Fluid, Electrolyte

and
Acid-Base Balance
 Total Fluid Volumes
by Age and Sex
90

80
70
60

50
40

30

20
10

0
Premature Newborn Child 1-12 Puberty- Puberty- 40-60 40-60 >60 Male >60
Infant 39 Male 39 Female Male Female Female
 Normal Water Balance

• Intake:
Fluid ingestion 60%
Foods 30%
Metabolism 10%
II. Output:
Urine 60%
Sweat 8%
Feces 4%
"Insensible" loss 28%
(skin, lungs)
Fluid Compartments Extracellular

Intracellular

l ar
sc u
av a
Intracellular
I ntr

Interstitial
 ¾ of ECF

¼ of ECF

Fluid is in both compartments 50-60% of body weight

Intravascular Fluid or Plasma
(1/4 of ECF)
1. Volume
Necessary for BP Maintenance
2. Maintenance of Proportional Distribution
Protein content of blood (Serum proteins- globulin
and albumin
Integrity of blood vessels linings
Hydrostatic pressure inside blood vessels
3. Osmolarity
Concentration of dissolved substances expressed in
mOsm/L (Normal 280-300)
Movement of Body Fluids
1) Filtration
Hydrostatic pressure
2) Osmosis
Concentration- solvent moves to make
concentrations even although volume is not.
3) Diffusion
Redistributing - high to low to make even
4) Active Transport
Energy requirement for selective admission
Filtration
 Osmosis

–Movement of fluid through semipermeable membrane

–Concentration controls- solvent moves to make
concentrations even although volume is not
Filtration Pressures in a Capillary
Problem Examples:
Edema
Congestive heart failure
Diffusion
- movement of solutes against a concentration
gradient; tries to to balance cations + with anions -
 Active Transport

• Requires energy from metabolism to

move larger or uneven substances
across cell membranes

– Glucose needs insulin to enter cell

– Na/K pump
Active Transportation
of Glucose
Na-K Pump: For every molecule of ATP, 3 molecules of Na
move to outside of cell and 3 molecules of K move inside the cell
 Factors Affecting
Fluid & Electrolyte
Movement

1) Osmotic Pressure and Tonicity

2) Hydrostatic Pressure

3) Filtration Pressure
 Osmolality and Tonicity

• Osmolality (Kg) and osmolarity (L) are

determined by the solutes (mainly Na) in the
ECF
– Abnormalities tell us that there are problems with water
regulation in the ECF.

• Tonicity is the force that the ECF solutes

(mainly Na) have to pull water into the ECF.
– (Na, glucose, mannitol, sorbitol are effective osmoles.)
 Osmosis and Tonicity
Na is the main determinant of plasma tonicity.

Swelling of Thirst and

cells ADH release
Problem Examples:
Edema
Congestive heart failure
Tonicity
0.45% saline (1/2 normal)
Moves fluid into cells
HYPO
Tonicity
Same osmolarity as plasma
0.9 % saline (Normal saline)
ISO – no fluid shift
Tonicity
3% saline
Pulls fluid from cells

HYPER
Tonicity
 - + +
Electrolytes
-
- -
+ +
+ -
 ECF Electrolytes
 Sodium - Na 135-145mEq/L
 Potassium - K 3.5-5.0 mEq.L
 Calcium - Ca 4.5-5.5 mEq/L
 Magnesium - Mg 1.5 - 2.5 mEq/L
 Chloride - Cl 90-110 mEq/L
 Bicarbonate – HCO3
• Arterial 22-26 mEq/L
• Venous 24-30 mEq/L
 Sodium and ECFV
• The total amount of Sodium in ECF is the major
determinant of the size of the ECF Volume

– Na increases = ECFV increases until ECF

‘volume overload’ results (edematous states)
• CHF, Cirrhosis of the liver, nephrotic syndrome
• Pleural effusions, pulmonary edema, ascites

– Na decreases = ECFV decreases eventually

leading to ‘volume depletion’ manifested by poor
skin turgor, tachycardia, orthostatic hypotension
 Sodium Regulation
• Kidney receptors sense changes in renal perfusion
causing renin-angiotensin system to retain sodium in
kidney.
• Volume receptors in great veins sense filling and
release atrial natriuretic factor that promotes Na
excretion.
• Pressure receptors in aorta and carotid sinus activate
sympathetic NS to retain Na.
Water ALWAYS follows Na
Therefore when ECFV increases, these mechanisms are
activated to increase Na excretion; and conversely, if
ECFV decreases, the same means promotes Na
retention.
 Water Regulation
(Hypo- and Hyper-Natremia are always a
problem with water, not Sodium)

• Osmolality increase in ECF -> Thirst

• Renal responsiveness to tonicity
• Adequate delivery of water and solutes to
glomerulus of kidney (Problem: Early reabsorption of
water due to volume depletion or edematous states)
• Water conservation mechanisms in kidney (Can
be overridden by diuretics either in loop or in distal tubule.
• ADH in response to tonicity changes, i.e., Na, or
in response to volume changes (Problems: SIADH
and DI)
 Diuretics
• Both Thiazides and Loop diuretics block
Na reabsorption and cause decrease in
ECF, too.
• Loop cause greater loss of Na but equal
water, but thiazides lose less water than
Na and can cause hyponatremia.
 Manifestations of Fluid, and
Electrolyte Imbalances

• Imbalances of Intake and Output

and Body Weight
• Changes in Mental Status
• Changes in Vital Signs
• Abnormal Tissue Hydration
• Abnormal Muscle Tone
 Signs and Symptoms of Dehydration

Early Dehydration Advanced Dehydration

Headache
Difficulty swallowing
•Fatigue
•Clumsiness
•Loss of appetite
•Shriveled skin
•Flushed skin
•Sunken eyes
•Heat intolerance
•Visual disturbances
•Light-headedness
•Painful urination
•Dry mouth or eyes
•Numb skin
•Burning sensation in
•Muscle spasm
stomach
•Delirium
•Dark urine with strong odor
*Poor skin turgor (tenting of the skin of the back of the hand is common in normal
geriatric patients b/c of age-related skin changes A recent history of poor oral intake
and/or a documented weight loss are probably better warning signs of dehydration in
geriatric residents.
 Nursing Interventions
• Health Promotion
– Teaching depending upon setting
• Altered Function
– Oral fluid increase
– Oral fluid restriction
– Electrolyte replacement
• Diet or supplement
• IV therapy
 Serum Electrolytes

Normal
Name Symbol Function Hypo Causes Hyper Causes
Value

Maintains GI Losses High fever, heatstroke

Sodium Na 135-145 concentration of Diuretics, burns, wound due to insensible water
ECF drainage loss, diabetes insipidus

Major ICF cation;

Acidosis
cellular and GI Losses – diarrhea,
Renal disease
Potassium K 3.5-5.0 metabolic functions vomiting, duretics,
K containing drugs
including cardiac diaphoresis
K salt substitute
rhythms

Transmission of Chronic renal failure,

nerve impulses, Vit D deficiency, Mult. Myeloma,
Calcium Ca 4.5-5.5 cardiac pancreatiti,s, loop thiazide diuretics,
contractions, bone, diuretics, diarrhea malignancies,
blood clotting hyporparathyroidism

Diarrhea, vomiting, NG Maalox and Milk of

Muscle, RBC’s and
Magnesium Mg 1.5-2.5 Suction, hyper Magnesia in patients
CNS, metabolism
aldosteronism with renal failure

Muscle, RBC’s, Malnourished, alcohol Renal failure,

Phosphate Phos 1.7-4.6 CNs, w/ Calcium in withdrawal, phosphate- chemoTx, enemas
bones and teeth binding antacids containing
 Objective Data
• Neck Vein Distention
• Central Venous Pressure
• Pulmonary Artery Pressure
• Bowel Assessment
• Laboratory and Diagnostic Tests
– Urine Tests
– Blood Tests
Central Venous Pressure or
Jugular Venous Distention
 Assessment
• Subjective Data
– Normal Pattern Identification
– Risk Identification
– Dysfunction Identification
• Objective Data—Physical Assessment
– Intake and Output
– Body Weight
– Integumentary Assessment
 Solution Osmolality Usage and Limitations
replaces NaCl deficit and restores/expands extracellular
NS - 0.9% NaCl Isotonic fluid volume; the only solution that may be
(308mOsm/L) administered with blood products--does not provide
free water that causes hemolysis of red blood cells

assists with renal function; provides free water, Na and

1/2 NS - 0.45%NaCl Hypotonic Cl.; replaces normal hypotonic daily fluid losses- assists
(154 mOsm/L) with daily body fluid needs, but not with electrolyte
replacement or provision of calories.

D5 1/2 NS - 5% Dextrose & Hypertonic to promote renal function and excretion; basically the
0.45NaCl (406 mOsm/L) same as .45NS except provides 170 calories per liter

to treat fluid volume deficit; for daily maintenance of

D5NS - 5% Dextrose & Hypertonic body fluids and nutrition; basically the same as NS,
0.9NaCl (559 mOsm/L) except provides 170 calories per liter

provides free water (hypotonic) to the extracellular and

intracellular spaces, as the dextrose is quickly
D5W - 5% Dextrose in water Isotonic metabolized; promotes renal elimination of solutes;
(252 mOsm/L) treats hypernatremia; does not provide electrolytes; one
liter is 170 calories

closely resemble the electrolyte composition of normal

Lactated Ringer’s Solution Isotonic blood serum and plasma; will need additional K; does
(273 mOsm/L) not provide calories or free water; used to treat losses
from lower GI tract and burns.

10% Dextran 40 in 0.9%NS Isotonic plasma expander

(308 mOsm/L)
 Third Spacing:
Loss of fluid into a space that cannot contribute
to ICF/ECF equilibrium
S&S: Urine output decreases
Increased heart rate
Decreased BP
Decreased CVP
Increased body weight
Edema
I & O imbalance

Causes: Burns
Ascites
Peritonitis
Bowel obstruction
Massive bleeding into joint or body cavity
 Factors Affecting
Fluid, Electrolyte, and Acid-Base
Balance

• Fluid and Food Intake

• Fluid and Electrolyte Output
• Stress
• Chronic Illnesses
• Surgery
• Pregnancy
 Acid Base Balance

Two systems work to maintain correct pH.

Respiratory System by adjusting respirations.

Metabolic system by adjusting serum HCO3

Acid Base Balance
 Acidosis
pH < 7.4

Decrease
d HCO3

Increase
d paCO2
Acid…………………Base
• High C02 • Low CO2
• Low HCO3 • High HCO3

pCO2 = 35-45
HCO3 = 22-28
 Respiratory Acidosis

• Hypoventilation for any reason

• COPD
• Paralysis of respiratory muscles
• Cardiac Arrest – Code
 Metabolic Acidosis

• Starvation
• DKA
• Renal Failure
• Lactic Acidosis from heavy exercise
• Drugs – EtOH, ASA
• Diarrhea
 Alkalosis
pH > 7.4

Increase
d HC03
Decreased
CO2
 Respiratory Alkalosis

– Hyperventilation from any cause

– Pneumonia
– Too high ventilator settings
 Metabolic Alkalosis

• Excessive vomiting
• Gastric suctioning
• Hypokalemia OR Hypercalcemia
• Excess aldosterone
• Drugs – Steroids, diuretics, NaHCO3
 Easy Read of Blood Gases
1. Check pH
2. <7.4 = Acidosis; > 7.4 = alkalosis
3. Which of the following parameters matches the
pH?
– CO2 or HCO3?
• High C02 is acid; low CO2 is alkaline- respiratory
• High HCO3 is alkaline; low HCO3 is acid -metabolic

Matching parameter + pH direction is diagnosis!

If both parameters match, then it is a combined _____; if opposite parameter

is abnormal, compensation is occurring.