Imbalance

Contributing Factors

Signs/Symptoms and Laboratory Findings

Fluid volume decit (hypovolemia)

Loss of water and electrolytes, as in vomiting, diarrhea, stulas, fever, excess sweating, burns, blood loss, gastrointestinal suction, and third-space uid shifts; and decreased intake, as in anorexia, nausea, and inability to gain access to uid. Diabetes insipidus and uncontrolled diabetes mellitus also contribute to a depletion of extracellular uid volume.

Fluid volume excess (hypervolemia)

Sodium decit (hyponatremia) Serum sodium _135 mEq/L

Acute weight loss, decrease skin turgor, oliguria, concentrated urine, weak rapid pulse, capillary lling time prolonged, low CVP, decrease blood pressure, attened neck veins, dizziness, weakness, thirst and confusion, increase pulse, muscle cramps, sunken eyes Labs indicate: increase hemoglobin and hematocrit, increase serum and urine osmolality and specic gravity, decrease urine sodium, increase BUN and creatinine, increase urine specic gravity and osmolality Compromised regulatory Acute weight gain, peripheral mechanisms, such as renal edema and ascites, distended failure, heart failure, and jugular veins, crackles, cirrhosis; overzealous elevated CVP, shortness of administration of sodiumbreath, increase blood containing uids; and uid pressure, bounding pulse and shifts (ie, treatment of burns). cough, increase respiratory Prolonged corticosteroid rate therapy, severe stress, and Labs indicate: decrease hyperaldosteronism augment hemoglobin and hematocrit, uid volume excess. decrease serum and urine osmolality, decrease urine sodium and specic gravity Loss of sodium, as in use of Anorexia, nausea and diuretics, loss of GI uids, vomiting, headache, lethargy, renal disease, and adrenal dizziness, confusion, muscle insufciency. Gain of water, cramps and weakness, as in excessive administration muscular twitching, seizures, of DW and water supplements papilledema, dry skin, for patients receiving increase pulse, decrease BP, hypotonic tube feedings; weight gain, edema disease states associated with Labs indicate: decrease serum

SIADH such as head trauma and oat-cell lung tumor; medications associated with water retention (oxytocin and certain tranquilizers); and psychogenic polydipsia. Hyperglycemia and heart failure cause a loss of sodium. Sodium excess (hypernatremia) Serum sodium _145 mEq/L Water deprivation in patients unable to drink at will, hypertonic tube feedings without adequate water supplements, diabetes insipidus, heatstroke, hyperventilation, watery diarrhea, burns, and diaphoresis. Excess corticosteroid, sodium bicarbonate, and sodium chloride administration, and salt water near-drowning victims

and urine sodium, decrease urine specic gravity and osmolality

Potassium decit (hypokalemia) Serum potassium _3.5 mEq/L

Potassium excess (hyperkalemia) Serum potassium _5.0 mEq/L

Thirst, elevated body temperature, swollen dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, focal or grand mal seizures, pulmonary edema, hyperreexia, twitching, nausea, vomiting, anorexia, increase pulse, and increase BP Labs indicate: increase serum sodium, decrease urine sodium, increase urine specic gravity and osmolality, decrease CVP Diarrhea, vomiting, gastric Fatigue, anorexia, nausea and suction, corticosteroid vomiting, muscle weakness, administration, polyuria, decreased bowel hyperaldosteronism, motility, ventricular asystole carbenicillin, amphotericin B, or brillation, paresthesias, bulimia, osmotic diuresis, leg cramps, decrease BP, alkalosis, starvation, diuretics, ileus, abdominal distention, and digoxin toxicity hypoactive reexes. ECG: attened T waves, prominent U waves, ST depression, prolonged PR interval Pseudohyperkalemia, oliguric Muscle weakness, renal failure, use of tachycardia bradycardia, potassium-conserving dysrhythmias, accid diuretics in patients with renal paralysis, paresthesias, insufciency, metabolic intestinal colic, cramps, acidosis, Addisons disease, abdominal distention, crush injury, burns, stored irritability, anxiety. bank blood transfusions, rapid ECG: tall tented T waves,

Calcium decit (hypocalcemia) Serum calcium _8.5 mg/dL

Calcium excess (hypercalcemia) Serum calcium _10.5 mg/dL

Magnesium decit (hypomagnesemia) Serum magnesium _1.8 mg/dL

IV administration of potassium, and certain medications such as ACE inhibitors, NSAIDs, cyclosporine Hypoparathyroidism (may follow thyroid surgery or radical neck dissection), malabsorption, pancreatitis, alkalosis, vitamin D deciency, massive subcutaneous infection, generalized peritonitis, massive transfusion of citrated blood, chronic diarrhea, decreased parathyroid hormone, diuretic phase of renal failure, c PO , stulas, burns, alcoholism Hyperparathyroidism, malignant neoplastic disease, prolonged immobilization, overuse of calcium supplements, vitamin D excess, oliguric phase of renal failure, acidosis, corticosteroid therapy, thiazide diuretic use, increased parathyroid hormone, and digoxin toxicity Chronic alcoholism, hyperparathyroidism, hyperaldosteronism, diuretic phase of renal failure, malabsorptive disorders, diabetic ketoacidosis, refeeding after starvation, parenteral nutrition, chronic laxative use, diarrhea, acute myocardial infarction, heart failure, decreased serum K and Ca and certain pharmacologic agents (such

prolonged PR interval and QRS duration, absent P waves, ST depression

Numbness, tingling of ngers, toes, and circumoral region; positive Trousseaus sign and Chvosteks sign; seizures, carpopedal spasms, hyperactive deep tendon reexes, irritability, bronchospasm, anxiety, impaired clotting time, decrease prothrombin, diarrhea, decrease BP. ECG: prolonged QT interval and lengthened ST Labs indicate: Decrease Mg Muscular weakness, constipation, anorexia, nausea and vomiting, polyuria and polydipsia, dehydration, hypoactive deep tendon reexes, lethargy, deep bone pain, pathologic fractures, ank pain, calcium stones, hypertension. ECG: shortened ST segment and QT interval, bradycardia, heart blocks Neuromuscular irritability, positive Trousseaus and Chvosteks signs, insomnia, mood changes, anorexia, vomiting, increased tendon reflexes, and increase BP. ECG: PVCs, flat or inverted T waves, depressed ST segment, prolonged PR interval, and widened QRS

Magnesium excess (hypermagnesemia) Serum magnesium _2.7 mg/dL

as gentamicin, cisplatin, and cyclosporine) __ Oliguric phase of renal failure (particularly when magnesium-containing medications are administered), adrenal insufciency, excessive IV magnesium administration, diabetic ketoacidosis, and hypothyroidism Refeeding after starvation, alcohol withdrawal, diabetic ketoacidosis, respiratory and metabolic alkalosis, decrease magnesium, decrease potassium, hyperparathyroidism, vomiting, diarrhea, hyperventilation, vitamin D deciency associated with malabsorptive disorders, burns, acidbase disorders, parenteral nutrition, and diuretic and antacid use Acute and chronic renal failure, excessive intake of phosphorus, vitamin D excess, respiratory and metabolic acidosis, hypoparathyroidism, volume depletion, leukemia/lymphoma treated with cytotoxic agents, increased tissue breakdown, rhabdomyolysis Addisons disease, reduced chloride intake or absorption, untreated diabetic ketoacidosis, chronic respiratory acidosis, excessive sweating, vomiting, gastric suction, diarrhea, sodium and

Phosphorus decit (hypophosphatemia) Serum phosphorus _2.5 mg/dL

Flushing, hypotension, muscle weakness, drowsiness, hypoactive reexes, depressed respirations, cardiac arrest and coma, diaphoresis. ECG: tachycardia bradycardia, prolonged PR interval and QRS, peaked T waves Paresthesias, muscle weakness, bone pain and tenderness, chest pain, confusion, cardiomyopathy, respiratory failure, seizures, tissue hypoxia, and increased susceptibility to infection, nystagmus

Phosphorus excess (hyperphosphatemia) Serum phosphorus _4.5 mg/dL

Tetany, tachycardia, anorexia, nausea and vomiting, muscle weakness, signs and symptoms of hypocalcemia; hyperactive reexes; soft tissue calcications in lungs, heart, kidneys, and cornea

Chloride decit (hypochloremia) Serum chloride _96 mEq/L

Agitation, irritability, tremors, muscle cramps, hyperactive deep tendon reexes, hypertonicity, tetany, slow shallow respirations, seizures, dysrhythmias, coma Labs indicate: decrease

Chloride excess (hyperchloremia) Serum chloride _108 mEq/L

potassium deciency, metabolic alkalosis; loop, osmotic, or thiazide diuretic use; overuse of bicarbonate, rapid removal of ascitic uid with a high sodium content, intravenous uids that lack chloride (dextrose and water), draining stulas and ileostomies, heart failure, cystic brosis Excessive sodium chloride infusions with water loss, head injury (sodium retention), hypernatremia, renal failure, corticosteroid use, dehydration, severe diarrhea (loss of bicarbonate), respiratory alkalosis, administration of diuretics, overdose of salicylates, Kayexalate, acetazolamide, phenylbutazone and ammonium chloride use, hyperparathyroidism, metabolic acidosis

serum chloride, decrease serum sodium, increase pH, increase serum bicarbonate, increase total carbon dioxide content, decrease urine chloride level, decrease serum potassium

Tachypnea, lethargy, weakness, deep rapid respirations, decline in cognitive status, decrease cardiac output, dyspnea, tachycardia, pitting edema, dysrhythmias, coma Labs indicate: increase serum chloride, increase serum potassium and sodium, decrease serum pH, decrease serum bicarbonate, normal anion gap, increase urinary chloride level