.
chloride, 5% dextrose in ringer’s lactate o Potassium chloride is used to treat
[D5LR]). It causes the osmotic movement hypokalemia. If the serum postasium
of water out of the cells and into the levels is below 3.5 mmol/L, potassium
intravascular space to dilute the solutes chloride will be administered through IV
in the blood resulting for the cell to shrink. drip. It comes in a vial or ampule which is
o These solutions are called crystalloids labeled 2 mEq/ml. It is administered as
which are composed of water and small 20 mEq dissolved in 90 cc PNSS via
solutes such as electrolytes and glucose. soluset to run for 1 hour for 3 series. Drop
• Diuretics factor should be 60 ugtts/ml.
o Osmotic diuretics which increase o Calcium gluconate is used to manage
urinary flow by osmotic retention of water hypocalcemia.
throughout the nephron. o Magnesium sulfate is used to treat
▪ Mannitol which is used to hypomagnesemia.
decrease intracranial pressure • Administration of blood transfusion, if condition is
and edema. due to blood loss
o Loop diuretics have their effects in the o If whole blood is use, the patient is at
ascending limb of the loop of Henle. risk for hyperkalemia because prolonged
▪ Furosemide is one of the first- administration may result in hemolysis of
line therapy for acute relief of RBC which is converted into potassium.
pulmonary and peripheral edema o Some patients may be at risk for
due to heart failure but are also hypocalcemia because of the
used to treat edema associated preservatives used on the blood bank
with liver cirrhosis, and renal which contains citrate. One it is infused,
disease, including nephrotic the albumin or protein in the blood will
syndrome. die.
o Potassium sparing diuretics increase
nephron reabsorption of potassium by
interrupting sodium reabsorption in the ALTERATIONS IN FLUID BALANCE
collecting duct.
▪ Spironolactone is typically used A. FLUID VOLUME DEFICIT
with a thiazide or loop diuretic to • Is called hypovolemia, is decreased in fluid
enhance its action, as volume or blood volume
potassium-sparing diuretics • Maybe isotonic, hypotonic, hypertonic
have weak diuretic and
B. FLUID VOLUME EXCESS
antihypertensive effects when
• Commonly called hypervolemia, fluid intake
used alone.
excess loss, or excess adm of hypotonic
o Thiazide diuretics inhibit sodium
solutions, inc ADH released
chloride reabsorption in the distal
• Its danger is it may result to CHF
convoluted tubule.
• Maybe isotonic, hypotonic, hypertonic
▪ Hydrochlorothiazide is one of
the first-line agents for the
treatment of hypertension and ISOTONIC VOLUME DEFICIT
are often used together with loop Causative Factors
diuretics for their synergistic • Due to excessive loss of isotonic body fluids from
diuretic effects in heart failure. vomiting, diarrhea, NGT suctioning
o Regardless of the age of a person, the • Losses from the kidneys through diuresis in renal
normal urine output is 1ml/kg/hr or at disease
least 30ml/hr.
• Fluid loss through excessive diaphoresis
o If the environment is warm, there is
• Hemorrhage
lesser urine output because of the
• Lack of intake of fluids & electrolytes due to
increase in insensible fluid loss. The
inability to ingest orally
more concentrated the urine, the darker
it is in color. • Shift of fluids into body spaces like in ascites,
edema, fluid is not readily available for exchange
• Dietary management
(third space fluid shift)
o Dilute 1ml per kcal of water for
blenderized foods. Assessment Findings
• Surgical procedures • Acute weight loss (esp.if greater than 5% of total
body weight

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

• Changes in cardiac function ( increased HR, • GI fluid losses through diarrhea, vomiting
dec.BP, signs of postural hypotension, increased • Renal loss of electrolytes like in Na wasting
RR. • Iatrogenic fluid replacements with hypotonic
• Decreased hydration of the skin & mucous solutions
membrane, dry oral cavity.
• Decreased & concentrated urine output Clinical Symptoms
• Increased Hematocrit • Same with isotonic fluid volume deficit
• Sunken eyeballs • Additional symptoms:
• If dehydration is severe, patient may be irritable o Fatigue
o Weakness
Potential Nursing Diagnosis o Muscle cramps
• Fluid Volume Deficit o Postural hypotension
• Altered tissue perfusion o Confusion if deficit is severe
• High Risk for Injury
Medical Interventions
• Ineffective Breathing Pattern
• Same interventions with Isotonic Volume Deficit
• Decreased Cardiac Output
• Additional:
• Altered Nutrition, less than Body Requirements o Replacement of electrolyte losses like
• Altered Oral Mucous Membrane Na, potassium, if below normal.
• Fatigue
• Risk for activity intolerance Evaluation
• Same evaluation with isotonic volume deficit
Interventions
• Medical Interventions:
o IVF replacement with isotonic solutions FLUID VOLUME EXCESS
o Adm.of BT if deficit is due to blood loss • Fluid volume excess is an increase in water
o Treatment for contributory underlying volume & solute concentration in the ECF.
cause. (vomiting, diarrhea, blood loss ).
Causes
o Removal of third space fluid shift (
paracentesis in ascites, insertion of peri- • Excessive intake of sodium & water, or through
cardiac tube if pericardial effusion, IVF replacement.
thoracostomy tube ). • Iso-osmolar fluid retention due to compromised
o Mobilization of interstitial fluids into the regulatory mechanisms
vascular system with caution. • Use of corticosteroids.
• Nursing Interventions: • Chronic Liver Disease
o Assess cardiovascular, respiratory, &
Signs and Symptoms
neurologic status.
• Increased BP, HR, RR due to circulatory overload
o Assess skin turgor & condition of oral
• Interstitial edema
mucous membrane.
o Monitor laboratory values. • Rapid weight gain esp.if more than 5% of total
o Measure & monitor I&O, minimum 30 body weight
ml/hr of urine output • In severe cases, condition not resolve, patient’s
o Monitor body weight daily, weight loss of condition may progress into CHF, and pulmonary
more than 0.5 lb/d is considered fluid edema which makes the condition life
loss. threatening.
o Provide teaching about medication • Excretion of diluted urine
regimen, prescribed diet, & foods to • Low serum sodium level
avoid.
Potential Nursing Diagnosis
o Monitor signs of cardiac overloading
• Fluid Volume Excess
during IVF replacement.
• Decreased Cardiac Output If heart fails to
Evaluation function
• Patient’s v/s are within normal. • Ineffective Breathing Pattern
• Characteristics of urine output are normal; urine • Anxiety
output is 30 ml/hr • If fluid will shift into the cells, it will result to
• Breaths sounds clear. swelling of the brain cells, wherein patient
• With good skin turgor. manifests neurologic symptoms like lethargy,
• Patient is free from injury headache, seizures, irritability, nausea.
• With I&O balance. Medical Interventions
• Restriction of water intake to a volume less than
urine output
HYPOTONIC VOLUME DEFICIT • Increase salt in the diet
• There is the loss/decrease solute concentration • Administration of IVF with sodium. Observe for
with water volume remaining normal rebound effect of sodium administration.
• Due to loss of solutes in the ECF, fluid shifts into
Nursing Interventions
the cell by osmosis.
• Nursing interventions are the same with isotonic
Causes fluid volume excess.

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

HYPERTONIC VOLUME EXCESS • The intravascular has the same amount of

• An increase in sodium concentration with water electrolytes with that of the interstitial, but the
volume remaining normal. intravascular fluids is the only measurable fluid to
• ICF shifts into ECF determine the serum sodium level of the body
fluid.
Causes
• Excess intake of hypertonic fluids or adm.of Excretion of Electrolytes
hypertonic solutions through IV. • They are lost during excretion of body fluids.
• It is manifested by neurologic symptoms such as • Renal excretion of electrolytes are abnormal with
muscle twitching, possible seizure, with the use of diuretics.
subsequent dehydration of cerebral cells. • GIT excretion of electrolytes occur during
• Hypernatremia, where Na is retained or in excess vomiting, & diarrhea. During vomiting, potassium
from abnormal sources, increase aldosteronism. & HCL acid is excreted.
• In lower GI elimination, hydrogen & potassium
Nursing Diagnosis are lost.
• Fluid Volume Excess • Excessive diaphoresis contributes to Na & Cl
• Impaired neurologic function, lethargy losses.
• Risk for injury • Surgical drains also contribute to electrolyte loss.
• Ineffective Breathing Pattern
Electrolyte Regulation
Interventions 1. Renal Regulation
• Treat underlying cause of the disease. • In the kidneys, electrolytes are balanced by
• Adm of potassium sparing diuretics glomerular filtration, tubular reabsorption, and
• Monitor I & O, v/s, body weight secretion.
• Provision of safety • In the distal & collecting tubules, water is
reabsorbed only in the presence of ADH.
• Electrolyte secretion occurs when an electrolyte
ELECTROLYTES moves from the blood into the tubule.
Description
2. Endocrine Regulation
• These are solutes found in body fluids • The pituitary adrenocorticotropic hormone
• They developed an electrical charges once stimulation enhances adrenal release of
dissolved in water. aldosterone.
• Major Body Electrolytes: • It enhances sodium reabsorption , another
o Sodium positively charged electrolyte- K+ is secreted into
o Potassium the tubules for excretion
o Magnesium 3. GI Regulation
o Calcium • Electrolytes are secreted, absorbed across the
o H+ small intestines same way in the kidneys
o Chloride
o Phosphorous
o Bicarbonate SODIUM:
NORMAL AND ALTERED BALANCE
Sources of Electrolytes
• Normal sources are intake from foods and fluids.
A. NORMAL BALANCE
• Abnormal sources:
• It is the major cation in the ECF
o Medications
• Normal serum Na: 135 to 145 mEq/L
o IVF solutions
• Most Na is found in the ECF where it can be
o Hyperalimentation
measured by serum tests
Functions of Electrolytes • It can be taken from the foods we eat, &
• Maintain osmolality of body fluids; & cellular beverages we drink
osmolality • The normal requirement for an adult individual is
• Regulate acids & bases 2 gms daily
• Aid in neurologic & neuromuscular conduction
Functions
Electrolyte Distribution and Excretion • Facilitate transmission of impulse in nerves &
1. ICF Electrolytes muscle fibers
• Potassium – major intracellular electrolyte • Assist in acid-base balance by combining with
• Phosphorous – the chief or major anion HCO3 & Cl
• Large amount of CHON • It determines the volume & osmolality of the ECF,
• Small amount of magnesium, calcium, S04, & thereby regulates body water
HCO3
Regulation of Sodium to Maintain Balance
• Extremely small amount of sodium & chloride
• The kidneys through filtration, reabsorption in the
2. ECF Electrolytes
presence of ADH
• Sodium – the chief/major cation
• Through endocrine regulation, secretes
• Chloride – the chief anion
aldosterone & ADH
• HCO3
• Small amounts of potassium, calcium, Mg, SO4,
PO4
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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

B. SODIUM IMBALANCE • Altered nutrition: Less than body requirements

Interventions
b.1. HYPONATREMIA
• Serum sodium level below 135 mEq/L • Identify risk individuals; those receiving
hypertonic solutions, TPN
Causes • Monitor I & O, monitor body weight
• Prolonged use of diuretic therapy ( impairs Na • Monitor v/s
reabsorption in the loop of Henle) • Provide safety
• Excessive burns in which it results to loss of Na • Administer hypotonic solution with caution;
in the ECF, Na leak into the burned areas of the hypotonic Na solutions
body.
• Excessive diaphoresis
• Prolonged vomiting, diarrhea, NGT suction POTASSIUM:
• Renal disease result to Na wasting NORMAL AND ALTERED BALANCE
• Excessive administration of water through IV
route A. NORMAL BALANCE
• SIADH where water is retained results to • Serum level of 3.5 to 5 mEq/L
hyponatremia • Major cation in the ICF
• Sources: fruits, vegetables, chocolates
Clinical Symptoms • Nutritional supplements of k+
• Vomiting, diarrhea, which maybe the cause of • IV infusion of K+
hyponatremia
• Neurologic & musculoskeletal symptoms like Functions
muscle cramps, muscle twitching, headache, • Regulates ECF osmolality by exchanging with
confusion, convulsion coma (due to shifting of Na.
fluid into the cells resulting to swelling of brain • Maintain normal neuromuscular contraction by
cells) participation in Na-K+ pump.
• Maintain muscular activity – with particular
Potential Nursing Diagnosis
sensitivity to cardiac muscle
• Potential for fluid volume excess • Regulate acid-base balance in exchange with
• High risk for injury hydrogen ion.
• Anxiety • It is needed for all metabolic processes ( CHO,
• Impaired physical mobility Glycogen, CHON )
Interventions Regulation of Potassium in the Body
• Early detection of signs & symptoms of • Renal System
hyponatremia by identifying risk patients for • Renin-aldosterone Mechanism
hyponatremia. • Regulated by plasma CHON
• Restrict fluid intake to allow Na & water to
balance naturally. B. POTASSIUM IMBALANCE
• Replace sodium through administration of IVF
solutions with Na. b.1. HYPOKALEMIA
• Monitor I & O • Serum K+ below 3.5 mEq/L
• Monitor v/s, & serum sodium levels.
Causes
b.2. HYPERNATREMIA • Prolonged used of osmotic diuretic like
• Serum level above 145 mEq/L furosemide
• Prolonged vomiting, diarrhea, laxative abuse,
Causes NGT suctioning
• Sodium gain in excess of water from adm of • Renal disease where potassium is not secreted
excessive IVF solutions containing sodium or by the kidney tubules for absorption
tube feedings • Excessive removal during dialysis.
• Excessive intake of sodium in the diet. • Inadequate intake during anorexia & alcoholism
• Water loss in excess like severe diarrhea, burns, • Adm of hypertonic glucose, shift of k+ from ECF
osmotic diuresis to ICF
• Fluid shifts out of the ICF into ECF to balance the • During administration of insulin, where k+ moves
excess ECF Na. into cell with glucose
Clinical Symptoms • During metabolic alkalosis where potassium
• Commonly associated with dehydration moves into the cell in exchange of hydrogen ion.
o Thirst • During hyperaldosteronism, increased Na
o Tachycardia enhances K+ excretion.
o Dry mucous membrane Signs and Symptoms
o Hyperactive reflexes
• Vomiting or diarrhea which may be the actual
o Seizures
cause of the imbalance.
Potential Nursing Diagnosis • Muscle weakness & cramps, hyporeflexia,
• Fluid volume deficit paresthesia, hypotension, cardiac dysrhythmia
• High risk for injury due to decrease muscular contraction

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

• Serum level below 3.5 mEq/L, increased bld pH, • In cases of great cell damage like in burns,
elevated blood glucose chemotherapy to treat Cancer, potassium is
• ECG tracing appear inverted flat T-wave. released into the serum.
• Adm of WB nearly of its expiry date
Potential Nursing Diagnosis
• Decreased cardiac output Signs and Symptoms
• High risk for injury • Confusion, paresthesia, abdominal cramps,
• Impaired physical mobility muscle paralysis – hyperkalemia affects the
• Activity intolerance musculoskeletal system, smooth muscle
• Risk for cardiac dysrhythmia function, & nerve cell function.
• ECG changes which appears prolonged P-R
Interventions intervals, wide QRS & tented T-wave, which may
• Identify high risk patients to prevent hypokalemia. result to cardiac arrest.
• Teach patients receiving diuretics to increase
intake of potassium rich-foods. Potential Nursing Diagnosis
• Monitor I & O, keeping in mind diuresis increase • Decreased Cardiac Output
k+ loss. • Risk for Injury
• Caution patients receiving digitalis, digitalis • Impaired Physical Mobility
toxicity may occur along with the use of diuretic • Anxiety
furosemide.
Interventions
• Replace potassium losses through dietary
• Identify risk individuals those receiving IV
interventions.
potassium replacement, patients with severe
• Administer oral potassium supplements, note
burns, cellular damage, those with renal failure.
these drugs are GI irritants, give with water.
• Check patient’s urine output, and serum
• Administer IV solutions with potassium, note kCl
potassium levels.
should not be given by IVP or in concentrated
• Attach patient to cardiac monitor if they have
forms. It can result to dysrhythmia
signs of hyperkalemia
• Monitor v/s,
• Administer sodium bicarbonate as ordered with
• Monitor serum potassium level, after IV K+
caution
replacement.
• To patient with CKD, they may undergo dialysis
Nursing Considerations in IV infusion of K+ • Monitor I & O, report if urine output is below 30
• Concentrated use of potassium should not be ml/hour
given by direct IVP, make sure to have adequate
solvent to administer by drip.
CALCIUM:
• Commonly potassium is ordered to dilute 20 mEq
dissolved in 90-100 cc of solvent given in 1 hour NORMAL AND IMBALANCE
drip for 3 doses depends on the ordered
medication to correct hypokalemia. A. NORMAL BALANCE
• It is recommended that IV cannula should be • Serum level of 8.5mg/dL - 10.5mg/dL
inserted in a central vein, because drug is • It is regulated with Mg & PO4
irritating to the veins. • Its sources: 99% found in the bones & teeth
• Monitor urinary output while patient is given • Calcium not bound to bone is either bound to
potassium supplement to ensure excretion of plasma proteins or ionized ( calcium that is not
potassium. attached to proteins)
Evaluation • It is taken through the diet
• Serum potassium level is within normal range. Functions of Calcium
• Patient’s cardiac output is normal. • Calcium that are bound to bones & teeth
• Patient is free from injury. maintains their strength & rigidity.
• With balance intake & output. • Calcium is needed for nerve, muscle, and cardiac
• Vital signs within normal. conduction
• Patient’s mobility improved, able to ambulate • It is required for hormonal secretion
without assistance.
Regulation of Calcium Level
b.2. HYPERKALEMIA • It is absorbed in the small intestine & excreted in
• Serum K+ above 5.0mEq/L the urine.
Causes
• Vit D in its active form 1,25-
dihydroxycholecalciferol is required in the
• IV replacement of potassium
absorption of calcium in the S.I. Conversion
• Potassium rich hyperalimentation
occurs in the kidneys
• Excessive use of salt substitutes
• Poor elimination of potassium due to kidney
failure. Renal Regulation of Calcium Level
• In metabolic acidosis where hydrogen ion enters • Calcium is filtered in the glomerulus and
the cell in exchange of potassium. absorbed in the tubules.
• If excessive calcium is present, it can precipitate
into stone.

NCA 1 ┃ NURSING COURSE APPRAISAL 1

 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

Endocrine Regulation of Calcium Level • Administer calcium gluconate with caution & to
• The parathyroid gland responses to low calcium patients receiving digitalis, it may result to digitalis
level by releasing PTH, stimulates the release of toxicity.
calcium from the bones until it becomes normal. • Ca gluconate is also use to antagonize
• If serum phosphorous level is higher than normal, magnesium toxicity.
calcium binds with phosphorous. • Encourage patient to ambulate & do some
exercises as tolerated
B. CALCIUM IMBALANCE
b.2. HYPERCALCEMIA
b.1. HYPOCALCEMIA • Serum Calcium level below 10.5mg/dL
• Serum Calcium level below 8.5mg/dL
Causes
Causes • Over administration of calcium supplements.
• Inadequate intake of calcium in the diet due to • Increased vit D intake
anorexia, dieting. • Hyperparathyroidism which accelerates PTH
• In CKD, vit D is not activated or effects on bones
dihydroxycalceferol is not activated. • Increased in renal disease which decrease renal
• Vit D deficiency regulation of electrolytes.
• Inadequate exposure to sunlight, w/c hinders • Hypophosphatemia due to inverse relationship of
activation of vit D calcium with phosphorous
• Malabsorption of calcium due to GI disease, or • Thyrotoxicosis accelerates release of calcitonin.
alcohol abuse. • Immobility, if bones are not used, calcium moves
• Acute pancreatitis which results to hypocalcemia out from the bones
• Low PTH level, reduce calcium absorption. • In cases of bone cancer, calcium moves out from
the bones.
Signs and Symptoms
• Tetany & seizures Signs and Symptoms
• ECG result prolonged Q-T intervals • Assess level of serum calcium level especially to
• Appearance of petechiae and easy bruising patients who are at risk for hypercalcemia.
observed on the skin. • Hypercalcemia affects the skeletal, cardiac &
• Hyperphosphatemia is noted smooth muscles which are manifested by dec
• Prolonged prothrombin time intestinal peristalsis, muscle weakness, cardiac
dysrhythmia manifested by shortened Q-T
Potential Nursing Diagnosis interval.
• Decreased cardiac output • Excess calcium may result to formation of urinary
• Risk for bleeding calculi manifested by hematuria, dysuria,
• Risk for injury presence of calcium oxalate in the urinalysis.
• Ineffective breathing pattern • Patient is risk for pathologic fracture.
• Impaired physical mobility
• Activity Intolerance Potential Nursing Diagnosis
• Decreased cardiac output
• Because calcium is a critical part in • High risk for injury
neuromuscular contraction, low calcium levels • Altered nutrition: less than body requirements
affect the contraction of the smooth, skeletal, & • Risk for constipation R/T decreased GI function
cardiac muscles which include: from immobility.
o Muscle cramps in arms & legs • Impaired memory, confusion R/T altered
o Muscle spasms ( spasms in bronchial & neurologic function.
laryngeal muscles which are dangerous
signs of hypocalcemia) Interventions
o Cardiac dysrhythmias ( prolonged Q-T • Institute measures to prevent hypercalcemia to
interval) high risk patients.
• It is also a critical part of nerve cell conduction, • Encourage patient to ambulate and do exercise
w/c makes nerve cells more excitable results to as tolerated.
hyperactive deep tendon reflexes, paresthesia, • Institute measures to eliminate excess calcium
+Chvostek’s sign, +trousseaus sign. from the blood by administration of loop diuretics
as ordered
Interventions • Administer calcitonin as ordered enhance
• Identify patients at risk for hypocalcemia; those movement of calcium into the bones.
with thyroid disease or have undergone • Monitor v/s, and electrolytes
thyroidectomy, or patients with GI disorders.
• Assist patient to restore serum calcium level to MAGNESIUM:
normal NORMAL AND IMBALANCE
• Patient maybe prescribed of calcium
supplements, vit D, provide calcium rich foods. A. NORMAL BALANCE
• Provide safety always. Description
• Monitor v/s • The second most abundant cation in the ICF
• Normal serum Mg level – 1.5-2.5 mEq/L

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

Causes • Monitor patients with hypomagnesemia who are

• Increased intake of Mg rich-foods, or receiving digoxin for signs of digitalis toxicity.
administration of magnesium through IV route in • Assess for deep tendon reflex, refer to physician
the treatment of eclampsia, IV supplements, if noted.
Hyperalimentation. • Monitor v/s, intake & output.
• Institute seizure precaution.
Functions
• Infuse MgSO4 with caution, can be given by IM,
• Assists in the contraction of cardiac, & skeletal IVP, IV infusion with caution. Assess patient’s
muscles status: v/s, deep tendon reflex, RR, urine output
• Has an effect of vasodilation, results to of patient.
decreased BP & cardiac output.
• Facilitates sodium & potassium transport across
cell membrane. b.2. MAGNESIUM EXCESS
• Serum Calcium level above 2.5mEq/L
Regulation
• Mg is filtered along with other electrolytes in the Causes
tubules • Mg gain from medication & hyperalimentation
• Mg is reabsorbed in the renal tubules as the body • Inadequate excretion due to renal disease.
needs Mg. If serum Mg level is low, Mg is re-
absorbed, if high excreted.
Signs and Symptoms
• Osmotic diuretics can excrete excess Mg.
• Decreased cardiac output manifested by
hypotension.
B. MAGNESIUM IMBALANCE • Since magnesium causes warm systemic
sensation, patient may appear flush, may
b.1. HYPOMAGNESEMIA verbalized feeling of warmth.
• Serum Calcium level below 1.5mEq/L • Hypoactive deep tendon reflexes or decreased
motor function of extremities; decreased neuro-
Causes
muscular activity.
• Can be loss from vomiting, diarrhea, NGT suction
( more Mg is lost from the bowel compared to Potential Nursing Diagnosis
vomiting) • decreased cardiac output
• Administration of loop diuretics. • risk for injury
• Inadequate intake or absorption due to • Ineffective breathing pattern
malnutrition, starvation, excess dietary intake of
calcium or vit D Interventions
• Hypercalcemia • Prevent hypermagnesemia to high risk patients
• Hypoparathyroidism by identifying early signs of the deficit.
• Monitor v/s, urine output
Signs and Symptoms • Administer calcium gluconate as ordered to
• Patient may be manifesting vomiting & diarrhea counter effect magnesium toxicity
which may be the cause of the Mg deficit.
• Hypotension, because Mg is required for
neuromuscular & cardiac muscle function ACID - BASE:
• Patient may manifest same manifestation with NORMAL AND IMBALANCE
that of a patient with hypocalcemia: tetany,
seizure, tremors, confusion, hyperactive deep A. HYDROGEN ION BALANCE (Basic Concepts)
tendon reflex, positive Chvostek’s & trousseau’s Description
signs. • Hydrogen ion is present in body fluids, both in the
• Memory loss ECF & ICF
• Lab results: Mg below normal, hypocalcemia, • It determines the acidity or alkalinity of a solution
hypokalemia or body fluids.
• ECG results; prolonged P-R interval, inverted T- • The greater the number of hydrogen ion the more
wave. acid the solution is; the smaller the hydrogen ion
the more alkaline the solution.
Potential Nursing Diagnosis • The acidity or alkalinity of body fluids or blood is
• Risk for injury measured in terms of pH – normal blood pH –
• Decreased cardiac output 7.35-7.45
• Altered nutrition: less than body requirement • If blood pH drops to below 7.35, it is acidosis; if
• Altered memory blood pH is above 7.45 it is alkalosis.
• Hydrogen circulates within the body in 2 forms:
Interventions
o Volatile hydrogen, when CO2 is
• Prevent hypomagnesemia to high risk patients; dissolved in water, it forms carbonic acid,
early detection of hypomagnesemia to high risk excreted in gaseous form by the lungs.
patients. o Non-volatile hydrogen ion ( metabolic )
• Monitor patients with hypokalemia for impending – produced as a result of metabolic
hypomagnesemia processes.

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

• Some are formed from organic acids like uric • When H2CO3 decreases in the blood, blood pH
acid; some are found in the form of sulfuric acid , increased, the PCO2 is decreased which maybe
phosphoric acids, some are formed from due to hyperventilation, the respiratory center will
catabolic processes from fats forming ketone decreased its function resulting to
acids when glucose is elevated & not used by the hypoventilation.
cells as source of energy. • Hypoventilation results to retention of CO2,
• Excess metabolic acids formed as a result of combines with water to form carbonic acid until
anaerobic metabolism like in severe tissue blood pH returns to normal
damaged forming lactic acids in burns, or tissue • But if blood pH is decreased, H2CO3 is
injury or trauma. increased, CO2 is retained maybe due to
• Excretion of hydrogen ion hypoventilation from sedation, obstruction of air
o The lungs primarily eliminate volatile passages, CO2 is not given off, reaction of the
hydrogen ion of carbonic acid as CO2 & medulla is to stimulate respiration through
water hyperventilation to excrete the excess CO2 that
o The kidneys eliminate volatile acids in the are retained until the H2CO3 & blood pH back to
form of: normal level.
▪ 60% is excreted in the urine as • Lungs limitation to correct acid-base imbalance is
NH4 chloride they are only capable of excreting volatile acids.
▪ 40 % is excreted as weak acids
a.4. The Renal System
• The kidneys regulate bicarbonate in the HCO3-
HYDROGEN IONS CONCENTRATION H2CO3 in the buffer system & eliminate non-
REGULATION volatile hydrogen ions.
• Dilution of EXCESS hydrogen ion in the ECF, first • It works slowly, takes several days to correct
line of defense imbalance.
• Buffer by the following systems ; H2CO3- HCO3 • The kidneys work to correct acid-base
buffer system; Protein Buffer System ; imbalances by:
Phosphorous Buffer System. o Reabsorption of filtered bicarbonate
• Respiratory Buffer System o Hydrogen ion secretion in the kidney
• Kidney Buffer System tubules
o Production of NH3.
a.1. Local Dilution of the Hydrogen Ion
• Reabsorbing filtered bicarbonate- blood entering
• Kidney Buffer System the glomeruli contains bicarbonate ions, passes
• Example: if you do exercise, hydrogen is build up through the tubules & reabsorbed if needed &
in the circulation, then automatically distributed excreted if the body’s blood pH is normal.
within the body with out any symptoms of • Net secretion of H+ - cellular metabolism
increased hydrogen ion, later it will have normal
produces hydrogen ions that must be excreted in
distribution.
the urine to keep the blood from too acidic.
a.2. Buffer System • H+ entering the renal tubular fluids combines with
• The buffer system of the body is composed of ammonia rather than with HCO3.
weak acid that coexists with a salt: ex. HCl • NH3 Mechanism – when certain amino acids
(strong acid) + NaHCO3 > H2CO3 (WEAK ACID) break down, NH3 is formed w/in the distal tubular
+ NaCl (salt). Results to normal blood pH. cells. When NH3 diffuses from the cells into the
• It can buffer 90% of the hydrogen ion in the ECF. renal tubules, it reacts w/ H+ to form NH4,
• It is the most important buffer system in the ECF; excreted in the urine, this will increase the
Lungs excrete H2C03 while the kidneys excrete bicarbonate level.
HCO3 ( alkali ) B. HYDROGEN ION IMBALANCES
• There should be 1 part of H2CO3 & 20 parts of Description
HCO3 ( 1:20 ) ratio. • Hydrogen ion balance depends on the normal
a.3. The Respiratory System function of the buffer system, lungs & kidneys.
• The lungs removed CO2 from the body in • Types of hydrogen imbalances:
response to increase hydrogen ion concentration o Acidosis – a condition where the
in the blood. hydrogen ion concentration in the blood
is elevated, normal bicarbonate is
• Arterial blood gases is measured by partial CO2
pressure (PaCO2), Normal is 35-45 mmHg. elevated, blood pH is decreased.
o Alkalosis – a condition where hydrogen
• The partial pressure of oxygen (PO2) is called
ion concentration in the blood is
oxygen tension. Normal is 75-100 mmHg.
decreased, bicarbonate is elevated,
blood pH is increased.
FEEDBACK MECHANISM OF REGULATION OF
CO2 DEFENSE MECHANISM AGAINTS IMBALANCES
• The respiratory center in the medulla controls the • Correction of the buffer system. The first line of
carbonic acid in the bicarbonate-carbonic acid defense against hydrogen imbalance is through
buffer system by means of a feedback buffer system
mechanism between the respiratory center & the • The second line of defense is the respiratory
lungs. system
• The third line of defense is the renal system

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

• Assessment: all major manifestations are caused • Monitor respiratory rate, depth, & rhythm.
by the CNS. • Monitor O2 saturation, indicate if room air, w/ O2
o In respiratory or metabolic acidosis, the via nasal cannula,/ face mask
major problem is CNS depression • Administer low flow of oxygen as ordered.
resulting in decreased respiratory & renal • Monitor ABG levels
function • Force fluids as tolerated and if not
o In respiratory or metabolic alkalosis, the contraindicated.
problem is CNS stimulation • Administer nebulization, antibiotics as ordered
• Attach to mechanical ventilator if indicated
Diagnosis of Hydrogen Ion Imbalances
• Blood pH – determines the acidity or alkalinity of
the blood; it does not indicate if imbalance is B. Respiratory Alkalosis
respiratory or metabolic in nature. Causes
o Normal – 7.35-7.45 • Excessive CO2 excretion which results to
o Below 7.35 – acidosis ; above 7.45 is decreased in PaCO2, increased in H2CO3,
alkalosis increased in blood pH.
• PaCo2 determination – measures the amount of • This may be the result of hyperventilation &
CO2 pressure of arterial blood which its normal overstimulation of the respiratory center.
value is 35-45 mmHg • Anxiety may result to hyperventilation
• HCO3 – measures the bicarbonate level of the • After a series of exercises, a person
arterial blood; normal level is 22-26 mEq/L. hyperventilates
• the above diagnostic exam is known as the ABG • Hypoxia in high altitudes
exam • Defect in the adjustment of ventilators
Interventions to Correct Acid-Base Imbalance • Conditions that causes overstimulation of the
respiratory center of the brain:
• Identify & treat cause of imbalance
o Fever
• Assist the respiratory &/ or the renal system
o CNS infection like meningitis
through supportive interventions to correct &
o Intracranial surgery
compensate for the imbalance.
o ASA toxicity
• Monitor the renal & respiratory functions.
o The increased blood pH of the blood
• Asses for patient’s condition, ensure physiologic
increased neuromuscular irritability
& psychologic safety.
manifested by hyperreflexia, positive
• Administer medications that neutralize excess Chvostek’s sign, & muscular twitching,
acids or base with caution; commonly seizures sometimes occur.
bicarbonate is given to correct acidosis, &
ammonium chloride to correct excess base or Interventions
alkali. • Identify patients at risk for respiratory alkalosis.
Identify early symptoms of the disease.
THE FOUR ACID - BASE IMBALANCES
• Assist the patient to breath slowly or normally.
A. Respiratory Acidosis
• Listen with sympathy to a patient with anxiety
Causes
having hyperventilation.
• Conditions that results to retention of CO2 results
• Ask the person to re-breath his/her own exhaled
to increased CO2 level of the blood, decreased
CO2 in a paper bag thus increasing the H2CO3
serum pH level.
in the blood.
• Any condition that obstruct the excretion of CO2
• Take precautions to prevent injury.
• Impaired neuromuscular function e.g. GBS, chest
• Monitor v/s, I& O, record.
trauma
• Check adjustment of ventilators.
• Depressed respiratory function

Assessment
C. Metabolic Acidosis
• Dyspnea upon exertion, DOB, tachycardia,
• Increased in H2CO3 & Blood pH
restlessness, irritability, in severe cases patient
may become disoriented, confused, then coma Causes
• Overproduction of metabolic acids produced from
Interventions
metabolism, such as DM, high fat, low CHO diet,
• Goal: improve respiratory function, Provide prolonged fasting.
patient’s comfort and safety.
• Excessive ingestion of acids like ASA, ferrous
• Plan activities that patient able to have rest SO4, ammonium chloride.
periods in between activities
• Renal Disease – in renal disease, the kidneys are
• Encourage deep breathing, coughing exercises unable to excrete the excess acids from the
to improve exchange of CO2 & oxygen in the blood, and decrease retention/ reabsorption of
respiratory system. HCO3.
• Place patient in semi-fowler’s position. • Abnormal losses of Alkali – losses from
Encourage change of position q 2 hrs. pancreatic, biliary, & lower GI secretions through
• Institute chest physiotherapy diarrhea results to retention of acids.
• Suction secretions if needed. • Severe tissue anoxia results to anaerobic
• Provide emotional support & reassure to allay metabolism like in cases of burns, anemia,
anxiety cardiac disorders.

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 LECTURE 17: FLUID, ELECTROLYTE, AND ACID-BASE BALANCE
Rebecca De Asis, MAN, RN

Interventions NURSING EXPERIENCING BURNS

• Goal: restore normal blood volume & osmolality; • Burns as defined caused by flames, chemicals,
Correct HCO3 deficit; Prevent electrolyte radiation, or electrical current.
imbalances; Maintain safety of patient. • Thermal burns is the most common, caused by
• Restore normal blood volume & osmolality - fires in home, vehicular accident, playing with
Commonly patients with acidosis are dehydrated, matches in children, poorly stored gasoline.
monitor body weight, I & O, administer isotonic
solutions as ordered. Functions of the Skin
• Correct HCO3 deficit. Na HCO3 may be given • Protection against infection.
cautiously as ordere; It maybe add to IV solutions • Prevent loss of body fluids.
or given by IVP slowly or IV drip through • For excretion, use for sensation
volumetric set. • Produce vit D
• Prevent electrolyte imbalances; Patients w/
metabolic acidosis may develop hyperkalemia as Pathophysiology of Burns
k+ shifts from ICF to ECF in exchange of H+; • Following burns, increased capillary permeability
Observe for signs of hypocalcemia, because as results, plasma seeps into surrounding tissues,
metabolic acidosis is corrected, calcium bind to causing edema.
plasma protein, citrate, which contribute to • This leads to body fluid loss w/c is greatest within
hypocalcemia. Observe for signs of tetany, 18-36 hrs.
because calcium regulates neuromuscular • In mild cases of burns, fluid leak into the burned
irritability. areas; while in severe cases, it leads to systemic
• Protect patient from potential injury. Patients fluid loss.
w/ metabolic acidosis may have altered level of • Factors determining burn severity:
consciousness like seizure, irritability; Always put o Burn depth
side rails up, don’t leave patient unattended. ▪ First degree – affects superficial
part of the skin or the epidermis.
Skin appears pink & red, w/ small
D. Metabolic Alkalosis thin blisters
• Blood pH above 7.45, HCO3 above 26 mEq/L ▪ Second degree burn or partial
thickness, where only part of the
Causes
skin is damaged. Both dermis &
• It results to excessive loss of hydrogen ion or epidermis are affected. Large
excessive ingestion of alkali. thick-walled blisters develop,
• Excessive use of hydrogen ion commonly covering the burned
o From severe vomiting where Hcl acid area.
stomach content is lost. ▪ Third degree burn or full
o Patients w/ GI suction where there is no thickness burn – all the skin,
electrolyte replacement. dermis, epidermis are destroyed
o Loss of chloride which causes the including the subcutaneous,
kidneys to retain bicarbonate. muscle & bone. The color may
• Excessive ingestion of alkali - patients with peptic be deep red, white or black, or
ulcer & given antacids brown.
▪ Full-thickness burn –
Interventions
structures beneath the skin are
• Identify cause of imbalance, & correct the
severely affected.
imbalance.
• Determining Burn Size: determine BSA affected
• Patients treated with peptic ulcer disease should
o It is determined by the “Rule of Nine” or
be careful not to overdose the intake of antacid.
the “Lund and Browder” method. But
• Commonly patient is given PLR to replace fluid commonly the rule of nine is used in the
losses like in vomiting, it contains 10 mEq of hospital.
chloride, an alkali. o According to the rule of nine, the body is
• Correct water, cl-, Na, & potassium deficits, divided into 9% of the total body areas
important when correcting alkalosis. affected.
• Monitor v/s, I & O, record. o Head & neck – 9% ; right upper ext. 9%;
• Observed signs of rebound effect of metabolic left upper ext. 9%; anterior trunk – 18%;
alkalosis. posterior trunk – 18%; right lower ext.
18%; left lower ext. 18%; perineum 1%
Evaluation
• Patient has normal breathing pattern.
• Vomiting is controlled, able to tolerate oral
feeding.
• Intake & output are within normal balance.
• Patient is free from injury.

NCA 1 ┃ NURSING COURSE APPRAISAL 1