Francis M.

Albances, RN
SPU Iloilo 2009
BODY FLUIDS

WATER
-Major body component
- approximately 60% of adult body weight

-2/3 of body water – ICC

-1/3 of body water – ECC
ECC
-Intravascular – 25%
-Interstitial – 75%
-Transcellular

-Water can freely cross the cell membrane and

can move from one compartment to the other;
In contrast ions cannot easily cross the cell membrane
WATER

Young > Old

Men > Women

Obese < Thin

Average Daily Intake and Output in an Adult

INTAKE (ml) OUTPUT (ml)

Oral liquids – 1300 Urine – 1500
Water in food – 1000 Stool – 200
Water produced Insensible loss : Lungs – 300
By metabolism – 300 : skin 600

TOTAL GAIN = 2600 TOTAL LOSS = 2600

Fundamental Concepts in F & E

DIFFUSION
-Movement of solutes
-High concentration to low concentration
-Does not require ATP
OSMOSIS
Movement of solvent (fluid)
-Low concentration to high concentration
-Does not require ATP
Fundamental Concepts in F & E

HYDROSTATIC PRESSURE
Pressure created by the weight of the fluid
Against the wall that contains it
-Results from the weight of the fluid &
force of cardiac contraction
- “hydrostatic push”

COLLOID ONCOTIC PRESSURE

-Osmotic pressure exerted by proteins
-“oncotic pull”
Fundamental Concepts in F & E

OSMOLALITY
-Number of osmoles per kilogram of solution
-Expressed in mOsm/kg
-Used to evaluate serum and urine
-Major determinants – Na, urea, glucose
-275-295mOsm/kg
-“ tonicity”

OSMOLARITY
-Number of osmoles per liter of solution
-Expressed in mOsm/L
-Describes the concentration solutes or dissolved particles
 FLUID IMBALANCES
I. FLUID VOLUME DEFICIT
• DEHYDRATION
• HYPOVOLEMIA
• CELLULAR DEHYDRATION
II. FLUID VOLUME EXCESS
• FLUID OVERLOAD
• HYPERVOLEMIA
• WATER INTOXICATION
• THIRD-SPACING
ELECTROLYTE IMBALANCES

• SODIUM IMBALANCE
• POTASSIUM IMBALNCE
• CALCIUM IMBALNCE
• CHLORIDE IMBALANCE
• PHOSPHATE IMBALANCE
• MAGNESIUM IMBALANCE
WATER

- responsible for body’s structure & function

- maintenance of equilibrium
- maintenance of life
I. FLUID VOLUME DEFICIT
 EXTRACELLULAR FLUID VOLUME DEFICITS - ECFVD

Types

I. Hyperosmolar (hypertonic) fluid volume deficit

- water loss is greater than electrolyte (Na) loss
- “dehydration”

II. ISO-OSMOLAR (isotonic) fluid volume deficit

- water and electrolyte losses are equal
- “hypovolemia”

III. HYPOTONIC fluid volume deficit

- electrolyte loss is greater than fluid loss (rare)
DEHYDRATION
- Most common F & E imbalance
- Most common
- Common F & Eelderly
among imbalance
– 60%
- 60%
- 17% - mild to moderate
to 50% morbiditydehydration
and mortality rate
- 17% to 50% morbidity and mortality rate
- is loss of “water” from the extracellular fluid volume;
- hyperosmolar (hypertonic) fluid volume deficit
(water loss is greater than electrolyte loss)
- loss is from the vascular and interstitial fluids
- can be called extracellular fluid volume deficit (ECFVD)

 HYPOVOLEMIA
DEHYDRATION
Losses can be:
MILD – loss of 1 – 2 L of water (2% of body weight)
MODERATE – loss 3 – 5 L of water (5% of body weight)
SEVERE – 5 – 10 L loss of water (8% of body weight)

Etiology
a. Lack of fluid intake
b. Excess fluid loss
PATHOPHYSIOLOGY

• Lack of fluid
intake
• Excess fluid loss

Decreased IVF

COMPENSATION
RASS ADH SNS-inc. per. Vasoconstriction
Thirst mechanism
GIT – inc. water reabsorption

If compensation fails

DEHYDRATION
PATHOPHYSIOLOGY

DEHYDRATION

If not corrected

Fluid shifting – intracellular to intravascular

Loss of body weight

Changes in intake and output
Changes in VS

cerebral cell dehydration

Apprehension, restlessness, headache
Hallucinations, confusion, coma

others
 DEHYDRATION
Clinical
S/Sx MILD MODERATE SEVERE

• LOC Alert Lethargic Obtunded

• CRT 2 seconds 2-4 seconds > 4 sec.
• MM Normal Dry cracked
• HR Slight inc. Increased Very inc.
• BP Normal Increased Decreased
• ST Normal Slow Tenting
• Eyes Normal Sunken Very sunken
• UO decreased oliguria Oliguria/
anuria
DIAGNOSTIC FINDINGS

DHN  HEMOCONCENTRATION

a. Osmolality
b. Plasma Na
->295mOsm/kg
c. BUN
-> 145meq/L
d. Hematocrit
-> 25mg/dl
e. Urine specific gravity
- > 55%
-> 1.030
 MANAGEMENT

Depends on the acuteness and severity of the fluid deficit

GOALS:
a. Restore normal fluid volumes
b. Replace ongoing losses
c. Correct underlying problem

A. Fluid Restoration
Oral Rehydration
Intravenous Rehydration
Monitoring for Complications of Fluid Restoration
 Management

1. Keep fresh water or other fluids in an easy accessible location.

Remind older clients to drink fluids hourly because
their thirst mechanism is diminished.
2. Provide oral care every 2 hours to help decrease discomfort
from dry mucous membranes.
3. Record all intake and output accurately
4. Report diarrhea, excessive sweating or rapid breathing
5. Report urine that is dark, produced at less than 0.5 ml/kg/hr
over 2 consecutive hours, or produced at more than 150ml/hr.
6. Report weight changes of 2 lbs or more from the previous day.
An adult suffered second and third degree burns
over 20% of his body two days ago. The nurse knows
that the best way to assess fluid balance is to
a. maintain strict records of intake and output
b. weigh the client daily
c. monitor skin turgor
d. check for edema

b.
“Ensure that the rate of IV fluid
via the pump is accurate;

Significant errors in setting

IV pumps have occurred.”
Provide safety through “stepped-progression position changes”
- Gives the client’s body time to adapt to changes in position.

a. raise the head of the bed

b. sit at the edge of the bed- “dangling”
c. Stand and assist to chair

Do not progress to the next position

until the client tolerates the current position
(without dizziness or marked hypotension)
CELLULAR
DEHYDRATION
Also called intracellular fluid volume deficit (ICFVD)
-Relatively rare among adults, common among older people
- due to acute water loss
-

Cellular Manifestations
Fever, CNS changes, cerebral hemorrhage, coma
CELLULAR
DEHYDRATION
-severe dehydration

cell becomes dehydrated

HYPOVOLEMIA
Occurs when loss of ECF volume exceeds the intake of fluid
Occurs when water and electrolytes are lost in the same proportion
Iso-osmolar (isotonic) fluid volume deficit

Causes
Vomiting, diarrhea, GI suctioning, sweating, decrease intake

Additional Risks
DI, adrenal insufficiency, osmotic diuresis,
hemorrhage, third-space fluid shifts
An adult has been shot. VS are as follows:
BP 90/60, PR 120, weal and thready, RR 20.
During the initial assessment, he is placed in a
modified trendelenberg position. If the position change
has the desired effect, the nurse would expect
a. an increase in the client’s BP
b. an increase in the client’s HR
c. an increase in the client’s RR
d. a faster capillary refill time in the toes

a.
I. FLUID VOLUME EXCESS
 FLUID OVERLOAD

-Overhydration
- extracellular fluid volume excess (ECFVE)

Excess fluid in the vascular system – HYPERVOLEMIA

Excess fluid in the interstitial space – THIRD SPACING

Etiology
1. Administration of too much fluid or
Too rapid administration
2. Failure to excrete fluids
Pathophysiology

Too much/rapid fluid administration

Fluid overload

Increased hydrostatic pressure

Pushing of excess fluids into the interstitial spaces

Clinical Manifestations

Respiratory

Cough, dyspnea, crackles

Impaired O2 and CO2 transport, cyanosis, desaturation
Anxiety,

Pulmonary edema, pleural effusion

Cardiovascular
Jugular vein distention, bounding pulse, elevated BP, increased CVP,

Increased peripheral vascular resistance, heart failure

Clinical Manifestations

Central Nervous System

Changes in LOC, confusion, headache

Lethargy, seizure , coma

Others
Ascites
hepatomegaly
Periperal edema
DIAGNOSTIC FINDINGS

a. Plasma osmolality < 275mOsml/kg

b. Plasma Na < 135 meq/L
c. Hematocrit < 45%
d. Specific gravity < 1.010
e. BUN < 8 mg/dl
 Management

1. Restriction of Sodium and fluids

Sodium Restriction
Mild – 4-5gram of Na
Moderate – 2 gram Na
Severe – 0.5 High Na foods
Breads
Cereals
Chips
Cheese
Meats – luncheon, bacon , ham
convenience food – pizza, pies, soups
Fast foods
Restriction of Sodium and fluids

Strict I & O
Collaborate with dietitian regarding fluid restriction
Give ice chips (decreases sensation of thirst)
Suggest alternatives for seasoning
- lemon, garlic, pepper, etc.
2. Promoting urine output

Diuretics

Mild diuretics
K-sparring diuretics

Mobilize fluids- avoid prolonged standing

Bed rest (HF-promotes diuresis)
3. Reduce Complications

Head elevation (30-45degrees)

Keep O2 saturation >90%
If taking diuretics, digitalis –
monitor electrolyte levels
Edema – provide frequent skin care, turning
Weigh daily – decrease in body weight
about 0.5 – 1 pound/day
HYPERVOLEMIA
Excess fluid in the vascular system
WATER INTOXICATION
- Intracellular fluid volume excess (ICFVE)

Causes
Causes
Water excess (normal solute but diluted by water)

-excess in hypo-osmolar IV fluids

-SIADH
-Psychiatric disorders

Solute deficit (primarily Na) (water is normal but too few solute particles)
 WATER
INTOXICATION

• ICFVE •T
• Diabetis insipidus •F

• Normal Na •T
• Decreased Na •T
• Normal water •T
Pathophysiology

Water excess
Solute deficit

Osmosis

Cellular edema
Clinical Manifestations

CNS
- “cerebral cells absorb hypo-osmolar fluid more quickly than other cells”
-Due to increased ICP

-Changes in mental status

-Pupillary changes
-Vital sign changes
Management

Reduce ICP
Steroids
Osmotic diuretics

Identify and manage the underlying cause

Immediate surgical intervention in necessary

Correct / prevent Hypo-osmolality

-Administer IVF-containing Na
Management

Neurologic checks
Notify the care provider if neurologic response deteriorates
from the baseline assessment
Monitor IV fluids and I&O hourly
Monitor weight daily
Administer prophylactic antiemetics as ordered

“TIME equals BRAIN CELL SURVIVAL”

-The longer the manifestations of increased ICP persist,
-And the more serious they are, the graver the prognosis
THIRD-SPACING
Excess/accumulation of fluid in the interstitial space

“third-space fluid is physiologically useless;

it does not circulate to provide
nutrients for the cells”

Common sites:
Pleural cavity, peritoneal cavity, pericardial sac
Causes
Increased hydrostaic pressure
Increased capillary permeabilty
Decreased serum protein levels
Obstruction in capillaries/lymphatic drainage system
 Clinical Manifestations

Hypololemia-like manifestations
Pallor, cold limbs, weak and rapid pulse
Oliguria, decreased level of consciousness

Body weight
No change, only redistributed

Severe fluid shifting or losses  hypovolemic shock

DIAGNOSTIC FINDINGS

Na
Hct
BUN
Urine spec.gravity
 Management

“not a primary disease, but only a manifestation”

-Determine the underlying cause

If third spacing has occurred:

Around the heart – pericardial effusion – pericardiocentesis
Around the lungs – pleural effusion – thoracentesis
In the peritoneal cavity – ascites - paracentesis
 Management

Replace fluids
Isotonic IV fluids
Albumin

Stabilize other problems

Sepsis – IV antibiotics
vaso-active medications
Bowel obstruction  third spacing  gangrene
Severe inflammatory disorders - steroids
 Management

Monitor IV fluid replacement needs

“anticipate a reduction in IVF needs as the third-space fluid

shifts back into the plasma during the capillary repair stage

Assessment – ascites, breath sounds, VS, per. Pulses

Monitor UO –(report if less than 0.5ml/kg/hr if it persists for more than 2 hours
ELECTROLYTES

-Active chemicals in the body

-Maintain voltages across cellmembranes
-Expressed in terms of MILLIEQUIVALENTS (meq) per liter
-Measure of chemical activity

-Positively charge – CATIONS

-Negatively charge – ANIONS

-Used by the cells to conduct electrical impulses

-Kidney – maintain electrolyte balance in the body
ELECTROLYTES

INTRACELLULAR
EXTRACELLULAR
Potassium
Sodium
Magnesium
chloride
phosphorus
ELECTROLYTES
Potassium (K)
-Main ICF cation
-Regulates cell excitability
-Influences skeletal and muscle activity

Sodium (Na)
-Main ECF cation
-Primary determinant of ECF osmolality
-Major controller of water distribution in the body
- necessary for muscle contraction and nerve impulse transmission
ELECTROLYTES
Calcium
-major cation in teeth and bones
-Found fairly in both ICF and ECF
-Necessary for muscle contraction and nerve transmission
-Aids in coagulation

Chloride
- Main ECF anion
-Helps maintain ECF osmolality
-Plays a vital role in maintaining acid-base balance
- combines with hydrogen ion to produce hydrochloric acid
ELECTROLYTES
Magnesium
-A leading ICF cation
-Plays a role in CHO and CHON metabolism
-Important in neuromuscular function
-Causes peripheral vasodilation

Phosphorus
-Main ICF anion
-Promotes ATP formation and energy storage
-Promotes CHO, CHON, fat metabolism
-Essential for muscle and RBC function
-Essential for nervous system function
-Acts as a hydrogen buffer

Bicarbonate
- Regulates acid-base balance
Serum Electrolyte Levels (5s)
Na – 135 – 145 meq/L
Mg – 1.5 – 2.5 meq/L
P - 2.5 – 4.5
K – 3.5 – 5 meq/L
Ca - 4.5 – 5 mg/dl (ionized)
– 8.5 – 10 mg/dl (total)
Cl – 95 – 105 meq/L
 ELECTROLYTE IMBALANCES

HYPONATREMIA HYPERNATREMIA
HYPOKALEMIA HYPERKALEMIA
HYPOCALCEMIA HYPERCALCEMIA
HYPOMAGNESEMIA HYPERMAGNESEMIA
HYPOPHOSPHATEMIA HYPERPHOSPHATEMIA
HYPOCHLOREMIA HYPERCHLOREMIA
A 78 year old male has been working on his lawn
for two days, although the temperature has been
above 90 degrees F. He has been on thiazide diuretics
for hypertension. His laboratory values are:
K 3.7meq/L, Na 129meq/L, Ca 4.9meq/L and
chloride 95meq/L. When preparing for his care the nurse would
a. make sure he drinks eight glasses of water a day
b. monitor for fatigue, muscle weakness, restlessness and flush
c. look for signs of hyperchloremia
d. observe for neurologic changes

d.
HYPONATREMIA

Plasma level less than 135meq/L

One of the most common electrolyte disorders in adult

Causes
Decreased serum Na level
(water excess)

Serum osmolality falls to < 280mOsm/kg

Decrease thirst mechanism

(Decrease water intake)

ADH release is suppressed

Renal water excretion increases

Serum osmolality normalizes

Clinical Manifestations
HYPERTONIC saline must be given very slowly in a large vein, using an IV pump,
To decrease the risk of hyperthermia, pulmonary overload and phlebitis
Management
An adult who has gastroenteritis and is on digitalis
has lab values of K 3.2 meq/L, Na 136meq/L,
Ca 4.8meq/L, Cl 98meq/L. The nurse puts which
of the following on the client’s plan of care?
a. monitor for hyperkalemia
b. avoid food rich in potassium
c. observe for digitalis toxicity
d. observe for Trousseau’s and Chvostek’s signs
HYPERNATREMIA

Plasma Na level greater than 145meq/L

Occurs in about 1% of hospitalized client
High mortality rate

Causes
Increased serum Na level
(water deficit)

Serum osmolality rises to > 300mOsm/kg

Thirst increases
Increased water intake

ADH release increases

Renal water excretion diminishes

Serum osmolality normalizes

“Use IV pumps in high risk clients.
Initiate safety and seizure precautions if the client manifests
weakness or cerebral changes”.
Clinical Manifestations
Management
 HYPOKALEMIA

Plasma K level less than 3.5meq/L

Common electrolyte disorder esp. among older adult population

Causes

Inadequate K intake

-”the body does not conserve K efficiently”

-
Clinical Manifestations
Management
HYPERKALEMIA

Causes
Clinical Manifestations
Management
. A client on hemodialysis is complaining of
muscle weakness and numbness in his legs.
His lab results are: Na 136meq/L, K 5.9meq/L,
Cl 100meq/L, Ca 4.5meq/L. The nurse knows
the client is suffering from
a. hyperkalemia
b. hypernatremia
c. hypocalcemia
d. Hypochloremia

a.
HYPOCALCEMIA

Causes
Clinical Manifestations
Management
HYPERCALCEMIA

Causes
Clinical Manifestations
Management
HYPOMAGNESEMIA
HYPERMAGNESEMIA
HYPOPHOSPHATEMIA
HYPERPHOSPHATEMIA
HYPOCHLOREMIA
HYPERCHLOREMIA
 INTRAVENOUS FLUID REPLACEMENT

CRYSTALLOIDS

COLLOIDS
 INTRAVENOUS FLUID REPLACEMENT

DELIVERY METHODS

Peripheral Lines

Central Lines
Total parenteral nutrition (TPN) is ordered for an adult client.
Which nutrient is not likely to be in the solution?

a. dextrose 10%
b. trace minerals
c. electrolytes
d. amino acids

a.
The nurse is caring for a client who is receiving IV fluids.
Which observation the nurse makes best indicates
the IV has infiltrated?
a. pain at the site
b. a change in flow rate
c. coldness around the insertion site
d. redness around the insertion site

c.
A 93 year old adult is hospitalized for the treatment
of gastroenteritis complicated by dehydration and hyponatremia.
The nurse expects that an early symptom of hyponatremia
exhibited by the client was
a. ataxia
b. hunger
c. thrist
d. Weakness

c.
An adult is receiving TPN. The nurse knows
which of the following assessment is essential?
a. evaluation of peripheral IV site
b. confirmation that the tube is in the stomach
c. assessment of the GIT, including bowel sounds
d. fluid and electrolyte monitoring

d.