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• Fluid and electrolyte balance is a dynamic process vital for life and homeostasis.
• Nurses prevent and treat fluid, electrolyte, and acid-base balance disturbances.
• Homeostasis refers to the state of equilibrium in the body's internal environment.
• This equilibrium is maintained by keeping the composition and volume of body fluids within normal limits.

Amount & Composition of Body Fluids

• Total body fluid accounts for 50%-60% of body weight.
• Cell fluid makes up 35%-40% of body weight.
• Plasma accounts for 5% of body fluid.
• Interstitial fluid accounts for 10%-15% of body fluid.
• Extracellular fluid makes up 15%-20% of body weight.

Fluid Compartments

• Intracellular fluid (ICF)
• Extracellular fluid (ECF)
• The ECF includes intravascular (plasma) and interstitial fluids.
• Transcellular fluid is also a compartment.

Body Fluid Components

• Intracellular Fluid (ICF) is located within cells and comprises 42% of body weight.
• Potassium (K+) is the most prevalent cation (positively charged ion) in ICF.
• Phosphate (PO4) is the most prevalent anion (negatively charged ion) in ICF.
• Extracellular Fluid (ECF) exists in spaces between cells (interstitial fluid) and the plasma space.
• Chloride (Cl-) is the most prevalent anion in ECF.
• Sodium (Na+) is the most prevalent cation in ECF.
• ECF expands and contracts, with 2/3 in interstitial fluid.
• Intravascular fluid is within the vascular space.
• Intravascular fluid measurements are done with blood tests.
• 1/3 of ECF is in the intravascular space.
• Transcellular fluid is a small, important compartment, approximately 1L.
• Transcellular Fluid includes cerebrospinal fluid, gastrointestinal (GI) tract fluids, pleural, synovial, and peritoneal fluid spaces.

Regulation of Body Fluid Compartments

• Diffusion: Particles move from high to low concentration areas.
• Osmosis: Solvent molecules pass through a semipermeable membrane from a less concentrated solution to a more concentrated one.
• Osmotic Pressure: Hydrostatic pressure applied to a solution prevents solvent movement across a semipermeable membrane.

Osmotic & Hydrostatic Balance

• Oncotic Pressure (colloid-osmotic pressure) is the osmotic pressure caused by proteins.
• Hydrostatic Pressure is the pressure exerted by a fluid at equilibrium due to gravity.
• Filtration is when hydrostatic pressure in capillaries filters fluid from the intravascular compartment out into the interstitial fluid.
• Water and solutes move from areas of high to low hydrostatic pressure.
• Sodium-Potassium Pump: Is when energy is expended for movement to occur against a concentration gradient.
• This pump moves sodium from the cell into the ECF and potassium into the cell.

Fluid Shifts

• Interstitial fluid shifts into plasma with elevation of hydrostatic pressure.
• Interstitial fluid shifts into plasma with a decrease in plasma oncotic pressure.
• Interstitial fluid shifts into plasma with elevation of interstitial oncotic pressure.
• Fluid is drawn into plasma with increased plasma osmotic or oncotic pressure.
• Wearing compression stockings has a therapeutic effect on this.

Fluid Movement between Extracellular and Intracellular

• Water Deficit ( ECF) shows symptoms of cell shrinkage as water is pulled into the vascular system.
• Water Excess ( ECF) is developed from a gain or retention of excess water.

Management of Water Deficit & Excess

• Management of Water Deficit (Gain) includes dietary intake of fluid, foods, and parenteral fluids.
• Management of Water Excess (Losing) via kidneys, skin, lungs, and GI tract.
• Kidney's urine output should be 1ml/kg/hr when losing excess water.
• Sensible (sweating) and insensible losses (evaporation) happen via skin.
• Insensible losses (evaporation) happen via lungs.
• Loss via Gl tract: as with diarrhea.

Daily Fluid Gain and Loss

• Water Gain: metabolic water (200mL), ingested foods (700 mL), and ingested liquids (1600 mL).
• Water Loss: GI tract (100mL), lungs (300 mL), skin (600 mL), and kidneys (1500mL).

Evaluating Fluid Status - Lab Tests

• Osmolality (mOsm/kg) measures solute concentration per kilogram in blood and urine.
• Serum osmolality is mainly the concentration of sodium (280-300mOsm/kg).
• Urine osmolality is determined by urea, creatinine, and uric acid (200-800mOsm/kg).
• Osmolarity describes solution concentration (mOsm/L).
• Urine Specific Gravity: Measures the kidney's ability to excrete or conserve water (1.010-1.025).
• Urine specific gravity is less reliable than urine osmolality.
• Specific gravity varies inversely with urine volume.

Blood Content Tests

• Blood Urea Nitrogen (BUN) measures the end product of protein metabolism (muscle and dietary intake).
• Normal BUN is 10-20 mg/dl (3.6-702mmol/L).
• High BUN indicates GI bleeding, dehydration, fever, and sepsis.
• Low BUN indicates low-protein diet, starvation, and liver disease.
• Creatinine measures the end product of muscle metabolism.
• Creatinine is the indicator of renal function.
• Normal serum creatinine is 0.7-1.4 mg/dl (62-124 mmol/L)
• Creatinine increases when renal function decreases.
• Hematocrit measures the volume percentage of RBCs in whole blood, with normal ranges being 42%-52% for males and 35%-47% for females.

Fluid Volume Disturbances

• Fluid Volume Deficit (FVD) refers to hypovolemia.
• Fluid Volume Excess (FVE) refers to hypervolemia.

Fluid Volume Deficit (FVD)

• Extracellular fluid loss goes over the intake of solutes.
• Electrolytes are lost in the same proportion as they exist in normal body fluids.
• Dehydration refers to loss of water alone with increased serum sodium level, and may occur in combination with other imbalances.
• FVD is caused by vomiting, diarrhea, GI suctioning, sweating, decreased intake, and inability to gain access to fluids.
• Risk factors include diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, and third space shifts.

FVD Manifestations & Medical Management

• Manifestations of FVD includes rapid weight loss and decreased skin turgor.
• Oliguria, concentrated urine, postural hypotension, and a rapid, weak pulse are also manifestations of FVD.
• Increased temperature, cool and clammy skin (due to vasoconstriction), thirst, nausea, muscle weakness and cramps are manifestsions too.
• Diagnostic Data for FVD: Elevated BUN in relation to serum creatinine, and increased hematocrit.
• Assessments include:skin dryness, mucous membrane, and conjunctiva.
• Assessments include: vital signs and mental status, observing for confusion and lethargy.
• Assess neuromuscular functions like muscle tone and strength for movement, tremors and co-ordination.
• Neuromuscular assessment and strict I & O chart review required
• Medical Management: Reverse the cause if possible, provide oral fluids, and administer IV fluids and blood transfusion.
• Drug Therapy: Depends on cause (antiemetic, anti-diarrheal).
• Isotonic electrolyte solutions (lactated Ringer's, 0.9% sodium chloride) are used for hypotensive patients with low FVD.
• Hypotonic solutions (0.45% sodium chloride) give electrolytes and water for renal excretion when the patient becomes normotensive.
• Nursing Management involves measuring I&O, daily body weight, and evaluating tongue turgor.
• Also measure urine specific gravity (normal 1.015- 1.025); urine SG increases as the kidney attempts to conserve water.

Fluid Volume Excess (FVE)

• FVE: Expansion of the ECF caused by abnormal retention of water and sodium.
• FVE may be related to fluid overload or diminished homeostatic mechanisms.
• This is caused by excessive dietary sodium or sodium-containing IV solutions.
• Heart failure and renal failure may cause this
• Primary polydipsia and Syndrome of inappropriate antidiuretic hormone secretion (SIADH) may case this too.
• Long-term use of corticosteroids also causes this

FVE Manifestations & Medical Management

• FVE Manifestations: Edema, distended neck veins, abnormal lung sounds (crackles), shortness of breath, and wheezing.
• Tachycardia with bounding pulse; increased BP, pulse pressure, and CVP.
• Increased weight and urine output are manifestsions too.
• In severe FVE, seizures and coma can occur.
• Medical Management: Cornerstone is directing treatment at the cause, restricting fluids and sodium, and administering diuretics.
• Drug therapy includes osmotic diuretics first, then loop diuretic, and finally Lasix.
• Monitor responses to medications such as diuretics.
• In severe FVE, dialysis may be needed.
• Nutritional therapy is also an important aspect.

Nursing Management for Fluid Overload

• Monitoring weights daily, along with serum electrolytes, ECG, and albumin levels is needed.
• Assessment of cardiopulmonary, renal, mental, lung sounds, edema & skin should be done by the nurse.
• VS should be monitored every 4 hrs.
• Strict I&O monitoring is needd each shift.
• Check IV fluids hourly.
• Use semi-Fowler's position for orthopnea.
• Monitor responses to medications- diuretics.
• Promotion of adherence to fluid restrictions and educating them on sodium and fluid restriction are needed.
• Provision of skincare while positioning/turning since the patient is very prone to skin breakdown and infections is key.
• Teaching patients also about edema, localized or generalized symptoms helps with compliance.

Fluid Solution - Effects on Cells

• Isotonic solutions include Normal Saline (NaCl.9%), Dextrose water (D5W), R/L.
• Isotonic Solutions: Fluids have the total osmolality of the ECF and do not cause cells to swell or shrink.
• Isotonic fluids expand ECF volume; 1L fluid expands ECF by 1L and plasma by 0.25L.
• Isotonic fluids are crystalloid and quickly diffuse into ECF.
• Hypotonic solution: Half-Strength Saline (NaCl 0.45%), with osmolality of 154mOsm/L.
• Hypotonic Solutions: Replace cellular fluid and provide free water for excretion of body wastes.
• Hypotonic solutions treat hypernatremia and other hyperosmolar conditions.
• Excessive hypotonic solution infusion can lead to intravascular depletion, BP, cellular edema, and death.
• Hypertonic solutions are Normal saline or R/L containing 5% dextrose (D 5% NaCl0.9%), (D 5% NaCl0.45%), higher concentration of dextrose (D50%W), (DW 10%).
• Hypertonic Solutions draw water from the ICF to the ECF and cause cells to shrink.
• Rapid or excessive hypertonic solution admiration may cause EC volume excess and circulatory overload.

Electrolytes and Acid-Base

• Electrolytes are substances splitting into ions when placed in water.
• Major cations: Sodium (Na+), Potassium (K+), Calcium (Ca++), Magnesium (Mg++), Hydrogen ions (H+).
• Major anions: Chloride (Cl-), Bicarbonate (HCO3¯), Phosphate (PO43-).
• Electrolyte concentrations differ in fluid components.
• Acid-Base Balance involves regulating acidity and alkalinity, measured by pH.
• Regulation of Acidity and Alkalinity: is important for regulating homeostasis.
• An acid releases hydrogen ions (H+) (e.g., Hydrochloric acid (HCL)).
• Bases (alkalis) have low hydrogen ion concentration and accept hydrogen ions.
• Normal Body fluids are slightly alkaline between 7.35 and 7.45.
• Normal Arterial Blood pH: 7.35-7.45.
• Normal Mixed Venous Blood pH: 7.32-7.42
• Arterial Blood PCO2 Norm: 35-45 mm Hg
• Mixed Venous Blood PCO2 range: 38-52mm Hg
• Arterial Blood PO2 Norm: >80 mm Hg.
• Mixed Venous Blood PO2 Norm: 24-48mmHg
• Normal Arterial Blood HCO3: 22-26 mEq/L
• Mixed Venous Blood HCO3 range: 19- 25 mEq/L
• Respiratory Regulation: Lungs regulate acid-base balance by eliminating or retaining carbon dioxide (CO2).
• When combined with water, carbon dioxide forms carbonic acid (CO2 + H2O = H2CO).
• Renal Regulation: Kidneys maintain acid-base balance by selectively excreting or conserving bicarbonate (HCO3) and hydrogen ions.
• Electrolyte Imbalances: Sodium (hyponatremia and hypernatremia), potassium (hypokalemia and hyperkalemia).
• Calcium: hypocalcemia and hypercalcemia.
• Magnesium: hypomagnesemia and hypermagnesemia.
• Phosphorus and Chloride imbalances
• Phosphorus: includes hypophosphatemia and hyperphosphatemia.
• Chloride: includes hypochloremia and hyperchloremia.

Sodium Basics & Imbalances

• Sodium (Na) Normal range: 135 – 145 mEq/L.
• Imbalances associates with changes in osmolality
• Sodium plays a major role in: ECF volume and concentration
• Generation and transmission of nerve impulses, acid-base balance
• Hypernatremia: Elevated serum sodium with water loss/sodium gain (> 145 mEq/L).
• Hypernatremia is caused by hyperosmolality leading to cellular dehydration
• Primary protection is thirst from the hypothalamus.
• Hypernatremia Manifestations :include thirst, lethargy, agitation, seizures, and coma.
• Hypernatremia can be produced by central/nephrogenic diabetes insipidus.
• Medical Management: Treat underlying cause, and if oral fluids cannot be ingested, administer IV solution of 5% dextrose in water or hypotonic saline.
• Consider diuretics.
• Sodium levels are reduced gradually to avoid cerebral edema.
• Nursing Management Assess over-the-counter OTC medications as they may be high in sodium.
• Encourage fluids for pt

Sodium Imblances - Hyponatremia

• Hyponatremia Results from loss of sodium-containing fluids/water excess (< 135 mEq/L).
• Manifested by confusion, nausea, vomiting, seizures, and coma.
• Causes: Water excess and fluid restriction are needed.
• In the event of severe symptoms (seizures) occurring, a small amount of intravenous hypertonic saline solution (3% NaCl) is given
• in the event of abnormal fluid loss, fluid replacement with sodium-containing solution is needed.
• Medical management: Water restriction, sodium replacement (by mouth, NGT, or parenteral), Assessment, prevention.
• Identify high risk patients and meds that may contribute
• Nursing alert Hyponatremia can dangerous for persons taking Lithium.
• Hypertonic solutions, to be administered only in ICU.

Potassium Basics & Imbalances

• Potassium Normal range 3.5 – 5.5 mm/L
• Potassium is a major ICF cation.
• Main components include: Transmission, conduction of nerve impulses, maintenance of normal cardiac rhythms, contraction of skeletal muscles, and acid-base balance.
• Hyperkalemia is > 5.5 mm/L.
• Hyperkalemia Causes: Increased retention, potassium-sparing diuretics.
• Muscle contraction or Acidosis
• Manifestations: Skeletal muscles weak or paralyzed, leads to V-fib etc.
• Medically: Monitor ECG, cation exchange resin (oral or by enema), and stop K+ intake.
• Increase elimination by managing diuretics.

Potassium Regulation - cont

• To force K+ from ECF to ICF bicarbonate is needed.
• To maintain myocardium function from to much hyperkalemia adminsiter IV calcium gluconate,
• As a last resort peform dialysis
• Nurse Managemt : Assess and monitor potassium levels and medication effects.
• Educate patients about a diet restricted in potassium

Pootassium Defcieny

• Hypokalemia < 3.5 mm/L
• Causes. Increasd loss of solds due aldosterone diuretics
• Manifested by lethal ventricular arrthymias
• Skeletal Msucle deficciencies too via myoglobin
• Medically: Potassium suplemnts are given via Iv orally etcc
• diet may need to be changes.
• Nurses Monitor test and ecgs

Calciu Basics & Imblances

• Calcium Normal range 8.6 to 10.2 mg/dL.
• High levels may decrease concentration
• Calcium also maintians balance and controls transports.
• The functions of the muscular system is regulated with its help
• Hypercalcemia can cause
• Renal deficiceny and confusion.
• Medically, patients should be mobile

Calcium Defciency

• Hypocalcemia can cause trousseau’s Sign
• This test is preformed by testin a ight tap on teh ear.
• Can be medically supplemnted after this

Magnesium Facts

• **
• Magnesium can regualte the neromuculature funcitn
• Alcohol consumptuoin can cause hypmag
• Nerve irreitability s a symptopm also ekg chanfes

Magnesium

• Reankl Failure
• Flushed Skin
• Administer Gluconate.

Nursing Care & Intravenous (IV) Therapy Management for patients

Nurse Responsibilities

• Preparing administration of Intravenous (IV) Therapy.
• Choosing an intravenous site, based on: The condition of the vein, the type of fluid and medications needed, the duration of therapy, patient age, and whether or not pt is right or left-handed.
• Selecting vein puncture devices: • Cannulas • Needes intravenous delivery systems • Peripherally inserted central catheter (PICC) line

Selection Points

• Anterir Palmar
• Posterior Dorsal.

Tips

• Teach tthe patients more
• ensure it easy to access and maintans its safety

Steps

• Desable the flow
• check if the patient is doing OK before and after
• stop Complications