Kozier & Erb's

Fundamentals of Nursing
Concepts, Process, and Practice

CHAPTER Fluid and

Electrolyte
Basics

Copyright © 2021, 2016, 2012, 2008

Kozier & Erb's Fundamentals of Nursing, Audrey Berman |
Pearson Education, Inc.
Shirlee Snyder | Geralyn Frandsen
All Rights Reserved
 Characteristics of Body Fluids
Fluid = Water that contains dissolved or suspended
substances such as glucose, mineral salts, and
proteins.
Fluid amount = Volume.

Fluid concentration = Osmolality.

Fluid composition (electrolyte concentration)

Degree of acidity = pH

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Location and Movement of Water and
Electrolytes

Intracellular Fluid Extracellular Fluid (ECF)

(ICF) = Fluid outside of cells
= Fluids within cells  ~1/3 of total body water
 ~2/3 of total body  Three divisions:

water – Interstitial
– Intravascular
– Transcellular

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Body Fluid Compartments

Interstitial
Fluid 12
Liters

Intracellular
Fluid
25 Liters

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 Case Study
 Susan Reynolds, a 42-year-old married
accountant, has just been admitted to the
acute care unit with a history of nausea, loss
of appetite, and vomiting and diarrhea for 7
days. She feels her symptoms are related to
“bad food” she had on her recent business
trip. Past medical history includes
hypertension controlled by furosemide (Lasix)
40 mg by mouth once a day and a no-salt-
added diet.

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 Electrolytes and Ions
 Electrolytes (mineral salts)
 Compounds that separate into ions (charged
particles) when they dissolve in water
 Ions (charged particles)
 Cations: positively charged
 Anions: negatively charged

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 Terms
 Solutes
 Crystalloids & Colloids
 Solvent
 Osmolality
 Colloid Osmotic Pressure

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Isotonic, Hypotonic, and Hypertonic
Solutions

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Movement of Water and Electrolytes

Active transport Diffusion

Movement of ions against Passive movement of
osmotic pressure to an area electrolytes or other particles
of higher pressure; requires down the concentration
energy gradient (from higher to
lower concentration)
Osmosis Filtration
Movement of water (or other Movement across a
solute) from an area of membrane, under pressure,
lesser to one of greater from higher to lower
concentration pressure

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 Osmosis

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 IV Fluids

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 Filtration

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 Fluid Balance
 Fluid balance consists of
 Fluid intake and absorption
 Fluid distribution
 Fluid output
 Fluid intake
 Drinking and foods
 Thirst and habit
 Fluid distribution = Movement of fluid among
its various compartments.

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 Case Study (cont’d)
 Robert is a junior nursing student assigned to
Mrs. Reynolds. He has cared for other
patients with gastrointestinal problems but
never one with fluid and electrolyte problems.
Robert plans his care by reviewing Mrs.
Reynolds’ chart and her health care
provider’s orders.

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Thirst Mechanism

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 Fluid Balance
 Fluid output
 Normally via skin, lungs, GI tract, kidneys
 Abnormally via vomiting, wound drainage,
hemorrhage
 Influenced by
• Antidiuretic hormone (ADH)
• Renin-angiotensin-aldosterone system (RAAS)
• Atrial natriuretic peptides (ANPs)

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Hormones Influencing Fluid Output

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 Fluid Balance (cont’d)
Fluid intake Fluid distribution
 Thirst regulates fluid intake  Extracellular and

 ~2300 mL/day intracellular

 Vascular and

interstitial
Hormonal Influences
 Antidiuretic hormone

 Renin-angiotensin-aldosterone mechanism

 Atrial natriuretic peptides

Fluid output
 Through kidneys, skin, lungs, and GI tract

 Insensible loss

 Sensible loss

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 Quick Quiz!
1. A patient is diaphoretic and has an oral
temperature of 104° F. These are classic
signs of
A. ADH deficit.
B. Extracellular fluid loss.
C. Insensible water loss.
D. Sensible water loss.

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 Fluid Imbalances
 Two basic types
 Isotonic
• Fluid Volume Deficit
• Fluid Volume Excess
 Osmolar
• Dehydration
• Overhydration

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Fluid Volume and Osmolality
Imbalances

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 Regulating Electrolytes
 Electrolytes: Present in all body fluids and
compartments. Maintaining balance is vital to
normal body functioning. Important for:
 Maintaining fluid balance
 Contributing to acid-base regulation
 Facilitating Enzyme reactions
 Transmitting neuromuscular reactions

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 Electrolyte Imbalances
 Potassium (K+)
 Hypokalemia
 Hyperkalemia
 Calcium (Ca2+)
 Hypocalcemia
 Hypercalcemia
 Magnesium (Mg2+)
 Hypomagnesemia
 Hypermagnesemia

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 Deficits Excesses
Hypokalemia Potassium (K+) (3.5 – 5.0 mmol/L) Hyperkalemia
Irritability, fatigue, Irritability, fatigue, leg cramps,
muscle weakness or weakness, paralysis, abdominal
cramping, nausea, cramping, cardiac arrest or
vomiting, cardiac rhythm abnormalities, death
conduction abnormality

Hypomagnesemia Magnesium (Mg2+) (1.5 – 2.5 mEq/L) Hypermagnesemia

Confusion, tremors, Diminished DTRs, Shallow resps,
seizures, Hyperactive somnolence, Lethargy,
DTRs, increased pulse drowsiness, N/V, Lethargy,
and BP, muscle cramps, drowsiness, flushed, warm skin,
cardiac dysrhythmias decreased pulse and BP, Muscle
weakness, Cardiac Arrest!

Hyponatremia Sodium (Na+) (135 – 145 mEq/L) Hypernatremia

Irritability, Apprehension, Restlessness, agitation,
Confusion, Seizures, twitching, seizures, Coma,
Coma, Changes in VS, intense thirst, dry, swollen
tongue, weakness, lethargy

Hypocalcemia Calcium (Ca2+) (total) (8.5 – 10.5 mg/dL) Hypercalcemia

Fatigue, numbness, Calcium (ionized) (4.6 – 5.3 mg/dL) Lethargy, weakness, decreased
tingling, hyperreflexia, DTR’s, decreased memory,
Chvostek’s, Trousseau’s, confusion, nephrolithiasis, EKG
Laryngeal Spasms, changes
Hyperactive DTR’s, EKG
changes

Hypophasphatemia Phosphate (PO4) (2.4 – 4.4 mg/dL) Hyperphosphatemia

Often goes unnoticed, if Often Associated with
severe it causes CNS hypocalcemia and is caused by
depression, confusion, acute kidney disease.
muscle weakness Asymptomatic

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mmol/L) 26
 Quick Quiz!
2. The body’s fluid and electrolyte balance is
maintained partially by hormonal regulation.
You will express an understanding of this
mechanism in which of the following
statements?
A. “The pituitary secretes aldosterone.”
B. “The kidneys secrete antidiuretic hormone.”
C. “The adrenal cortex secretes antidiuretic
hormone.”
D. “The pituitary gland secretes antidiuretic
hormone.”
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 Case Study (cont’d)
 Mrs. Reynolds’ physician has admitted her for
observation and has obtained a blood sample
for electrolyte levels, CBC, and an ECG.
Orders include nothing by mouth, an IV
infusion of 0.9% saline at 125 mL/hr, intake
and output (I&O) recordings, and vital signs
every 4 hours, in addition to daily weights.
 What assessment activities do you anticipate
Robert will perform?

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 Acid-Base Balance
 Acid production, buffering, and excretion
interplay to create balance.
 Acids release hydrogen (H+) ions; bases
(alkaline substances) take up H+ ions.
 pH scale: 1.0 (very acid) to 14.0 (very base)
 pH of 7.0 is neutral; normal arterial blood is
7.35 to 7.45.

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 pH

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 Acid-Base Balance (cont’d)
 Acid excretion systems: lungs and kidneys
 Lungs excrete carbonic acid.
 Kidneys excrete metabolic acids.
 Excretion of carbonic acid
 When you exhale, you excrete carbonic acid in the
form of CO2 and water.
 Excretion of metabolic acids
 The kidneys excrete all acids except carbonic
acid.

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Acid Production and Excretion

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 Acid-Base Imbalances
 Acidosis
 Respiratory
 Metabolic
 Alkalosis:
 Respiratory
 Metabolic

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 Nursing Knowledge Base
 Use the scientific knowledge base in clinical decision
making to provide safe, optimal fluid therapy.
 Apply knowledge of risk factors for fluid imbalances
and physiology of normal aging when assessing older
adults, knowing that this age group is at high risk for
fluid imbalances.
 Ask questions to elicit risk factors for fluid, electrolyte,
and acid-base imbalances.
 Perform clinical assessments for signs and
symptoms of these imbalances.

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 Nursing Process: Assessment
 Nursing history
 Age: very young and old at risk
 Environment: excessively hot?
 Dietary intake: fluids, salt, foods rich in potassium,
calcium, and magnesium
 Lifestyle: alcohol intake history
 Medications: include over-the-counter (OTC) and
herbal, in addition to prescription medications

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 Nursing Process: Assessment
(cont’d)
 Medical history
 Recent surgery (physiological stress)
 Gastrointestinal output
 Acute illness or trauma
• Respiratory disorders
• Burns
• Trauma
 Chronic illness
• Cancer
• Heart failure
• Oliguric renal disease

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 Physical Assessment
 Daily weights
 Indicator of fluid status
 Use same conditions.
 Fluid intake and output (I&O)
 24-hour I&O: compare intake versus output
 Intake includes all liquids eaten, drunk, or received
through IV.
 Output = Urine, diarrhea, vomitus, gastric suction,
wound drainage
 Laboratory studies

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 Diagnosing
 Deficient Fluid Volume
 Excess Fluid Volume
 Risk for Imbalanced Fluid Volume
 Risk for Deficient Fluid volume
 Impaired Gas Exchange

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 Diagnosing
 Etiology of other diagnoses
 Impaired Oral Mucous Membrane
 Impaired Skin Integrity
 Decreased Cardiac Output
 Ineffective Tissue Perfusion
 Activity Intolerance
 Risk for Injury
 Acute Confusion

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 Case Study (cont’d)
 Mrs. Reynolds states that she has no appetite, is
nauseous, and has been vomiting and has had
diarrhea for 7 days.
 Bowel sounds are hyperactive in all four quadrants.
The patient has had only two loose stools since
midnight. She voids with difficulty, with dark yellow
urine. Her 24-hour intake was 1850 mL; her output
was 2200 mL (of which urine was only 1000 mL).
 Temperature 99.6° F; pulse 100 bpm; BP 110/60 mm
Hg with no changes when standing
 What are some possible Nursing Diagnoses for Ms
Reynolds
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 Case Study (cont’d)
 Mrs. Reynolds’ laboratory results:
 Hematocrit 44% (suggesting hypovolemia)
 Potassium 3.6 mEq/L and sodium 138 mEq/L
(both low normal because of prolonged vomiting
and diarrhea)
 Electrocardiogram (ECG) showed normal sinus
rhythm.

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 Case Study (cont’d)
 Nursing diagnosis: Deficient fluid volume
related to excessive diarrhea, vomiting, and
use of potassium-wasting diuretic
 Goals:
 Mrs. Reynolds’ will have UOP of at least 30mL/hr
by the end of the shift.
 Mrs. Reynolds will have electrolyte values WNL by
discharge.

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 Case Study (cont’d)
 Fluid balance
 Urine output will equal intake of ~1500 mL in 2 days.
 Mucous membranes will be moist in 24 hours.
 Skin turgor will return to normal within 24 hours.
 Daily weights will not vary by more than 2 lbs over the next 2
days.
 Electrolyte and acid-base balance
 Serum electrolyte and blood counts will be within normal
limits within 48 hours.
 Mrs. Reynolds will not have any nausea or vomiting in 24
hours.

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 Case Study (cont’d)
Interventions:
 Administer IV fluids (0.9% normal saline) at 125
mL/hr.
 Provide patient with an additional 480 mL of
noncaffeinated oral fluids every 8 hours.
 Administer as ordered bismuth subsalicylate (Pepto
Bismol) for diarrhea.
 Maintain accurate I&O measurements.
 Weigh Mrs. Reynolds daily; monitor trends.
 Teach Mrs. Reynolds and family about specific
dietary modification (potassium-rich foods).

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 Case Study (cont’d)
 Findings
 Serum electrolyte levels: potassium 4.0 mEq/L and sodium
140 mEq/L
 Mucous membranes remain dry; skin turgor normal
 Mrs. Reynolds’ 24-hour intake is 2800 mL, and output is
2200 mL with 1800 mL urine. Urine specific gravity is 1.025,
and weight has returned to 143 lb.

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 Evaluation
 “What difficulties are you having with
measuring your I&O daily and keeping a
record?”
 “What barriers are you experiencing to
obtaining the potassium-rich foods you
need?”
 “Are you continuing to have frequent loose
stools or diarrhea?”
 “Have you purchased an antacid, or are you
still using baking soda as an antacid?”

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 Figure 52–14 A, Format for a diagram of
serum electrolytes results; B, example that may
be seen in a primary care provider's
documentation notes.

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 Quick Quiz!
A senior student nurse delegates the task
of intake and output to a new nursing
assistant. The student will verify that the
nursing assistant understands the task of
I&O when the nursing assistant states,
 A. “I will record the amount of all voided urine.”
 B. “I will not count liquid stools as output.”
 C. “I will not record a café mocha as intake.”
 D. “I will notate perspiration and record it as a
small or large amount.”
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Which manifestations should the nurse
associate with the development
of hypocalcemia in the newly admitted
patient? Select all that apply:
 A. Diarrhea
 B. Excessive Drowsiness
 C. Positive Trousseau’s Sign
 D. Positive Chvostek’s sign
 E. Hyperactive DTR’s
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A patient is admitted to the hospital for
hypocalcemia. Nursing interventions
related to which system would have
highest priority?
 A. Cardiac
 B. Renal
 C. Gastrointestinal
 D. Neuromuscular
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 What change in assessment
findings should prompt the nurse to
request an order for serum sodium
concentration?
 A. Postural Hypotension and Tachycardia
 B. Development of Ankle or Sacral Edema
 C. Increased Skin Tenting and dry mouth
 D. A change in level of consciousness

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