Fundamentals of Fluids and Electrolytes Balance

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Sodium (Na++)

Physiological roles of Sodium

• Sodium helps to transmit nerve impulses
• Sodium assists in the osmolality of vascular fluids

The combination of sodium with chlorides or bicarbonate helps to regulate Acid -base balance.

• Sodium is responsible in maintaining water balance.
• Sodium is responsible for ECF volume.

Sodium Imbalance occurs when:

• There is a change in the sodium volume of the ECF
• There is a change in the chloride content
• There is a change in the quantity of water in the ECF

Effects of Serum Sodium Deficit

Hyponatremia

• Hyponatremia is a condition that occurs when the serum sodium level falls below normal [ that is less that 135nEq/L], so it occurs when there is High amount of water or reduction in sodium content. Sodium deficits are related to Hypervolemia conditions.
• Hyponatremia can also occur when there is an abnormal loss of gastrointestinal secretions.
• It also occurs when excessive sweating results in high volume of water consumption.
• Labor induction in women with Oxytocin can cause the reduction of sodium volume thereby, causing a dilutional Hyponatremia

Clinical Manifestations of Hyponatremia

Hyponatremia affects cells of the central nervous system, thus patients will experience:

• Impaired sensation of taste
• Muscle cramps
• Anorexia
• Anxiety
• Exhaustion
• Weakness

Treatment and Management of Hyponatremia

Patients can be treated using:

• Diets [ for those that can eat and drink]
• Parenteral routes [ patients unable to eat will have to take the electrolytes]
• Note that this treatment aims at replacing lost sodium
• Restoring the ECF volume to normal
• Correcting other losses in electrolytes
• Carefully examine laboratory test with emphasis on serum sodium
• Examine GI losses
• Monitor the intake , output plus daily weight of the patients
• Examine the signs and symptoms of Hyponatremia
• Restrict water intake.

Effects of Serum Sodium Excess

Hypernatremia

• Hypernatremia occurs when there is an elevation of serum sodium volume and a loss of water content
• Clinical Manifestations of Hypernatremia
• Patients’ experiences marked thirst
• High body temperature
• Swollen tongue
• Red, dry and sticky mucous membrane.

Treatment and Management of Hypernatremia

• The aim of this treatment is to lower the serum sodium content
• This can be achieved by infusion of a hypotonic electrolyte solution
• The use of diuretics
• The administration of Desmopressin acetate
• Discontinuing any medication that may be the cause of this elevated sodium content

Potassium (K+)

• Potassium is an intracellular electrolyte with 98% in the ICF and 2% in the ECF it is acquired through diet.
• Potassium helps to regulate fluid volume in the cell
• It promotes nerve impulse transmissions
• Potassium controls the hydrogen ion balance
• Potassium plays a part in the enzyme action of cellular energy production.
• Influences skeletal and cardiac muscle activity
• Potassium imbalance can occur when there is either an increase or decrease in the volume of serum potassium

Effects of potassium deficit [Hypokalemia]

• When the potassium level drops below 3.5mEq/L
• Excessive sweating
• Gastrointestinal loss due to laxative overuse or prolonged gastric suction

Clinical Manifestations

• Patients suffer weakness
• Diminished tendon reflexes
• Flaction paralysis
• Vomiting
• Increased sensibility to digitals
• Cardiac arrest

Treatment and Management of Hypokalemia

• This treatment must be administered slowly to watch for dysrhythmias
• Potassium replacement can be by mouth or intravenous.
• Salt substitutes can be used
• Never give a potassium I.V. push/Bolus.
• Make sure the test results are carefully examined
• Monitor signs and symptoms of hypokalemia
• Monitor changes in cardiac arrest

Effect of Potassium Excess [Hyperkalemia]

• Occurs less frequent. But more deadly than Hypokalemia. it is a function of excess serum potassium

Causes of Hyperkalemia

• It is caused by an increase in the volume of serum potassium
• It occurs when there is a decrease of urinary excretion of potassium
• It is caused by the movement of potassium out of the cells into extracellular space.
• Some drugs can predispose an individual to hyperkalemia , these drugs include potassium penicillin, beta blockers, amphetamines

Clinical Manifestations

• Irregular pulse
• Vague muscle weakness
• Paralysis
• Anxiety
• Cramping
• Nausea

Treatment / Management

• The aim of treatment is to return the serum potassium to the normal level while treating the cause.
• Stop the intake of potassium
• Discontinues supplements of potassium
• Introduction of cation – exchange resins
• Dialysis may be ordered
• Glucose and insulin should be administered to facilitate movement of potassium

Calcium (CA++)

Physiological Roles of calcium include:

• Maintaining skeletal elements for strong bones and teeth
• Regulates neuromuscular activity
• Influences enzyme activity
• Calcium helps in holding the cells together
• Calcium is present in three forms
• Ionized calcium, bound calcium and complex calcium

Effects of Serum Calcium deficit [Hypocalcaemia]

• Hypocalcaemia occurs when serum is low
• It is caused by inadequate secretion of PTH
• It can also result from calcium loss through diarrhea
• It can also result from radiographic contrast media

Clinical Manifestations

• Patients with hypocalcaemia show symptoms of neuromuscular such as numbness
• Cramps
• Deep tendon reflexes
• Deep irritability
• Memory impairment
• Development of laryngospasm and tetany contractions

Effects of Serum Calcium Excess Hypercalcemia

• It is caused by an increase in calcium content from its intake.
• Some drugs predispose Hypercalcemia, and they include Calcium salts , Megadozes of Vitamins A or D

Treatment / Management

• Causative disease must be treated
• Administer saline diuresis
• Administer inorganic phosphate salts orally
• Use furosemide to prevent volume overloading during saline administration
• Give bisphosphonates to inhibit bone reabsorption
• Administer calcitonin 4 to 8 U/kg intramuscularly.
• Monitor changes in vital signs
• Keep accurate fluids intake and output records
• Keep the patient off calcium foods.

Magnesium (MG++)

Physiologic Roles of Magnesium

• Magnesium influences enzyme action
• It regulates neuromuscular activity
• It regulates electrolyte balance

Effect of Serum magnesium Deficit [ Hypomagnesaemia]

• It occurs when the serum magnesium content drops below 1.0mEq/L
• It can result from chronic alcoholism, prolonged malnutrition , prolonged diarrhea

Clinical Manifestations

• Patients with Hypomagnesaemia show signs of neuromuscular symptoms
• Painful cold hands and feet
• Muscle cramps
• Coarse tremors

Laboratory Findings

• Serum magnesium drops less than 1.5mEq/L
• Urine magnesium helps to identify renal causes of magnesium depletion
• Serum calcium is reduced because of a reduction in the release and action of PTH

Treatments / Management

• Administer oral magnesium salts
• Give 4g diluted in 250mL of 5% dextrose in water at 3mL/min
• Give 1 to 2 g diluted 10mL of 5% dextrose in water by direct I.V push at a rate of 1.5ml/min

Effect of Excess Serum Magnesium Hypomagnesaemia

• It occurs when the patients serum magnesium is greater than 2.5mEq/L,
• It is caused by renal failure in patients who has increased intake of magnesium

Clinical Manifestations

• It causes depression of peripheral and central neuromuscular transmissions
• Vomiting
• Seizures
• Nausea

Treatment / Management

• The goal is to remove the cause of Hypomagnesaemia avoid using medications containing magnesium
• Administer diuretics and then administer I.V calcium gluconate
• Support respiratory function
• Administer peritoneal or hemodialysis
• Observe for flushing of skin and monitor for ECG changes
• Encourage fluid intake and provide ventilatory assistance

Phosphate (PO4-)

• Phosphorus is essential to all cells
• Influences metabolism
• Essential to energy formation
• It is a cellular building block
• It helps to deliver oxygen

Effects of Serum Phosphate deficit [ Hypophosphatemia]

• When the serum level drops below 2.5mg/dL Hypophosphatemia can occur

Clinical manifestations

• It affects the CNS
• Patients experience disorientation
• Confusion
• Weakness
• Profound muscle weakness
• Congestive cardiomyopathy

Laboratory Findings

• Serum phosphorus drops less than 2.5mg/dL
• Patients show skeletal changes of osteomalacia
• Patients show increase osteoblastic activity
• PTH is elevated

Treatments / Management

• Oral phosphate supplements are given
• Administer I.V sodium phosphorus

Effects of Serum Phosphate deficit [ Hypophosphatemia]

Hypophosphatemia occurs whenever there is renal insufficiency , hyperparathyroidism, or increased catabolism. This illness can be seen in severe cancer conditions such as myelogenous and lymphoma.

Clinical Manifestations

• Patients with hypophosphatemia experience confusion
• Coma, and increased 2,3- DPG levels in red blood cells

Treatment / Management

• Identify the cause if illness
• Restrict dietary intake
• Administer the intake of phosphate -binding gels
• Monitor for cardiac, GI abnormalities
• Keep accurate records

Chloride (CL-)

Physiological Role

• Chloride regulates serum osmolality
• Regulates fluid balance
• Control acidity of gastric juice
• Regulate acid-base balance
• Influences oxygen carbon dioxide exchange

Acid – Base Balance

The regulation of hydrogen ion concentration of body fluids is the key component of acid -base balance.

Three mechanisms operate to maintain the pH of the blood

• Chemical buffer systems in the ECF and within the cells
• Removal of carbon dioxide from the lungs
• Renal regulation of the hydrogen ion concentration

There are two types of Acid -base Imbalance

• Metabolic deficit or excess
• Respiratory deficit or excess

Chemical Buffer Systems

• Buffer systems protect against changes in the hydrogen ion of the ECF
• A buffer is a substance that reacts to minimize pH changes whenever acid or base is released into the system
• Hemoglobin and deoxyhemoglobin acts as buffer pairs together with their potassium salts.
• Plasma proteins act as a buffer
• The bicarbonates buffer system maintains the blood’s pH
• Acid Imbalance occurs when a strong acid is added to the body

Respiratory Regulation

• Lungs form a defense mechanism in maintaining acid – base balance
• Rate of respiration affects the hydrogen ion concentration
• The combination of carbon dioxide with water produces H2CO3so an increase in the acid , lowers the pH of the blood

Renal Regulation

• The Kidney regulates the Hydrogen ion by increasing or decreasing HCO3- in the body fluids
• The kidney regulates the extracellular concentration of H2CO3
• Phosphate buffer system and ammonia buffer systems helps the kidney to eliminate excess hydrogen

Metabolic Acid- Base Imbalance

• Metabolic Acidosis : Base Bicarbonate Deficit
• Metabolic Acidosis is a clinical disturbance which consist of a low pH and low plasma level
• This condition occurs by a gain of hydrogen ion or a loss
• Occurs with loss of HCO3- from diarrhea, draining fistulas

Clinician manifestations

• Patients experience headache,
• Confusion nausea
• Vomiting
• Increased respiratory rate

Laboratory findings

• ABG values PH less than 7.35
• Paco2 : Less than 38 mm Hg
• Serum electrolytes : Elevated potassium possible
• ECG : Dysrhythmias caused by hyperkalemia

Treatment/ Management

• Reverse underlying cause
• Eliminate the source
• Administer NaHCO3
• Potassium replacement

Key Nursing Interventions

• Provide safety precautions when patient is confused
• Monitor for signs and symptoms of Metabolic Acidosis
• Monitor laboratory changes

Metabolic Alkalosis : Bicarbonate Excess

• It is a clinical disturbance Characterized by a high pH and high Plasma and can be
• Produced by the gain or loss of hydrogen ion
• It occurs with GI loss of hydrogen ions from gastric suction and vomiting.
• Occurs when excessive ingestion of alkalis

Clinical Manifestations

• Dizziness and depressed respirations
• Hyperventilation

Laboratory findings

• ABG values pH greater than 7.45
• Low serum potassium
• Low serum chloride

Treatment / Management

• Reverse the cause
• Administer sufficient chloride for the kidney to excrete the excess ion
• Replace hydrogen
• Carbonic anhydrase inhibitors

Metabolic Alkalosis : Bicarbonate Excess

• It is a clinical disturbance Characterized by a high pH and high Plasma and can be
• Produced by the gain or loss of hydrogen ion
• It occurs with GI loss of hydrogen ions from gastric suction and vomiting.
• Occurs when excessive ingestion of alkalis

Clinical Manifestations

• Dizziness and depressed respirations
• Hyperventilation

Laboratory findings

• ABG values pH greater than 7.45
• Low serum potassium
• Low serum chloride

Treatment / Management

• Reverse the cause
• Administer sufficient chloride for the kidney to excrete the excess ion
• Replace hydrogen
• Carbonic anhydrase inhibitors

Respiratory Acidosis : carbonic Acid Excess

• Caused by inadequate excretion of carbon dioxide and inadequate ventilation
• Chronic respiratory acidosis results from obesity, and tight abdominal binders

Clinical Manifestations

• Dizziness
• Flushed skin
• Ventricular fibrillation

Nursing process

• It is a five or six step process for problem solving
• Laboratory findings
• ABG values pH less than 7.35
• Serum electrolytes not altered
• Drug screen

Treatment / Management

• Restore normal acid -base balance
• Administer bronchodilators or antibiotics
• Administer oxygen and adequate fluids

Respiratory Alkalosis : Carbonic Acid Deficit

• Caused by hyperventilation which causes blowing off of carbon dioxide and a
• Decrease in hydrogen ion content
• Caused by congestive heart failure, asthma,
• Inhalation of irritants

Clinical manifestations

• Cause light- headedness
• Inability to concentrate
• Blurred vision, seizures, loss of consciousness

Treatment/ Management

• Treat source of anxiety
• Administer a sedative as indicated
• Oxygen therapy
• Adjust ventilators

Case Study 2

The 28 year old woman lost 9.2% of her body weight upon admissionю

Laboratory Findings include

• Drop in serum potassium level
• Increased pH and bicarbonate ions [ Arterial blood gas]
• Increase insulin secretion and osmotic pressure
• Depression

Nursing Interventions

• This treatment must be administered slowly to watch for dysrhythmias
• Potassium replacement can be by mouth or intravenous
• Salt substitutes can be used
• Never give a potassium I.V. push/Bolus
• Make sure the test results are carefully examined
• Monitor signs and symptoms of hypokalemia
• Monitor changes in cardiac arrest
• Never administer potassium by I.V push

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