Fluids & Electrolytes-Enhance

Fluids and Electrolytes
Review
Prepared By:
Mr. Nestlee Sio Cabaccan RN,MSN

Key to Success!
 Confidence +
 Adequate test Preparation and review +
 Effective test taking strategy +
 Good study habits +
 Working Knowledge of Basic Nursing concepts = Success
in passing PNLE

Fluids and Electrolytes Outline
3 concepts
 Fluids
 Electrolytes
 Acids and Bases

Important Concepts
 Remember the ABC

 Safety of the patient
 Maslow’s Hierarchy of needs
 Utilize the NURSING PROCESS
◦ A-D-P-I-E

Summary of Subtopics
 Basic Definition
 Body Proportions and Distributions
 Sources
 Dynamics
 Regulation by 3 systems- renal, endocrine & GIT
 Balance
 Imbalances
 Application of the Nursing Process in the discussion

Sample Question
 The nurse is caring for a client with Congestive Heart Failure.

On assessment, the nurse finds the client complaining of
dyspnea and that rales are heard on auscultation. The nurse
suspects fluid volume excess. Which additional sign would the
nurse expect if fluid volume excess is present?
A. Flat neck and hand veins

B. Weight loss
C. Increased central venous pressure
D. Hypotension

THE BODY FLUIDS
 A solution of solvent and solutes
 Our body is made up of fluids and solids
 About 50-60% of the body weight is WATER
 In a 70 Kg adult male: 60% X 70= 40-42 Liters
 Note that 1 kg body weight= 1 liter of water
 The body has two major compartments:
1 Intracellular
2. Extracellular

*Body Water
Principal body fluids ;solvent responsible for the body’s
structures and function.
Consists of 45-75% of the total body weight.

NORMAL WATER DISTRIBUTION/BALANCE
Body Fluids Function

 Facilitates transport of nutrients, hormones,
CHON and other molecules into the cells.
 Aids in the removal of cellular metabolic
waste products.
 Provides the medium in which cellular
metabolism takes place.
 Regulates lubrication of musculo-skeletal
joints.
 Acts as a component all body cavities (
pericardial fluid, pleural, CSF)

The Proportion of Body Fluids
Interstitial
Intracellular 15%
fluid
40%
Intravascular
5%
Transcellular
1-2%

The Intracellular Fluid
 Found inside the cell surrounded by a membrane.
 This is compartment with the highest percentage

of water in adults.

1. Intracellular Fluid (ICF)
◦ Includes all water
and electrolytes
inside the cells.
◦ 2/3 of the body
weight is contained
within cell
membranes
Fluid Compartments:

The Extracellular Fluid
 Fluid found outside the cells
1. INTERSTITIAL FLUID
Found in between the cells
2. INTRAVASCULAR FLUID
Found inside the blood vessels and lymphatic vessels
3. TRANSCELLULAR FLUID
Found inside body cavities like pleura, peritoneum, CSF

2. Extra cellular Fluid (ECF)
◦ Includes interstitial fluid,
intravascular and
Trancellular fluid
◦ Constitutes about 1/3 of body water
Functions of ECF:
◦ Transports nutrients and electrolytes
to cell and waste products for
excretion
◦ Regulates heat
◦ Lubricates and cushions joints
◦ Hydrolyzes food for digestive process

Intake Output
Liquid 1,200-1,500 Urine 1,200 -1,500
Water in food ml Feces ml
Metabolism 700- 1,000 ml Insensible 100-250 ml
200- 400 ml Loses:
Skin 350 -400 ml
Lungs 350- 400 ml
TOTAL 2,100 – 2,900 TOTAL 2,100 – 2,900

ml ml
NORMAL WATER BALANCE

Routes of Gains and Losses
Sample question
1. A client with CHF is assessed by the nurse. Upon reviewing

the chart, it is determined that his weight increased by 4.5
pounds. The nurse estimates that client has gained how many
liters of fluid?
A. 3
B. 1
C. 2
D. 0.5

Sources of Fluids:
Fluid Input
1. Exogenous sources
 Fluid intake- water from foodstuffs
 IVF
 Medications
 Blood products
2. Endogenous sources
 By products of metabolism
 secretions

Fluid Losses
Routes of Fluid output
 Urine
 Fecal losses
Sensible losses
 Sweat
 Insensible losses though the skin and lungs as
water vapor

 2200 – 2700 ml – average daily fluid gains and losses
in adult.
Fluid gains
Oral fluids- 1100 – 1400ml
Solid foods- 800 – 1000ml
Metabolism- 300 ml
Fluid losses
Kidneys – 1200 – 1500 ml
Skin – 500 – 600 ml
Lungs – 400ml
Gastrointestinal - 100 -200 ml

Sample question
2. A nurse reads a doctor’s progress notes in the client’s chart

which states “insensible fluid loss approximately 800 ml.” The
nurse understands that this fluid loss may occur through:
A. The Gastrointestinal tract

B. Urinary output
C. Wound drainage
D. The skin

Sample question
A nurse is administering IVF as ordered to a patient who

sustained second-degree burns. In evaluating the adequacy of
fluid resuscitation, the nurse understands that the most
reliable indicator for fluid adequacy is the:
A. Blood pressure
B. Mental status
C. Urine output
D. Peripheral pulses

Sample question
The nurse receives the following endorsements. She is

certain that which patient is at most risk for the
development of fluid volume deficit?
A. The client who came from the OR after a

hemorroidectomy.
B. The client who has Renal failure undergoing
dialysis.
C. The client with AIDS taking corticosteroids.
D. The client with Rheumatic fever taking diuretics.

Fluid Dynamics
The movement of fluids (solutes and solvents) in

the body compartment
 Diffusion
 Osmosis
 Filtration
 Active transport

 Osmolality – refers to the concentration of solutes in 1
liter of solution
 OSMOSIS: diffusion of H2O across a selectively permeable
membrane from an area of lower solute concentration to an area of
higher solute concentration.

The Concept of TONICITY
 This is the concentration of solutes in a solution.

 A solution with high solute concentration is considered as
HYPERTONIC.
 A solution with low solute concentration is considered as
HYPOTONIC.
 A solution having the same tonicity as that of body fluid or
plasma is considered ISOTONIC.

Helpful Hints
 In a HYPERTONIC solution, fluid will go out from the cell, the

cell will shrink.
 In a HYPOTONIC solution, fluid will enter the cell, the cell will
swell.
 In an ISOTONIC solution, there will be no movement of fluid.

DIFFUSION
 The movement of SOLUTES or particles in a solution from a

higher concentration to a lower concentration.
 If a sugar is placed in plain water, the glucose molecules will
dissolve and diffuse distribute in the solution.

OSMOSIS
 The force that draws water or solvent from a less

concentrated solution into a more concentrated solution
through a semi-permeable membrane.
 The pressure that draws water inside the vessel which is more
concentrated is called Osmotic pressure.
 A special type of osmotic pressure is exerted by the proteins
in the plasma. It is called ONCOTIC PRESSSURE.

 Fluid Movement by Diffusion and Osmosis
 Diffusion- means by which substances such as nutrients and

wastes produces move between blood and interstitial spaces.

 Osmolality – refers to the concentration of solutes in 1
liter of solution
 OSMOSIS: diffusion of H2O across a selectively permeable
membrane from an area of lower solute concentration to an area of
higher solute concentration.

Sample question
 The nurse is caring for a psychiatric patient who ingested

high-sodium containing foods. She suspects hypernatremia in
this patient and expect to note:
A. Hyperactive deep tendon reflex

B. Chovstek’s Sign
C. Dry skin and sticky mucous membrane
D. Decreased muscle tone

FILTRATION
 The movement of both solute and solvent by hydrostatic

pressure, ie, from an area of a higher pressure to an area of a
lower pressure.
 An example of this process is urine formation.
 Increased hydrostatic pressure is one mechanism producing
edema.

Active transport
 This is the movement of solutes across a membrane from a

lower concentration to a higher concentration with utilization
of energy.
 Example is the Sodium-Potassium pump- a primarily active
transport process.

Sample question
 The nurse reviews the laboratory report of a patient with
fluid volume deficit. Which of the following laboratory
findings will support this condition?
A. WBC count of 9,000

B. Creatinine of 1 mg/dl
C. Sodium of 140 mEq/L
D. Hematocrit of 58%

Sample question
 The client is taking a high dose of Furosemide. To determine
the progress of the therapy, the nurse performs which of the
following important action?
A. Monitor urinary pH
B. Check the temperature periodically
C. Weight the patient daily
D. Obtain a serial serum Sodium level

Regulation of Body fluid balance
1. The Kidney
 Regulates primarily fluid output by urine formation
 Releases RENIN
 Regulates sodium and water balance

2. Endocrine regulation
 Regulates primarily fluid intake by thirst mechanism
 ADH increase water reabsorption on collecting duct
 Aldosterone increases Sodium retention in the distal
nephron
 ANF Promotes Sodium excretion and inhibits thirst
mechanism

3. Gastro-intestinal regulation
 The GIT digests food and absorbs water
 Only about 200 ml of water is excreted in the fecal material
per day

The ELECTROLYTES
 Electrolytes are charged ions capable of conducting

electricity and are solutes in all compartment.
 ANIONS are Negatively charged ions: Bicarbonate, chloride,
PO4-
 CATIONS are positively charged ions: Sodium, Potassium,
magnesium, calcium.

Helpful mnemonics
PI-SO
Potassium is inside
Phosphate is inside
Sodium is outside
Chloride is outside

Regulation of Electrolyte Balance
1. Renal regulation
 Occurs by the process of glomerular filtration,
tubular reabsorption and tubular secretion.
 Urine formation
◦ If there is little water in the body, it is
conserved.
◦ If there is water excess, it will be eliminated.

Formation of Urine
Figure 15.5
Regulation of Electrolyte Balance
2. Endocrinal regulation
 Hormones play a role in electrolyte regulation
 Aldosterone promotes Sodium retention and

Potassium excretion
 ANF promotes Sodium excretion
 Parathormone promotes Calcium retention and

Phosphate excretion
 Calcitonin promotes Calcium excretion and
Phosphate excretion

Roles of the Hypothalamus and Adrenal
Glands in the Stress Response
Figure 9.12
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide 9.31
Thyroid Hormone
 Major metabolic hormone

 Composed of two active iodine-
containing hormones
 Thyroxine (T4) – secreted by thyroid
follicles
 Triiodothyronine (T3) – conversion of T4 at
target tissues
Slide 9.24
Calcitonin
 Decreases blood
calcium levels by
causing its
deposition on bone
 Antagonistic to
parathyroid
hormone
 Produced by C
(parafollicular)
cells
Figure 9.9
Slide 9.25
REGULATION OF FLUID VOLUME
HYPERVOLEMIA HYPOVOLEMIA
inhibits stimulates
ADH Aldosterone Thirst Thirst ADH Aldosterone
INCREASED DECREASED
URINATION URINATION
of of
Dilute urine Concentrated urine
NORMAL FLUID VOLUME RESTORED

FLUID IMBALANCES
I. Extra Cellular Fluid Volume Deficit
MILD: 1-2 L of H2O (2% body wt.)
Causes:
MODERATE: 3-5 L of H2O (5%)
1. Lack of fluid intake
◦ 1,500 – 2,000 ml SEVERE: 5-10 L of H2O (8%)
RF:
◦ Hospitalized/bed bound
◦ People w/ dysphagia/ risk for aspiration
◦ Tube-fed patients who are not given adequate free water
◦ Pts. w/ decreased access to fluids
◦ Pts. w/ impaired thirst mechanism
 People w/ debilitating illnesses
 Older adults

2. Excessive Fluid Losses
◦ Vomiting, diarrhea, fever, hyperglycemia, suction,

fistula, burns, blood loss, diabetes insipidus,
diaphoresis, hyperthyroidism, excessive diuretics,
ileostomy, hyperventilation, Diuretic phase of ARF
Types of ECFVD
 Hyperosmolar (hypertonic): water loss is > electrolyte loss
 Hypotonic: electrolyte loss is > fluid loss
 Isotonic (iso-osmolar): water and electrolyte loss are equal

CLINICAL MANIFESTATIONS:
1. Loss of body wt.
◦ Most accurate indicator of fluid loss
◦ 1 L of sol’n=1 kg of body wt.
2. Changes in I &O
◦ U. O. of 400-500 ml/day- oliguria
◦ Thirst
3. Changes in V/S
◦ ↓ed BP
◦ Weak pulse
◦ ↓ed CVP, ↓ed PCWP
◦ Postural hypotension
◦ ↑ed PR
◦ Flat JV and prolonged peripheral venous filling time of more
than 5 sec.
◦ Elev. Body temp
4. Manifestations of cellular dehydration
◦ dry mucus membrane of mouth and eyes
◦ cracked lips
◦ poor skin turgor
◦ muscle weaknessMr. Nestlee Sio Cabaccan RN,MSN
FLUID VOLUME DEFICIT
•IS move to IV
•ADH & aldosterone is released
•Fluids reabsorbed in the ileum & colon
•Baroreceptors  SNS: increase HR &
Peripheral vasoconstriction
•Osmoreceptors: Thirst mechanism
DEHYDRATION
•Impaired temperature regulation

•Decrease ability to transport heat
•Decrease CSF
•Decrease Sodium

II. Intracellular Fluid Volume Deficit (ICFVD)
◦ Due to severe dehydration
RF:
- older clients; w/ acute water loss
s/sx:
- Thirst
◦ Oliguria
◦ Fever
◦ Confusion, coma, cerebral hemorrhage
 DIAGNOSTIC TEST FOR ECFVD/ICFVD:

Osmolality > 295 mOsm/L Na >145 mEq/l
BUN > 25 mg/dl Glucose >120 mg/dl
Hct > 55% Urine sp. Gr. > 1.030

III. Extra Cellular Fluid
Volume Excess
(ECFVE)
Fluid overload
2 types:
1. hypervolemia-↑ed fluids in
vascular system
2. third spacing-↑ed fluids in
interstitial space

Etiology
 Simple overloading of fluids (too many IVF)
 ↑ ADH and aldosterone
 ↓ kidney fxn
 CHF
 Liver Cirrhosis
 Venous disorder
 Excessive ingestion of fluids/ food with Na

MECHANISM OF EDEMA FORMATION
FLUID OVERLOAD
Increase hydrostatic
pressure in arterial end
of capillary
Increased peripheral
Vascular resistance
Fluid movement
into tissues
Increased left
Ventricular pressure
edema
Increased left atrial
pressure
Pulmonary edema
DECREASE PLASMA ALTERED LYMPHATIC TISSUE INJURY
& ALBUMIN FUNCTION
Decrease production Lymphatic obstruction Increase capillary

decreases absorption
of plasma CHON permeability
of interstitial fluid
Decrease Capillary Decrease transport Movement of plasma

Oncotic Pressure of capillary filtered
CHON in tissues
protein
Decrease
Increase tissue oncotic Increase tissue
Reabsorption pressure, which pulls
At venous end Oncotic pressure
fluid towards it
EDEMA EDEMA
EDEMA
IMPAIRED RENAL FXN
↓ Na and H20 excretion
↑ Fluid Volume
Heart compensates by increasing

HR and Hypertrophy
If compensatory mechanism fails,

heart failure develops

IV. Intracellular Fluid Vol. excess (ICFVE)- water
intoxication; cells are resistant to fluid shifts
Etiology:
◦ water excess- number of solutes is normal but
there is water excess
◦ solute deficiency=amt. of water is normal but ↓ed
solute
= most common cause: administration of excessive
amts. Of hypoosmolar IVF
= adults who
consume excessive amts. of tap H2O
w/o adequate nutrient intake
=SIADH
=people w/ psych. d/o → schizophrenia
with compulsive water consumption

V. Extracellular Fluid Volume Shifting – third spacing
2 types:
1. vascular fluid shifts to interstitial space (hypovolemia)
2. interstitial fluid shifts to vascular space (hypervolemia)
* third space= fluid that shifts into IS and remains there
= common sites:pleural cavity,
peritoneal cavity, & pericardial sac
Etiology:
 ↑ ed capillary permeability
 ↑ ed fluid reabsorption in venous end
 Decreased serum CHON levels
 Obstruction of venous end of capillary
 Non-functional lymphatic drainage system

Clinical Manifestations:
1. Fluid shifting from IV to IS
◦ Pallor, cold limbs, weak &rapid pulse, hypotension, oliguria, ↑ ed
skin turgor & ↓ ed level of consciousness
◦ No changes in body wt. because fluid has not been lost but
redistributed
2.fluid returns to the IV space from IS – s/sx similar to fluid overload
◦ bounding pulse, crackles, JVD, ↑ ed BP

 Clinical Manifestations:
> respiratory
> cardiovascular
> others
Edema
Anorexia/bloating
Wt. gain
Fluid shifting from IV/IS
DIAGNOSTICS:
Osmolality < 275 mOsm/L Na < 135 mEq/l
BUN < 8 mg/dl Urine sp. Gr. < 1.010 Hct <
45%

Electrolytes – these are chemical substances which
when dissolved dissociates into ions and passes
electrical potential.
Types:
 Cations – ions carrying positive charge
◦ Na
◦ K
◦ Ca
◦ Mg
 Anions – ions carrying negative

CATIONS ANIONS
Na- 135-145 m Eq/L
HCO3- 22-26 mEq/L
K- 3.5 – 5.0 m Eq/L
Cl- 96-106 mEq/L
Ca- 4.5-5.5 mEq/L
PO4 – 1.2 -3.0 mEq/L
Mg -1.5 – 2.5 mEq/L

THE CATIONS
 SODIUM
 POTASSIUM
 CALCIUM
 MAGNESIUM

SODIUM
 The MOST ABUNDANT cation in the ECF
 Normal range is 135-145 mEq/L
 Major contributor of plasma osmolarity
FUNCTIONS
 1. participates in the Na-K pump
 2. assists in maintaining blood volume
 3. assists in nerve transmission and muscle contraction
 Aldosterone increases sodium retention
 ANF increases sodium excretion
 Sodium balance is regulated by the interaction among neural,
hormonal, and vascular mechanisms
 Renal glomerulus filters 1000 mEq of sodium/hr and 99% is
reabsorbed in the loop of Henle
 Prostaglandin
POTASSIUM
 MOST ABUNDANT cation in the ICF

 Normal range is 3.5-5.0 mEq/L
 Major electrolyte maintaining ICVF balance
FUNCTIONS
 1. maintains ICF Osmolality
 2. nerve conduction and muscle contraction
 3. metabolism of carbohydrates, fats and proteins
 Aldosterone promotes renal excretion of K+
 Acidosis promotes exchange of K+ for H+
in the cell

CALCIUM
 Majority of calcium is in the bones and teeth
 Normal serum range 8.5-10 mg/dL
FUNCTIONS
 1. formation and mineralization of bones/teeth
 2. muscular contraction and relaxation
 3. cardiac function
 4. blood clotting
 5. enzyme activation

CALCIUM
Regulation:
 GIT absorbs Ca+ in the intestine with the help of Vit. D
 Kidney Ca+ is filtered in the glomerulus and reabsorbed
in the tubules
 PTH increases Ca+ by bone resorption, Ca+ retention
and activation of Vitamin D
 Calcitonin released when Ca+ is high, it decreases Ca+
by excretion in the kidney

MAGNESIUM
 Second to K+ in the ICF
 Normal range is 1.3-2.1 mEq/L
FUNCTIONS
 1. intracellular production and utilization of ATP
 2. protein and DNA synthesis
 3. neuromuscular irritability

THE ANIONS
 CHLORIDE
 PHOSPHATES
 BICARBONATES

CHLORIDE
 The MAJOR Anion in the ECF
 Normal range is 95-108 mEq/L
FUNCTIONS
 1. major component of gastric juice aside from H+
 2. together with Na+, regulates plasma osmolality
 3. participates in the chloride shift
 4. acts as chemical buffer

Hypo Chloremia
Cause/incidence:
1. Decrease chloride intake or absorption.
2. Low dietary sodium intake.
3. Potassium deficiency
4. Metabolic alkalosis
5. Administration of dextrose IV without electrolytes.
S/S:
 Associated with hyponatremia
 Muscle weakness and twitching
 ECF volume excess: agitation,tachycardia, HPTN,
dyspnea
DX:
 Chloride level below 98 meq/L confirms
hypochloremia ( Metabolic Alkalosis: PH above 7.45
and Serum Carbon Dioxide level above 32 Meq/L
Managent:
1. Oral replacement ( Salty Broth)
2. Normal Saline solution
3. Serum chloride and Potassium chloride
4. Check serum chloride q 3-6 hours
5. Watch for signs of metabolic acidosis
PHOSPHATES
 The MAJOR Anion in the ICF
 Normal range is 2.5-4.5 mg/L
FUNCTIONS
 1. component of bones
 2. needed to generate ATP
 3. components of DNA and RNA
 PTH decreases PO4 in blood by renal excretion
 Calcitonin increases renal excretion of PO4

BICARBONATES
 Present both in ICF and ECF

 Normal range- 22-26 mEq/L
FUNCTION
 1. regulates acid-base balance
 2. component of the bicarbonate-carbonic acid
buffer system

IMBALANCE: EXCESS
1. HYPERNATREMIA
 More than 145 mEq/L
 Fluid moves out of cell crenation
 Etiology:↑ sodium intake, IVF, water loss in excess
of water, diarrhea
 S/SX: dry, sticky tongue, thirst

IMBALANCE: EXCESS
2. HYPERKALEMIA
 K+ more than 5.0 mEq/L
 Etiology: IVF with K+, acidosis, Hyper-alimentation
and K+ replacement
 ECG: peaked T waves and wide QRS

 Hyperkalemia
◦ High K+
◦ Peaked T

IMBALANCE: EXCESS
3. HYPERCALCEMIA
 Serum calcium more than 10.5 mg/dL
 Etiology: Overuse of calcium supplements, excessive Vit. D,
malignancy, prolonged immobilization, thiazide diuretic
 ECG: Shortened QT interval

 Hypercalcemia
◦ Short QT
 Hypocalcemia
◦ Long QT

IMBALANCE: EXCESS
4. HYPERMAGNESEMIA
 Serum magnesium more than 2.1 mEq/L
 Etiology: use of Mg antacids, Renal failure, Mg medications
 S/SX: depressed tendon reflexes, oliguria, ↓RR

IMBALANCE: EXCESS
5. HYPERCHLOREMIA
 Serum chloride more than 108 mEq/L
 Etiology: sodium chloride excess

IMBALANCE: EXCESS
 HYPERPHOSPHATEMIA
 Serum PO4 more than 4.5 mg/dL
 Etiology: Tissue trauma, chemotherapy. PO4 containing
medications, osteoporosis

IMBALANCE : DEFICIENCY
1. HYPONATREMIA
 Na level is less than 135 mEq/L
 Water is drawn into the cell cell swelling
 Etiology: prolonged diuretic therapy, excessive burns,
excessive sweating, SIADH, plain water consumption
 S/SX: nausea, vomiting, seizures

1. Hyponatremia –one of the most common electrolyte
imbalance
Hypovolemic: Na loss > H2O loss
Euvolemic: TBW is mod. increased & total body Na is
normal
Hypervolemic: Greater increased in TBW than in total Na
Redistributive: no change in TBW or total body Na.
RF:
 Excessive perspiration
 Altered thirst mech.
 w/o access to fluids
 rapid rehydration after excessive fluid loss
 altered percentage of total body water
 decreased intake of sodium: fruits, vegetables, oatmeal, rice,
wheat, fresh meat, chicken, fish (1 oz)
 excessive administration of diuretic and laxatives
 NGT irrigation with plain water
 Vomiting, drh
Clinical Manifestations: 125 mEq/L
 neurological manifestations
 Cardiovascular manifestations
◦ Tachycardia-
◦ Sympathetic responses – stimulation of
chemoreceptors in the aortic and carotid bodies
 Respiratory Manifestations
◦ Crackles in the lungs
◦ Tachypnea, dypnea, orthopnea, SOB
 GI Manifestations
◦ n/v, drh, abdominal cramping, hyperactive bowel
sounds
 Others:
◦ Dry skin, tongue & mucus membrane

2. Hypernatremia - associated w/ water loss or sodium
gain
Types:
◦ Hypovolemic hypernatremia: TBW is greatly decreased
compared to Na
◦ Euvolemic hypernatremia: TBW is decrease relative to

normal total body Na
◦ Hypervolemic hypernatremia: TBW is increased but Na

gain is > H2O gain

Etiology/RF:
 Inadequate water intake in conjunction w/ decreased thirst
(hypodipsia)
 Lack of access to drinkable water
 Physical or chemical restraint
 Mental confusion
 NPO
 Excessive water loss & insufficient water replacement
 Increased Na+ intake: bread, cereals, chips, convenience food, fast
foods
 IV administration of hypertonic saline or hypertonic tube
feedings
 Retention of Na+ occurs in heart, renal or liver dse.
 Cushing’s Syndrome
 Hyperaldosteronism
 Uncontrolled DM

Clinical Manifestations: 155 mEq/L
 Polyuria
 Anorexia, N/V, weakness, restlessness
 Early neurologic S/Sx
 Hypervolemic state
 Hypovolemic state
 Dysrhythmia
 Crackles, dysnea, pleural effusion
 Fever and increased thirst
 Dry skin and mucous membrane, tongue furrows

Effect of Sodium to cells

B. Potassium Imbalances
 PISO
 Poorly stored in the body, daily K+ intake is necessary
 80 to 90% of K+ is excreted through the kidneys & remainder
is excreted in feces
Functions:
 Regulates ICF osmolality
 Promotes transmission and conduction of nerve impulses
 Muscle contraction
 Enzyme action for cellular metabolism and glycogen storage in
the liver
 acid-base balance

2. HYPOKALEMIA
 K+ level less than 3.5 mEq/L
 Etiology: use of diuretic, vomiting and diarrhea
 ECG: flattened , depressed T waves, presence of “U” waves
S&Sx
 Weakness & fatigue
 Constipation
 (+) “U” wave in ECG tracing

Alkalosis
◦ can cause hypokalemia
Acidosis
◦ can cause hyperkalemia
Substance that can alter K+ levels:
◦ Insulin
◦ Glucagon
◦ Adrenocortical hormones
 cortisol and aldosterone
 Stress
◦ Catecholamines & beta- adrenergic agonists
◦ Alpha-adrenergic agonists
◦ Epinephrine
◦ has alpha & beta – adrenergic properties

1. Hypokalemia
- common, especially in elderly pop’n
Etiology and RF:

A. Inadequate K+ intake body does not conserve K+
◦ Debilitated, confused, restrained, lacking access to K+
sources, malnourished, anorexic, bulimic
◦ Potassium- restricted diets or some wt. reduction diets
( corn, potato, apple, blueberry, cranberry, coffee, cola,
gingerale, soda)
◦ Those receiving K+ free IV sol’ns

B. K+ excretion exceeds K+ intake
◦ Vomiting, drh, suctioning, intestinal fistulae, ileostomy
◦ Osmotic diuresis that occurs with DKA
◦ Surgical clients
◦ Alcoholic clients
◦ Certain drugs (loop, osmotic, thiazide diuretics,
cathartics, steroids)
◦ Clients who are in the healing phase after a severe
tissue injury or burn
◦ Cushing’s syndrome
◦ Diuretic Phase of RF
◦ Hyperaldosteronism

↓ serum K
↓ K gradient
↑ resting membrane potential
↓ neuromuscular irritability
and excitability

 GI Manifestations
◦ Slowed smooth muscle contraction
◦ Anorexia, abdominal distention, constipation
◦ Extreme smooth muscle slowing - vomiting ileus, urinary
retention
 Slowed Skeletal Muscle Contraction- muscle weakness, Leg
cramps, fatigue, paresthesia, hyporeflexia, paralysis
 ECG-most reliable tool for identifying abnormalities in
intracellular K+ level (peaked P wave, ST depressed &
prolonged, Depressed or inverted T wave, prominent U
wave).
 ↓ ed myocardial contractility
 Pulmonary manifestations
 Progressive neurologic consequences of altered conduction –
dysphasia, confusion, depression, convulsions, areflexia, coma
 Polyuria, nocturia

 Administer K supplements – ex Kalium Durule, K chloride
 Potassium Rich food:
 ABC’s of K
 Vegetables Fruits
 A - asparagus A – apple
 B – broccoli (highest) B – banana – green
 C – carrots C – cantalope/ melon
 O – orange (highest) –
for digitalis toxicity also.
 Vit A – squash, carrots yellow vegetables & fruits, spinach,
chesa
 Iron – raisins,
 Food appropriate for toddler – spaghetti! Not milk – increase
bronchial secretions
 Don’t give grapes – may choke
Nursing Mgt:
2. Hyperkalemia
Etiology and RF:

 Retention of K+ by the body because of ↓ ed or inadequate
urine output
 Release of K+ from the cells during the 1st 24 to 72 hours
after traumatic injury on burns, or from cell lysis or acidosis
 Excessive infusion of IV solution that has K+ or excessive oral
intake of K+, especially in a person who has renal dse
 Therapy w/ K+ sparing diuretics, use of K+ supplements,
ACE inhibitors
 Adrenal insufficiency or addison’s disease

↑ serum K
Altered resting membrane potential
Cell membrane becomes easily excitable
Increased depolarization or action potential
Repeated irritation of cell membrane
↑ Excitation threshold of membrane
Cells become less excitable
Weak, flaccid paralysis of muscles

 N/V
 Diarrhea
 Impaired nerve & muscle function
 Severe neuromuscular weakness
 respiratory muscle paralysis
 ECG changes: (wide flat P wave, Depressed ST segment,
Narrow, peaked T wave)
 Impaired cardiac conduction (tachycardia, hypotension,
cardiac arrest, ventricular contractions)

Effect of Potassium on ECG

C. Calcium Imbalances:
FUNCTIONS:
catalyst (nerve impulses)

stimulates muscle contraction
normal cellular permeability
blood coagulation
absorption of Vitamin B12
Bones and teeth
99% of the body’s Ca# is in the bones & teeth
1 % is in the tses. And IV space

3 types:
1. free/ ionized
2. Ca# bound to CHON
3. Complex
Vit. D - is needed to absorb Ca# from GIT
PTH
◦ regulates plasma levels of Ca# and PO4 by ↑ ing resorption from bone
and reabsorption from renal tubule or the GIT
Calcitonin
◦ thyroid gland
◦ opposes action of PTH
◦ inhibits bone resorption

3. HYPOCALCEMIA
 Calcium level of less than 8.5 mg/dL
 Etiology: removal of parathyroid gland during thyroid surgery,
vit. D deficiency, Furosemide, infusion of citrated blood
 s/sx: Tetany, (+) Chovstek’s (+) Trousseaus’s
 ECG: prolonged QT interval
 Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml)
or Tetany:

Hypocalcemia
Etiology and RF:
 common in adult because of inadequate intake of Ca# and Vit. D (GI dses –
anorexia, liver dse., lactose intolerance, alcoholism): oatmeal, hamburger,
apples, bananas, chicken
 decreased intake for several days (NPO), high CHON diet
 hypoparathyroidism
 people who don’t have exposure to the sun
 pancreatitis
 Open wounds
 Excess Na

 Overcorrection of Acidosis
 Multiple BT
 Certain drugs
◦ MgSO4, Colchicine, and neomycin
◦ Aspirin, anticonvulsants, and estrogen
◦ PO4prep’n
◦ Steroids
◦ Loop diuretic
◦ Antacids and laxatives

↓ Calcium
Partial depolarization of nerves and muscles

because of ↓ threshold potential
Smaller stimuli initiates the action potential

 paresthesia
 ↓ ed CO
 ↑ ed peristalsis and drh
 Prolonged bleeding times and hemorrhage
 Bones become brittle and results in pathologic fractures
 Facial Twitching (Chvostek’s sign)
 Carpopedal spasm (Trousseau’s sign)
 ECG changes: prolonged QT interval
 Severe: seizure, tetany, hemorrhage, cardiac collapse
 True level of free Ca: ionized Ca level

Trousseau’s Sign
 S&Sx
 weakness
 Paresthesia
 (+) Trousseau sign – pathognomonic – or carpopedal
spasm. Put bp cuff on arm=hand spasm.
 (+) Chevostek’s sign
 Arrhythmia
 Laryngospasm
 Administer – Ca gluconate – IV slowly
Ca gluconate toxicity: Sx – seizure – administer Mg SO4

 Mg SO4 toxcicity– administer Ca gluconate
B – BP decrease
U – urine output decrease
R – RR decrease
P – patellar reflexes absent
2. Hypercalcemia
Etiology and RF: Major Causes

 Metastatic malignancy (Tumor Lysis Syndrome)
 Hyperparathyroidism
 Thiazide diuretic therapy
 Other Causes:
 Excessive intake of Ca supplements w/ vit. D, Ca containing antacids
 Prolonged immobilization
 Metabolic acidosis
 Hypophosphatemia
↑ Calcium
↑ cell membrane potential threshold
cell membrane becomes refractory to depolarization
cell membrane becomes less excitable and requires

greater stimulus to produce response

 GI- anorexia, N/V, abdominal distention & constipation
 Neurologic Depression – weakness, fatigue, depression, difficulty
concentrating
 Osmotic diuresis
 ureteral or kidney stones
 ECG Changes: short QT interval, widened T wave
(cardiac depression  dysrhythmias & arrest)

D. Phosphate Imbalances
 Phosphate promotes strong and
durables bones
 Phosphate is an integral part of ATP,
ADP
 Phosphate plasma level is regulated by
PTH
 Facilitates release of Hgb and
maintenance of acid-base balance,
nervous system, and intermediary
metabolism of CHO, CHON, and fats.
Foods high in Phosphorus
Food Portion Amount (mg)
Almonds 2/3 cup 475
Beef liver 31/2 oz 476
Broccoli (cooked) 2/3 cup 62
Carbonated 12 oz Ut to 500
beverage
Milk (whole) 8 0z 93
Turkey (roasted) 31/2 oz 251
1. Hypophosphatemia
Etiology and RF:
 Major loss/ long term lack of intake
 Other RF: periods of ↑ ed growth or tse. Repair
and recovery from malnourished states
 Prolonged/ excessive intake of antacids
 Administration of high levels of glucose via tube
feeding/ IV line
(glucose cause the P to enter the cell for
glucose phosphorylation)
 ↑ ed Na+, ↑ ed Ca, ↓ ed PaCO2 in resp. alkalosis
 Lead poisoning
 Burns
 ↓ ed cardiac and respiratory fxn
 Muscle weakness
 Fatigue
 Brittle bones
 Confusion and Seizures
2. Hyperphosphatemia
Etiology and RF:
 Excessive intake of high- PO4 foods
 Excess vit. D
 Impaired colonic motility from ↑ ed absorption
 Hypoparathyroidism and Addison’s dse.
 Renal failure
 TLS
 Post menopausal state

 ↑ ed PR
 Palpitations
 Restlessness
 Anorexia, N/V, tetany, hyperreflexia, dydrhymias
Food rich in PO4:

 Milk, ice cream, cheese, large amounts of meat and fish,
carbonated beverages.

 Actions similar to K+
 Signs of imbalance similar to K+
 2nd most abundant intracellular cation
 Fxns: transmission & conduction of nerve impulses
◦ Contraction of Muscle
◦ Responsible for the transportation of Na+ & K+ across
cell membrane
◦ Responsible for the synthesis & release of PTH
 increased Ca and Phosphorus= can ↓ Mg absorption from
intestines
 ↓ ed Mg can lead to hypokalemia and hypocalcemia
E. Magnesium Imbalances

 Acts as an activator for many intracellular enzyme
system and plays a role in both carbohydrate and
CHON metabolism
 1/3 CHON bound
 2/3 free Mg
 Predominantly found in bones and soft tissues and
eliminated by the kidney.

Hypomagnesemia
 Common cause of refractory hypokalemia and hypocalcemia
 ETIOLOGY AND RF:
◦ Critically ill
◦ Alcoholics
◦ Malabsorption syndromes
◦ GI losses
◦ Diuretic phase of renal failure
◦ Excess Ca and excess Na inhibits Mg
◦ Prolonged IV or TPN therapy w/ Mg replacement
◦ Hyperglycemia, osmotic diuresis
◦ Many medications
◦ Diuretics and antibiotics (aminoglycosides)
◦ Corticosteroids and digitalis – promotes uptake of Mg
◦ Estrogen

 Myocardial irritability
 Anorexia, nausea, abdominal distention
 Psychological disorders
 Neuromuscular Manifestations- Chvostek’s sign,
Trousseau’s sign, tetany, convulsions, vasospasm
leading to stroke
 ECG changes – prolonged QT, widened QRS,
broadened T-waves
Tx:
1. Daily magnesium supplement
2. Prepare calcium gluconate

2. Hypermagnesemia
Etiology and RF:

 Renal insufficiency
 Excessive use of Mg- containing antacids
 Excessive use of Mg- containing laxatives
 Administration of K+ sparing diuretics
 Severe dhn from DKA
 ↓ ed synthesis of aldosterone
 Overuse of IV MgSO4
 Decreased muscle activity
 Hypotension
 Severe muscle weakness, lethargy, drowsiness, loss of deep tendon reflex,
respiratory paralysis and loss of consciousness
 ECG – prolonged PR interval, widened QRS

Management:
1. Increase fluid intake
2. Loop diuretics
3. Hemodialysis /Peritoneal dialysis
ACID-BASE CONCEPTS
 Acid- substance that can donate or release

hydrogen ions
◦ Carbonic acid, Hydrochloric acid

ACID-BASE CONCEPTS
 Base- substance that can accept hydrogen ions

◦ Bicarbonate

ACID-BASE CONCEPTS
 Buffer- substance that can accept or donate hydrogen

◦ Hemoglobin buffer
◦ Bicarbonate : carbonic acid buffer
◦ Phosphate buffer

ACID-BASE CONCEPTS
 Acid- substance that can donate or release hydrogen ions

◦ Carbonic acid, Hydrochloric acid
 Base- substance that can accept hydrogen ions
◦ Bicarbonate
 Buffer- substance that can accept or donate hydrogen
◦ Hemoglobin buffer
◦ Bicarbonate : carbonic acid buffer
◦ Phosphate buffer

pH – used to express the degree of acidity or alkalinity of a
solution; normal serum pHs 7.35 -7.45
Normal concentrations of H+ in the body fluids: 0.00004

mEq/L
Functions of H+
 Necessary for proper cellular function
 Efficient functioning of every system
 Binding of O2 with hemoglobin
 Acts as powerful chemical adjutator with body fluids
 Determines the alkalinity and acidity of solution
Production of Acid
Regulation of Acid-Base Balance
1. Modulation of serum pH blood buffer system
Buffer System – consist of weak acid and salt of base

which act together to neutralize either acid or bases;
body line of defense against acid-base imbalance.
Bicarbonate Buffer System:

-Most important buffer system in the body (ECF)
-Comprises 1/12 of the buffer system
Helpful Hints
 Carbon dioxide is considered to be ACID because of its

relationship with carbonic acid
 pH measures the degree of acidity and alkalinity. It is
inversely related to Hydrogen. Normal ph 7.35-7.45
 Decreased pH- ACIDIC-increased Hydrogen—pH below
7.35
 Increased pH- ALKALOSIS-decreased hydrogen—pH above
7.45

Remember
 a high hydrogen acidic pH is low

 a low hydrogen alkalosis pH is high
 a high CO2may mean acidic

 a low CO2 may mean alkalosis

Dynamics of Acid and bases
 Acids and bases are constantly produced in the body.

 They must be constantly regulated.
 CO2 and HCO3 are crucial in the balance.
 A ratio of 20:1 is maintained (HCO3:H2CO3)
 Respiratory and renal system are active in regulation.

Ways to balance the acids and bases
Excretion
 Acid can be excreted, and Hydrogen can be excreted in
ACIDOTIC condition.
 Bicarbonate can be excreted in ALKALOTIC condition.

Production
 Bicarbonate can be produced in ACIDOTIC condition.
 Hydrogen can be produced in ALKALOTIC condition.

The respiratory system compensates for metabolic problems

 CO2 (acid) can be exhaled from the body
to normalize the pH in ACIDOSIS.
 CO2 (acid) can be retained in the body to
normalize the pH in ALKALOSIS.

The kidney can compensate for problems in the

respiratory system
 The Kidney reabsorbs and generates Bicarbonate
(alkaline) in ACIDOSIS.
 The Kidney can excrete H+ excess (Acidosis) to
normalize the pH in ACIDOSIS.

 The kidney can excrete bicarbonate (alkali) in

conditions of ALKALOSIS.
 The kidney can retain H+ (acid) in conditions
of ALKALOSIS.

Chemical buffers can also participate in the

balance of acid-base
 1. Carbonic acid- bicarbonate buffer
 2. Phosphate buffer
 3. protein buffer- ICF and hemoglobin
The action is immediate but very limited

 Rapid Respiratory Compensation. The power of the lungs to excrete
large quantities of carbon dioxide enables them to compensate
rapidly. Unless the respiratory system is diseased or depressed,
metabolic disturbances stimulate a prompt response, i.e., metabolic
acidosis and metabolic alkalosis normally elicit characteristic partial
respiratory compensation almost immediately.
 Slow Metabolic Compensation. The smaller capacity of the kidneys
corresponds to a relatively slower rate of compensation; a patient
can be ventilated at an abnormal PCO2 for a day or two before the
characteristic, partial compensation is achieved. In the operating
room and in the emergency room, therefore, an abnormal PCO2 is
not usually associated with a metabolic "compensation". It follows
that when a metabolic acidosis or alkalosis is detected, it usually
reflects either a separate metabolic disturbance or compensation for
a chronic respiratory problem.
The Difference in Compensation.

Normal Values of ABG ( arterial blood Gas) Analysis
pH = 7.35 to 7.45 mmHg
pCO2 = 34-45 mmHg
HCO3 = 24-26 mEq/L
pO2 = 90 -110 mmHg
In order to interpret ABG result, remember the following

 pCO2 = respiratory parameter
where: = acidosis
=alkalosis
 HCO3 = metabolic parameter
where: = acidosis
= alkalosis

Components of the Arterial Blood Gas
pH: Measurement of acidity or alkalinity, based on the hydrogen

(H+) ions present.
The normal range is 7.35 to 7.45
PaO2: The partial pressure of oxygen that is dissolved in arterial

blood.
The normal range is 80 to 100 mm Hg.
SaO2: The arterial oxygen saturation.

The normal range is 95% to 100%.
PaCO2: The amount of carbon dioxide dissolved in arterial blood.

The normal range is 35 to 45 mm Hg.
HCO3: The calculated value of the amount of bicarbonate in the

bloodstream.
The normal range is 22 to 26 mEq/liter
Step One
Assess the pH to determine if the blood is
within normal range, alkalotic or acidotic. If it
is above 7.45, the blood is alkalotic. If it is
below 7.35, the blood is acidotic.

 Step Two
If the blood is alkalotic or acidotic, we now need to
determine if it is caused primarily by a respiratory or
metabolic problem. To do this, assess the PaCO2 level.
Remember that with a respiratory problem, as the pH
decreases below 7.35, the PaCO2 should rise. If the pH
rises above 7.45, the PaCO2 should fall. Compare the pH
and the PaCO2 values. If pH and PaCO2 are indeed moving
in opposite directions, then the problem is primarily
respiratory in nature.

 Step Three
Finally, assess the HCO3 value. Recall that with a metabolic
problem, normally as the pH increases, the HCO3 should
also increase. Likewise, as the pH decreases, so should the
HCO3. Compare the two values. If they are moving in the
same direction, then the problem is primarily metabolic in
nature. The following chart summarizes the relationships
between pH, PaCO2 and HCO3.

pH PaCO2 HCO3
 Respiratory Acidosis ↓ ↑ normal
 Respiratory Alkalosis ↑ ↓ normal
 Metabolic Acidosis ↓ normal ↓
 Metabolic Alkalosis ↑ normal ↑

Following a motor vehicle accident and successful full
resuscitation, arterial blood gases are drawn from
a 13-year-old patient. The nurse utilizes the
results of the test to identify the patient's:
a. Prognosis.
b. Capillary metabolic exchange.
c. Carbonic acid level.
d. Acid-base balance.
Question: F&E
Arterial blood gases results indicate pH 7.33 and PCO2 of 38
mmHg following arrest and subsequent resuscitation of a
3-year-old child. Which nursing intervention should be
utilized to attempt to correct this metabolic disorder?
a. Treat the cause of the acidosis.
b. Assess the effectiveness of the respiratory pattern.
c. Determine if the endotracheal tube is positioned correctly.
d. Administer sodium bicarbonate 1 mEq/kg IV.
Question: F&E
 A child is 24 hours postoperative following major trauma,
and has received a total of eight units of packed red blood
cells during the perioperative period. The child now is
flaccid, and has diarrhea and peaked T-waves on the
electrocardiogram. The nurse calls the physician to obtain
an electrolyte panel, suspecting which of the following
electrolyte abnormalities?
a.Hypermagnesemia
b.Hypercalcemia
c.Hypernatremia
d.Hyperkalemia
Question: F&E
John Doe is admitted to the hospital. He is a kidney
dialysis patient who has missed his last two
appointments at the dialysis center. His arterial
blood gas values are reported as follows:
1. pH 7.32
2. PaCO2 32
3. HCO3 - 18
Acid base balance: ABG #1

pH PaCO2 HCO3
Metabolic Acidosis ↓ ↓ ↓
1. Assess the pH. It is low (normal 7.35-7.45); therefore we have
acidosis.
2. Assess the PaCO2. It is low. Normally we would expect the pH and
PaCO2 to move in opposite directions, but this is not the case. Because
the pH and PaCO2 are moving in the same direction, it indicates that
the acid-base disorder is primarily metabolic. In this case, the lungs,
acting as the primary acid-base buffer, are now attempting to
compensate by “blowing off excessive C02”, and therefore increasing
the pH.
3. Assess the HCO3. It is low (normal 22-26). We would expect the pH
and the HCO3 to move in the same direction, confirming that the
primary problem is metabolic.
Because there is evidence of compensation (pH and PaCO2 moving in the

same direction) and because the pH remains below the normal range, we
would interpret this ABG result as a partially compensated metabolic acidosis.
 Jane Doe is a patient with chronic COPD being
admitted for surgery. Her admission lab work reveals
an arterial blood gas with the following values:
 pH = 7.35
 PaCO2 = 48
 HCO3 = 28
Acidbase: #2
1. Assess the pH. It is within the normal range, but on the low side of neutral
(<7.40).
2. Assess the PaCO2. It is high (normal 35-45). We would expect the pH and PaCO2
to move in opposite directions if the primary problem is respiratory.
3. Assess the HCO3. It is also high (22-26). Normally, the pH and HCO3 should
move in the same direction. Because they are moving in opposite directions,
it confirms that the primary acid-base disorder is respiratory and that the
kidneys are attempting to compensate by retaining HCO3. Because the pH has
returned into the low normal range, we would interpret this ABG as a fully
compensated respiratory acidosis.
pH PaCO2 HCO3
Respiratory Acidosis normal ↑ ↑
but <7.40


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Fluids and Electrolytes

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

 Remember the ABC

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

 The nurse is caring for a client with Congestive Heart Failure.

A. Flat neck and hand veins

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

Body Fluids Function

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

 Found inside the cell surrounded by a membrane.

 This is compartment with the highest percentage

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

 Fluid found outside the cells

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

TOTAL 2,100 – 2,900 TOTAL 2,100 – 2,900

NORMAL WATER BALANCE

Mr. Nestlee Sio Cabaccan RN,MSN

1. A client with CHF is assessed by the nurse. Upon reviewing

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

2. A nurse reads a doctor’s progress notes in the client’s chart

A. The Gastrointestinal tract

Mr. Nestlee Sio Cabaccan RN,MSN

A nurse is administering IVF as ordered to a patient who

Mr. Nestlee Sio Cabaccan RN,MSN

The nurse receives the following endorsements. She is

A. The client who came from the OR after a

Mr. Nestlee Sio Cabaccan RN,MSN

The movement of fluids (solutes and solvents) in

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

 This is the concentration of solutes in a solution.

Mr. Nestlee Sio Cabaccan RN,MSN

 In a HYPERTONIC solution, fluid will go out from the cell, the

Mr. Nestlee Sio Cabaccan RN,MSN

 The movement of SOLUTES or particles in a solution from a

Mr. Nestlee Sio Cabaccan RN,MSN

 The force that draws water or solvent from a less

Mr. Nestlee Sio Cabaccan RN,MSN

 Diffusion- means by which substances such as nutrients and

Mr. Nestlee Sio Cabaccan RN,MSN

Mr. Nestlee Sio Cabaccan RN,MSN

 The nurse is caring for a psychiatric patient who ingested

A. Hyperactive deep tendon reflex

Mr. Nestlee Sio Cabaccan RN,MSN

 The movement of both solute and solvent by hydrostatic

Mr. Nestlee Sio Cabaccan RN,MSN

 This is the movement of solutes across a membrane from a

Mr. Nestlee Sio Cabaccan RN,MSN

A. WBC count of 9,000