FLUID AND ELECTROLYTE

BALANCES

WHY IS IT IMPORTANT WHY IS IT IMPORTANT FOR NURSES TO FOR NURSES TO

KNOW ABOUT FLUID KNOW ABOUT FLUID & ELECTROLYTE & ELECTROLYTE

BALANCEBALANCE

INTRODUCTIONINTRODUCTION

Water is found everywhere on earth including Water is found everywhere on earth including human bodyhuman body

In an adult 60% of the weight is waterIn an adult 60% of the weight is water Two third of the body’s water is found in the Two third of the body’s water is found in the

cellcell

DISTRIBUTION OF BODY DISTRIBUTION OF BODY FLUIDSFLUIDS

Body fluids are distributed in two distinct Body fluids are distributed in two distinct compartments:compartments:

1.Extracellular fluids[ECF] Which includes 1.Extracellular fluids[ECF] Which includes interstitial fliud & intravascular fluidinterstitial fliud & intravascular fluid

2.Intracellular fluids[ICF]2.Intracellular fluids[ICF]

COMPOSITION OF BODY COMPOSITION OF BODY FLUIDSFLUIDS

The fluids circulating throughout the body in The fluids circulating throughout the body in extracellular and intracellular fluid spaces extracellular and intracellular fluid spaces contain contain

1.Electrolytes1.Electrolytes

2.Minerals2.Minerals

3.Cells3.Cells

MOVEMENT OF BODY MOVEMENT OF BODY FLUIDSFLUIDS

DiffusionDiffusion OsmosisOsmosis FiltrationFiltration Active transportActive transport

REGULATION OF BODY REGULATION OF BODY FLUIDSFLUIDS

Fluid intakeFluid intake Fluid outputFluid output Hormonal influenceHormonal influence Lymphatic influencesLymphatic influences Neurologic influencesNeurologic influences Renal influencesRenal influences

ACID-BASE BALANCEACID-BASE BALANCE

Chemical regulation Chemical regulation Biologic regulationBiologic regulation Physiological regulationPhysiological regulation

1.Lungs1.Lungs

2.Kidneys2.Kidneys

FLUID ,ELCTROLYTE FLUID ,ELCTROLYTE AND ACID-BASE AND ACID-BASE

IMBALANCESIMBALANCES

FLIUD IMBALANCESFLIUD IMBALANCES

The five types of fluid imbalances that may The five types of fluid imbalances that may occur are:occur are:

Extracellular fluid imbalances(EVFVD)Extracellular fluid imbalances(EVFVD) Extracellular fluid volume excess(ECFVE)Extracellular fluid volume excess(ECFVE) Extracellular fluid volume shiftExtracellular fluid volume shift Intracellular fluid vloume excess(ICFVE)Intracellular fluid vloume excess(ICFVE) Intrcellular fluid volume deficit(ICFVD) Intrcellular fluid volume deficit(ICFVD)

EXTRACELULLAR FLUID EXTRACELULLAR FLUID VOLUME DEFICITVOLUME DEFICIT

An ECFVD, commonly called as dehydration , An ECFVD, commonly called as dehydration , is a decrease in intravascular and interstitial is a decrease in intravascular and interstitial fluidsfluids

An ECFVD can result in cellular fluid loss if it An ECFVD can result in cellular fluid loss if it is sudden or severe is sudden or severe

THREE TYPES OF ECFVDTHREE TYPES OF ECFVD

Hyperosmolar fluid volume deficit- water loss Hyperosmolar fluid volume deficit- water loss is greater than the electrolyte lossis greater than the electrolyte loss

Isosmolar fluid volume deficit – equal Isosmolar fluid volume deficit – equal proportion of fluid and electrolyte loss proportion of fluid and electrolyte loss

Hypotonic fluid volume deficit – electrolyte Hypotonic fluid volume deficit – electrolyte loss is greater than fluid lossloss is greater than fluid loss

ETIOLOGY AND RISK ETIOLOGY AND RISK FACTORSFACTORS

Severe vomiting Severe vomiting DiaphoresisDiaphoresis Traumatic injuriesTraumatic injuries Third space fluid shifts Third space fluid shifts

[percardial, pleural, [percardial, pleural, pertonial and joint cavities] pertonial and joint cavities]

FeverFever Gatrointestinal suctionGatrointestinal suction IleostomyIleostomy FistulasFistulas BurnsBurns

HyperventilationHyperventilation Decresed ADH secretionsDecresed ADH secretions Diabetes insipidusDiabetes insipidus Addison’s disease or adrenal Addison’s disease or adrenal

crisiscrisis Diuretic phase of acute Diuretic phase of acute

renal failurerenal failure Use of diureticsUse of diuretics

ELDERLY ARE HIGH RISK ELDERLY ARE HIGH RISK OF ECFVD DUE TO OF ECFVD DUE TO

Decreased thirst response Decreased thirst response Decreased renal concentration of urineDecreased renal concentration of urine Altered ADH response Altered ADH response Increased drug – drug interactionIncreased drug – drug interaction Multiple chronic diseases Multiple chronic diseases Decreased access to fluids due to financial or Decreased access to fluids due to financial or

transportation barrierstransportation barriers Debilitation Debilitation Chemical or physical restraintChemical or physical restraint Changes in mental status Changes in mental status

CLINICAL MANIFESTATION CLINICAL MANIFESTATION

In Mild ECFVD, 1to 2 L of water or 2% of the In Mild ECFVD, 1to 2 L of water or 2% of the body weight is lostbody weight is lost

In Moderate ECFVD, 3 to 5L of water loss or In Moderate ECFVD, 3 to 5L of water loss or 5%weight loss 5%weight loss

IN Severe ECFVD , 5 to 10 L of water loss or IN Severe ECFVD , 5 to 10 L of water loss or 8% of weight loss 8% of weight loss

CLINICAL MANIFESTATIONCLINICAL MANIFESTATION

Thirst Thirst Muscle weaknessMuscle weakness Dry mucus membrane;dry Dry mucus membrane;dry

cracked lips or furrowed cracked lips or furrowed tongue tongue

Eyeballs soft and sunken Eyeballs soft and sunken (severe deficit)(severe deficit)

Apprehension , restlessness, Apprehension , restlessness, headache , confusion, coma headache , confusion, coma in severe deficit in severe deficit

Elevated temperature Elevated temperature Tachycardia, weak thready Tachycardia, weak thready

pulsepulse

Peripheral vein fillingPeripheral vein filling> 5 > 5 secondsseconds

Postural systolic BP falls Postural systolic BP falls >>25mm Hg and diastolic fall 25mm Hg and diastolic fall >> 20 mm Hg , with pulse 20 mm Hg , with pulse increases increases >> 30 30

Narrowed pulse pressure, Narrowed pulse pressure, decreased CVP&PCWPdecreased CVP&PCWP

Flattened neck veins in Flattened neck veins in supine positionsupine position

Weight lossWeight loss Oliguria(Oliguria(<< 30 mlper hour) 30 mlper hour) Decreased number and Decreased number and

moisture in stoolsmoisture in stools

LABORATORY FINDINGSLABORATORY FINDINGS

Increased osmolality(Increased osmolality(>> 295 mOsm/ kg) 295 mOsm/ kg) Increased or normal serum sodium level (Increased or normal serum sodium level (>>

145mEq/ L )145mEq/ L ) Increase BUN (Increase BUN (>>25 mg / L )25 mg / L ) Hyperglycemia ( Hyperglycemia ( >>120 mg /dl )120 mg /dl ) Elevated hematocrit (Elevated hematocrit (>> 55%) 55%) Increased specific gravity ( Increased specific gravity ( >> 1.030) 1.030)

MANAGEMENTMANAGEMENT

Mild fluid volume loss can be corrected with oral Mild fluid volume loss can be corrected with oral fluid replacementfluid replacement

-if client tolerates solid foods advice to take -if client tolerates solid foods advice to take 1200 ml to 1500ml of oral fluids1200 ml to 1500ml of oral fluids

-if client takes only fluids, increase the total -if client takes only fluids, increase the total intake to 2500 ml in 24 hours intake to 2500 ml in 24 hours

Management of Hyperosmolar Management of Hyperosmolar fluid volume deficit fluid volume deficit

Administration of hypotonic IV solution , Administration of hypotonic IV solution , such as 5% dextrose in 0.2 %salinesuch as 5% dextrose in 0.2 %saline

If the deficit has existed for more than 24 If the deficit has existed for more than 24 hours,avoid rapid correction of fluid [sodium hours,avoid rapid correction of fluid [sodium solution to be infused at the rate of 0.5 to 0.1m solution to be infused at the rate of 0.5 to 0.1m EqEq// L L// hr] hr]

If heamorrhage is the cause for If heamorrhage is the cause for ECFVDECFVD

Packed red cells followed by hypotonic IV fluids is Packed red cells followed by hypotonic IV fluids is administeredadministered

In situations where the blood loss is less than 1 L In situations where the blood loss is less than 1 L normal saline or ringer lactate may be usednormal saline or ringer lactate may be used

clients with severe ECFVD accompanied by severe clients with severe ECFVD accompanied by severe heart , liver, or kidney disease cannot tolerate large heart , liver, or kidney disease cannot tolerate large volumes of fluid and sodium volumes of fluid and sodium

EXTRACELLULAR FLUID EXTRACELLULAR FLUID VOLUME EXCESSVOLUME EXCESS

ECFVE is increased fluid retention in the ECFVE is increased fluid retention in the intravasular and interstitial spacesintravasular and interstitial spaces

ETIOLOGY AND RISK ETIOLOGY AND RISK FACTORSFACTORS

Heart failureHeart failure Renal disordersRenal disorders Cirrhosis of liverCirrhosis of liver Increased ingestion of high sodium foodsIncreased ingestion of high sodium foods Excessive amount of IV fluids containing sodiumExcessive amount of IV fluids containing sodium Electrolyte free IV fluidsElectrolyte free IV fluids SIADH,SepsisSIADH,Sepsis decreased colloid osmotic pressuredecreased colloid osmotic pressure lymphatic and venous obstruction lymphatic and venous obstruction Cushing’s syndrome & glucocorticoids Cushing’s syndrome & glucocorticoids

CLINICAL CLINICAL MANIFESTATIONMANIFESTATION

Constant irritating coughConstant irritating cough Dyspnea & crackles in lungsDyspnea & crackles in lungs Cyanosis, pleural fffusionCyanosis, pleural fffusion Neck vein obstructionNeck vein obstruction Bounding pulse &elevated BPBounding pulse &elevated BP S3 gallopS3 gallop Pitting & sacral edemaPitting & sacral edema Weight gainWeight gain Increased CVP& PCWPIncreased CVP& PCWP Change in level of consiousnessChange in level of consiousness

LAB INVESTIGATIONLAB INVESTIGATION

serum osmolality <275mOsm/ kgserum osmolality <275mOsm/ kg Low , normal or high sodiumLow , normal or high sodium Decreased hematocrit [ < 45%]Decreased hematocrit [ < 45%] Specific gravity below 1.010Specific gravity below 1.010 Decreased BUN [< 8mg/ dl] Decreased BUN [< 8mg/ dl]

MANAGEMENTMANAGEMENT

Diuretics [combination of potassium sparing Diuretics [combination of potassium sparing and potassium depleting diuretics]and potassium depleting diuretics]

In people with CHF, ACE inhibitors and low In people with CHF, ACE inhibitors and low dose of beta blockers are used dose of beta blockers are used

A low sodium diet A low sodium diet

EXTRACELLULAR FLUID EXTRACELLULAR FLUID VOLUME SHIFT: THIRD VOLUME SHIFT: THIRD

SPACINGSPACING Fluid that shifts into the interstitial spaces and Fluid that shifts into the interstitial spaces and

remain there is called as third space fluid remain there is called as third space fluid Common sites are abdomen , pleural cavity, Common sites are abdomen , pleural cavity,

peritoneal cavity and pericardial sac peritoneal cavity and pericardial sac

RISK FACTORS RISK FACTORS

Crushing injuries, major tissue traumaCrushing injuries, major tissue trauma Major surgeryMajor surgery Extensive burnsExtensive burns Acid –base imbalances and sepsisAcid –base imbalances and sepsis Perforated peptic ulcersPerforated peptic ulcers Intestinal obstructionIntestinal obstruction Lymphatic obstruction Lymphatic obstruction Autoimmune disordersAutoimmune disorders HypoalbunemiaHypoalbunemia GI tract malabsorptionGI tract malabsorption

CLINICAL MANIFESTATION CLINICAL MANIFESTATION

skin pallorskin pallor Cold extremitiesCold extremities Weak and rapid pulseWeak and rapid pulse Hypotension Hypotension OliguriaOliguria

Decreased levels of consiousness Decreased levels of consiousness LAB INVESTIGATIONLAB INVESTIGATION Elevated hematocrit & BUN levelElevated hematocrit & BUN level

MANAGEMENTMANAGEMENT

Treat the causeTreat the cause

1.1. For burns and tissue injuries large volume of For burns and tissue injuries large volume of isosmolar IV fluid is administeredisosmolar IV fluid is administered

2.2. Albumin is administered for protein deficitAlbumin is administered for protein deficit

3.3. IV fluid intake is maintained after major surgery to IV fluid intake is maintained after major surgery to maintain kidney perfusion maintain kidney perfusion

4.4. Pericardiocentesis if pericarditis is the resultPericardiocentesis if pericarditis is the result

5.5. Paracentesis for ascitis Paracentesis for ascitis

INTRACELLULAR FLUID INTRACELLULAR FLUID VOULME EXCESS:WATER VOULME EXCESS:WATER

INTOXICATION INTOXICATION ICFVE is increase in amount of water inside ICFVE is increase in amount of water inside

the cellsthe cells

ETIOLOGYETIOLOGY

Administration of excessive amount of Administration of excessive amount of hyposmolar IV fluids[0.45%saline or hyposmolar IV fluids[0.45%saline or 5%dextrose in water]5%dextrose in water]

Consumption of excessive amount of tap water Consumption of excessive amount of tap water without adequate nutritional intakewithout adequate nutritional intake

SIADH SIADH Schizophrenia[compulsive water consumption]Schizophrenia[compulsive water consumption]

CLINICAL MANIFESTATIONS CLINICAL MANIFESTATIONS

HeadachesHeadaches Behavioral changes Behavioral changes ApprehensionApprehension Irritability, disorientation and confusionIrritability, disorientation and confusion Increased ICP – pupillary changes and decreased Increased ICP – pupillary changes and decreased

motor and sensory functionmotor and sensory function Bradycardia, elevated BP, widened pulse pressure & Bradycardia, elevated BP, widened pulse pressure &

altered respiratory patterns, Babinski’s response altered respiratory patterns, Babinski’s response flaccidity, projectile vomiting, Papilledema, delirium, flaccidity, projectile vomiting, Papilledema, delirium, convulsions &comaconvulsions &coma

LABORATORY FINDINGS LABORATORY FINDINGS

High serum sodium level- 125 mEq/L High serum sodium level- 125 mEq/L decreased hamatocritdecreased hamatocrit

MANAGEMENTMANAGEMENT

Early administration of IV fluids containing sodium Early administration of IV fluids containing sodium chloride cam prevent SIADHchloride cam prevent SIADH

oral fluids such as juices or soft drinks can be given oral fluids such as juices or soft drinks can be given orally every hourorally every hour

Perform neurologic checks every hour to see if Perform neurologic checks every hour to see if cranial changes are presentcranial changes are present

Monitor fluid intake , IV fluids and fluid output Monitor fluid intake , IV fluids and fluid output hourly and weight dailyhourly and weight daily

Administer antiemetics for food and fluid retention Administer antiemetics for food and fluid retention

INTRACELLULAR FLUID INTRACELLULAR FLUID VOLUME DEFICITVOLUME DEFICIT

Severe hypernatremia and dehydration can Severe hypernatremia and dehydration can cause ICFVDcause ICFVD

Relatively rare in healthy adults Relatively rare in healthy adults common in elderly people and in those common in elderly people and in those

conditions that result in acute water lossconditions that result in acute water loss Symptoms include confusion, coma, and Symptoms include confusion, coma, and

cerebral hemorrhagecerebral hemorrhage

Sodium imbalances

Definition

Risk factors/ etiology Clinical manifestation

Laboratory findings

management

 Hyponatr-aemia

  It is defined as a plasma sodium level below 135 mEq/ L

Kidney diseases

Adrenal insufficiency

Gastrointestinal losses

Use of diuretics (especially with along with low sodium diet)

Metabolic acidosis

•Weak rapid pulse•Hypotension•Dizziness•Apprehension and anxiety •Abdominal cramps •Nausea and vomiting•Diarrhea•Coma and convulsion•Cold clammy skin•Finger print impression on the sternum after palpation •Personality change

•Serum sodium less than 135mEq/ L

• serum osmolality less than 280mOsm/kg

•urine specific gravity less than 1.010

•Identify the cause and treat

*Administration of sodium orally, by NG tube or parenterally

*For patients who are able to eat & drink, sodium is easily accomplished through normal diet

*For those unable to eat,Ringer’s lactate solution or isotonic saline [0.9%Nacl]is given

*For very low sodium 0.3%Nacl may be indicated *water restriction in case of hypervolaemia

 

Sodium imbalan-ce

Definition

causes Clinical

manifestation

  Lab findings

 management

Hypernat-remia

It is defined as plasma sodium level greater than 145mEq/L

*Ingestion of large amount of concentrated salts*Iatrogenic administration of hypertonic saline IV *Excess alderosterone secretion

        Low grade fever        Postural hypertension        Dry tongue & mucous membrane        Agitation        Convulsions        Restlessness        Excitability        Oliguria or anuria        Thirst         Dry &flushed skin

*high serum sodium 135mEq/L  *high serum osmolality295mO sm/kg *high urine specificity 1.030

*Administration of hypotonic sodium solution [0.3 or 0.45%] *Rapid lowering of sodium can cause cerebral edema  *Slow administration of IV fluids with the goal of reducing sodium not more than 2 mEq/L for the first 48 hrs decreases this risk *Diuretics are given in case of sodium excess *In case of Diabetes insipidus desmopressin acetate nasal spray is used *Dietary restriction of sodium in high risk clients

 

Potassium imbalances

Definition

Causes Clinical manifestation

Lab findings Management

Hypokalemia                 

It is defined as plasma potassium level of less than 3.0 mEq/L

*Use of potassium wasting diuretic

*diarrhea, vomiting or other GI losses

*Alkalosis

*Cushing’s syndrome

*Polyuria

*Extreme sweating

*excessive use of potassium free Ivs

*weak irregular pulse

*shallow respiration

*hypotesion

*weakness, decreased bowel sounds,

heart blocks , paresthesia, fatigue,

decreased muscle tone

intestinal obstruction

* K – less than 3mEq/L results in ST depression , flat T wave, taller U wave

* K – less than 2mEq/L cause widened QRS, depressed ST, inverted T wave

Mild hypokalemia[3.3to 3.5] can be managed by oral potassium replacement

Moderate hypokalemia*K-3.0to 3.4mEq/L need 100to 200mEq/L of IV potassium for the level to rise to 1mEq/

Severe hypokalemia K- less than 3.0mEq/L need 200to 400 mEq/L for the level to rise to l mEq/L *Dietary replacement of potassium helps in correcting the problem[1875 to 5625 mg/day]

  Definition Causes Clinicalmanifestation

Lab findings Management

 Hyperkalemia

It is defined as the elevation of potassium level above 5.0mEq/L

Renal failure ,  Hypertonic dehydration,  Burns& trauma Large amount of IV administration of potassium, Adrenal insufficiency Use of potassium retaining diuretics & rapid infusion of stored blood

Irregular slow pulse,  hypotension,  anxiety,  irritability,  paresthesia,  weakness

*High serum potassium 5.3mEq/L results in peaked T wave HR 60 to 110 *serum potassium of 7mEq/L results in low broad P- wave *serum potassium levels of 8mEq/L results in no arterial activity[no p-wave]

*Dietary restriction of potassium for potassium less than 5.5 mEq/L  *Mild hyperkalemia can be corrected by improving output by forcing fluids, giving IV saline or potassium wasting diuretics *Severe hyperkalemia is managed by 1.infusion of calcium gluconate to decrease the antagonistic effect of potassium excess on myocardium2.infusion of insulin and glucose or sodium bicarbonate to promote potassium uptake3.sodium polystyrene sulfonate [Kayexalate] given orally or rectally as retention enema

Calcium imbalances

Definition

Causes Clinical manifestation

Lab findings

Management

hypocalcemia

It is a plasma calcium level below 8.5 mg/dl

•Rapid administration of blood containing citrate,

•hypoalbuminemia,

•Hypothyroidism ,  •Vitamin deficiency,

•neoplastic diseases,

•pancreatitis

•Numbness and tingling sensation of fingers,

•hyperactive reflexes,• Positve Trousseau’s sign, positive chvostek’s sign ,

•muscle cramps,

•pathological fractures,

•prolonged bleeding time

Serum calcium less than 4.3 mEq/L and ECG changes

1.Asymtomatic hypocalcemia is treated with oral calcium chloride, calcium gluconate or calcium lactate 2.Tetany from acute hypocalcemia needs IV calcium chloride or calcium gluconate to avoid hypotension bradycardia and other dysrythmias 3.Chronic or mild hypocalcemia can be treated by consumption of food high in calcium

 

Calcium imbalance

Definition Causes Clinical manifestation

Lab findings Management

  Hypercalcemia

It is calcium plasma level over 5.5 mEq/l or 11mg/dl

•Hyperthyro•idism, •Metastatic bone tumors,  •paget’s disease,

•osteoporosis ,

•prolonged immobalisation

•Decreased muscle tone,

•anorexia,  •nausea, vomiting,

•weakness , lethargy,  •low back pain from kidney stones,

•decreased level of consciousness & cardiac arrest

•High serum calcium level 5.5mEq/L,

• x- ray showing generalized osteoporosis,

•widened bone cavitation,

•urinary stones,

•elevated BUN 25mg/100ml,

•elevated creatinine1.5mg/100ml

1.IV normal saline, given rapidly with Lasix promotes urinary excretion of calcium  2.Plicamycin an antitumor antibiotics decrease the plasma calcium level 3.Calcitonin decreases serum calcium level 4.Corticosteroid drugs compete with vitamin D and decreases intestinal absorption of calcium 5. If cause is excessive use of calcium or vitamin D supplements reduce or avoid the same 

 

Acid-Base imbalance

Definition Causes Clinical manifestation

Lab findings Management

Respiratory acidosis Hypoventilation& excessiveCO2 production       

It is a clinical disorder in which the pH is less than 7.35 and the paCO2 is greater than 42mmHg

COPD, neuromuscular disorder, Guillian-Barre syndrome, Myssthenia gravis, Respiratory center depression, Drugs, late ARDS,

Dyspnea , disorientation, coma

PH lesser than 7.35,Paco2 greater than 45mmHg, Hyperkalemia, Hypoxemia

1.Treat underlying cause 2.Support ventilation 3.Correct electrolyte imbalance 4.Intravenous NaHCO3

Respiratory Alkalosis Hyperventilation

It is a clinical condition in which the arterial Ph is greater than7.45 and the paCO2 is less than 38mmHg

Hypoxemia, impaired lung expansion, thickened alveolar – capillary membrane, Chemical stimulation of respiratory center, traumatic stimulation of respiratory center

Tachypnea, giddiness, dizziness, syncope, convulsions, coma, weakness, paresthesia, tetany

PH greater than 7.35PaCO2 lesser than 35 mmHg, Hypokalemia,Hypocalcemia

Increase CO2 retention through CO2 rebreathing & sedation and mechanical hypoventilation

 

  Definition causes Clinical manifestation

Lab findings Management

Metabolic Acidosis      

It is a clinical condition in which the HCO3 & pH is decreased 

Renal failure, Diabetic ketoacidosis, Lactic acidosis, ingested toxins, renal tubular acidosis

Hyperventilation confusion, drowsiness, coma, headache

PH< 7.35,HCO3< 22mEq/L

1.Treat the underlying cause

2.Intravenous NaHCO3

3.correct electrolyte imbalance

Metabolic Alkalosis

It is a clinical condition in which PH is raised

Hypokalemia, gatric fluid loss, massive correction of whole blood, Overcorrection of acidosis with NaCO3

HypoventilationDysrythmias

PH >7.45HypokalemiaHypocalcemiaPaCO2 normal or increased

1.Treat the underlying cause

2.Administer KCL

3.intravenous acidifying salts[NH4CL]

4.Administer acetazolamide

 

CONCLUSIONCONCLUSION