1. Nursing Care
of Clients with
Altered Fluid,
Electrolyte, and
Acid–Base Balance

2. Fluid and Electrolyte Balance
Necessary for life, homeostasis
Nursing role: help prevent, treat fluid, electrolyte disturbances

3. Fluid Approximately 60% of typical adult is fluid Intracellular fluid
Varies with age, body size, gender
Intracellular fluid
Extracellular fluid
Intravascular
Interstitial
Transcellular
“Third spacing”: loss of ECF into space that does not contribute to equilibrium

4. Electrolytes
Active chemicals that carry positive (cations), negative (anions) electrical charges
Major cations: sodium, potassium, calcium, magnesium, hydrogen ions
Major anions: chloride, bicarbonate, phosphate, sulfate, and proteinate ions
Electrolyte concentrations differ in fluid compartments

5. Regulation of Fluid
Movement of fluid through capillary walls depends on
Hydrostatic pressure: exerted on walls of blood vessels
Osmotic pressure: exerted by protein in plasma
Direction of fluid movement depends on differences of hydrostatic, osmotic pressure

6. Regulation of Fluid
Osmosis: area of low solute concentration to area of high solute concentration
Diffusion: solutes move from area of higher concentration to one of lower concentration
Filtration: movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure
Active transport: physiologic pump that moves fluid from area of lower concentration of one of higher concentration

7. Active Transport
Physiologic pump that moves fluid from area of lower concentration to one of higher concentration
Movement against concentration gradient
Sodium-potassium pump: maintains higher concentration of extracellular sodium, intracellular potassium
Requires adenosine (ATP) for energy

8. Fluids Animation

9. Fluid Volume or Electrolyte Imbalance
Causes of fluid loss
Vomiting, diarrhea
Gastrointestinal suctioning, intestinal fistulas, and intestinal drainage
Diuretic therapy, renal disorders, endocrine disorders
Sweating from excessive exercise, increased environmental temperature
Hemorrhage
Chronic abuse of laxatives

10. Fluid Volume or Electrolyte Imbalance
Cause of Fluid Loss in the Older Adult
Self limiting fluids (fear of incontinence)
Physical disabilities
Cognitive impairments
Older adults without air conditioning

13. Fluid Volume Imbalances
Fluid volume deficit (FVD): hypovolemia
Fluid volume excess (FVE): hypervolemia

14. Fluid Volume Deficit
Loss of extracellular fluid exceeds intake ratio of water
Electrolytes lost in same proportion as they exist in normal body fluids
Dehydration: loss of water along with increased serum sodium level
May occur in combination with other imbalances

15. Fluid Volume Deficit (cont’d)
Dehydration
Causes: fluid loss from vomiting, diarrhea, GI suctioning, sweating, decreased intake, inability to gain access to fluid
Risk factors: diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third space shifts

16. Fluid Volume Deficit (cont’d)
Manifestations: rapid weight loss, decreased skin turgor, oliguria, concentrated urine, postural hypotension, rapid weak pulse, increased temperature, cool clammy skin due to vasoconstriction, lassitude, thirst, nausea, muscle weakness, cramps
Laboratory data: elevated BUN in relation to serum creatinine, increased hematocrit
Serum electrolyte changes may occur

18. Fluid Volume or Electrolyte Imbalance
Treatment for Fluid Volume Deficit (FVD)
Oral, intravenous, or enteral routes
Manage the effects and prevent further complications by monitoring intake, assessing lab values, and observing vital signs and skin integrity

19. Fluid Volume Deficit - Nursing Management
I&O, VS
Monitor for symptoms: skin and tongue turgor, mucosa, UO, mental status
Measures to minimize fluid loss
Oral care
Administration of oral fluids
Administration of parenteral fluids

20. Fluid Volume Excess
Due to fluid overload or diminished homeostatic mechanisms
Risk factors: heart failure, renal failure, cirrhosis of liver
Contributing factors: excessive dietary sodium or sodium-containing IV solutions
Manifestations: edema, distended neck veins, abnormal lung sounds (crackles), tachycardia, increased BP, pulse pressure and CVP, increased weight, increased UO, shortness of breath and wheezing
Medical management: directed at cause, restriction of fluids and sodium, administration of diuretics

21. Fluid Volume Excess - Nursing Management
I&O and daily weights; assess lung sounds, edema, other symptoms; monitor responses to medications- diuretics
Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions
Monitor, avoid sources of excessive sodium, including medications
Promote rest
Semi-Fowler’s position for orthopnea
Skin care, positioning/turning

22. Manifestations of Imbalances
Hyponatremia
Muscle cramps, weakness, fatigue
Dulled sensorium, irritability, personality changes
Hypernatremia
Most serious effects are seen in the brain
Lethargy, weakness, irritability can progress to seizures, coma, and death

23. Manifestations of Imbalances
Hypokalemia
EKG changes (flattened or inverted T waves)
Skeletal muscle weakness
Hyperkalemia
Cardiac arrest
Paresthesias
Abdominal cramping

24. Manifestations of Imbalances
Hypocalcemia
Tetany, paresthesias, muscle spasms
Hypotension
Anxiety, confusion, psychosis
Hypercalcemia
Muscle weakness, fatigue
Personality changes
Anorexia, nausea, vomiting

25. Manifestations of Imbalances
Hypomagnesemia
Muscle weakness and tremors
Dysphasia
Tachycardia hypertension
Mood and personality changes
Hypermagnesemia
Depressed deep tendon reflexes
Hypotension
Respiratory depression

26. Manifestations of Imbalances
Hypophosphatemia
Muscle pain and tenderness
Muscle weakness and paresthesias
Confusion
Manifestations of hypophosphatemia
Muscle spasms, tetany
Soft tissue calcifications

27. Maintaining Acid-Base Balance
Normal plasma pH : hydrogen ion concentration
Major extracellular fluid buffer system; bicarbonate-carbonic acid buffer system
Kidneys regulate bicarbonate in ECF
Lungs under control of medulla regulate CO2, carbonic acid in ECF

28. ACID–BASE DISTURBANCES
Plasma pH is an indicator of hydrogen ion (H+) concentration.
Normal range pH (7.35–7.45).
Buffer systems
Kidneys
Lungs
The H+ concentration is extremely important:
Increased concentration H+
Increased acidity
Lower the pH.
Deceased H+ concentration
Increased alkalinity
Higher the pH.
pH range compatible with life (6.8–7.8)

29. Acid-Base Disorders
Acidosis: hydrogen ion concentration above normal (pH below 7.35)
Alkalosis: hydrogen ion concentration below normal (pH above 7.45)
Metabolic Acidosis: bicarbonate is decreased in relation to the amount of acid

30. Acid-Base Disorders
Metabolic Alkalosis: excess of bicarbonate in relation to the amount of hydrogen ion
Respiratory Acidosis: CO2 is retained, caused by sudden failure of ventilation due to chest trauma, aspiration of foreign body, acute pneumonia, and overdose of narcotics or sedatives
Respiratory Alkalosis: CO2 is blown off, caused by mechanical ventilation and anxiety with hyperventilation

31. Arterial Blood Gases pH 7.35 - (7.4) - 7.45 PaCO2 35 - (40) - 45 mm Hg
HCO3ˉ 22 - (24) - 26 mEq/L
Assumed average values for ABG interpretation
PaO2 80 to 100 mm Hg
Oxygen saturation >94%
Base excess/deficit ±2 mEq/L

32. ACID–BASE DISTURBANCES AND COMPENSATION
DISORDER INITIAL EVENT COMPENSATION
Respiratory acidosis ↑ PaCO2, ↑ or normal Kidneys eliminate H and HCO3 −, ↓ pH retain HCO3−
Respiratory alkalosis ↓ PaCO2, ↓ or normal Kidneys conserve H+ and HCO3−, ↑ pH excrete HCO3−
Metabolic acidosis ↓ or normal PaCO2, Lungs eliminate CO2, ↓ HCO3−, ↓ pH conserve HCO3−
Metabolic alkalosis ↑ or normal PaCO2, Lungs ↓ ventilation to↑ ↑ HCO3−, ↑ pH PCO2, kidneys conserve H+ to excrete HCO3−

33. IV Site Selection

34. Complications of IV Therapy
Fluid overload
Air embolism
Septicemia, other infections
Infiltration, extravasation
Phlebitis
Thrombophlebitis
Hematoma
Clotting, obstruction