Fluid, Electrolyte, and Acid-Base Balance

Physiology of Fluid

 The body normally maintains a balance between the

amount of fluid taken in and the amount excreted.
The body’s fluid is contained within three
compartments:
1. Intracellular fluid: within the cell.
2. Intra vascular fluid: within blood vessels.
3. Interstitial fluid: between cells; fluid that
surrounds cells.
 Body Water Distribution

There are two types of body fluid

1. Intracellular fluid (ICF)
2. Extracellular fluid (ECF)
 Water is present in all body tissues and cells, and
serves two main functions:
1. to act as a solvent for the essential nutrients, so that
they can be used by the body.
2. transport nutrients and oxygen from the blood to the
cells and to remove waste material and other substance
from the cells back to the blood so they can be excreted
by the body.
- Water is also needed by the body to:
1. Give shape and form to the cells
2. Regulate body temperature
3. Act as a lubricant in joints

- Electrolytes :produce either positively charged

(cations) or negatively charged (anions)
 they are critical regulators in the distribution of
body fluid.
 Movement of Body Fluids

Diffusion:
 A solute in a solution moves from an area of higher
concentration to an area of lower concentration.

 smaller molecules or a gas diffuse faster than larger

molecules.

 The temperature of the solution (higher

temperatures increase the rate of diffusion.
Osmosis
 Is the movement of water across a semipermeable
membrane from an area of lower concentration to
one that has higher concentration.

 Osmotic pressure: Draws water from a less

concentrated solution to the more concentrated side.
Osmolality is the measure of a solution’s ability to
create osmotic pressure.
Active Transport
 is the movement of molecules across a membrane from a
region of their lower concentration to a region of their
higher concentration—in the direction against the
concentration gradient. Active transport requires
cellular energy to achieve this movement.
 Hydrostatic Pressure
The pressure exerted by a fluid at equilibrium at a given
point within the fluid, due to the force of gravity.
Filtration
The movement of fluid through semipermeable
membrane from an area with higher hydrostatic pressure
to an area with lower hydrostatic pressure creates an
outward gain of fluid in the interstitial spaces.
 Colloid Osmotic Pressure

Oncotic pressure, or colloid osmotic pressure, is a

form of osmotic pressure exerted by proteins, notably
albumin, in a blood vessel's plasma (blood/liquid)
that usually tends to pull water into the circulatory
system. It is the opposing force to hydrostatic
pressure.
 Regulators of Fluid Balance
 Regulation: Homeostasis is the process by which
body fluids are maintained in balance. Body fluids
are regulated through:
 Fluid intake: The thirst mechanism influences fluid
intake. Through its control centre in the
hypothalamus, thirst develops when osmolality
increases. Eating salty food can increase osmotic
pressure of the body fluids and stimulate the thirst
mechanism. Increased plasma osmolality can occur
in impaired oral fluid intake, hypertonic fluid
intake, or when fluids are lost.
Normal daily body Fluid intake for an adult:
 Ingested liquids 1500 ml
 Water in foods 700 ml
 Water from oxidation 200 ml
 TOTAL 2400 m
 Hormonal regulation: Antidiuretic hormone
(ADH), stored in the pituitary gland, is
released when there is an increase in
osmolarity. ADH acts on the kidneys and
prevents diuresis.
 Aldosterone (produced in the adrenal
cortex) causes the reabsorption of sodium
from the renal tubules. The increased
reabsorption of sodium causes water
retention in the extracellular fluid,
increasing its volume.
 Renin, which is released from the juxtaglomerular cells
of the kidneys, promotes vasoconstriction and the
release of aldosterone

The interaction of these hormones with regard to renal

functions serves as the body’s compensatory mechanism
to maintain homeostasis.
 Fluid output regulation: Fluid output occurs through
the:
 Kidneys: They receive about 180 L of plasma to
filter each day, and produce 1.2 to 1.5 L of urine.
 Skin: Fluid loss of 500 to 600 ml daily. Because the
 person is not aware of this water loss, it is called
insensible loss.
 Lungs: They expire about 400 ml of water daily.
 Gastrointestinal Tract :about 200 ml of water is lost
per day in feces.
Regulation of Electrolytes and Acid-Base Balance

Electrolytes:
Cations:
 Sodium Na+: (90% ECF) 135–154(mEq/L) Controls
water distribution between ECF and intracellular fluid
(ICF) compartments.
 Regulated by dietary intake and aldosterone secretion.

 Potassium K+: (2% ECF). 3.5–5 .Regulates osmolality

of ICF
 Promotes contraction of skeletal and smooth muscles.
 Regulated through renal excretion and dietary intake
(bananas, oranges, and dried fruits ).
Calcium (Ca2+) 4.5–5.5 Provides strength and
durability to bones and teeth. Establishes thickness
 Is essential for blood coagulation.
 Promotes absorption and utilization of vitamin
B12.
 Regulated through dietary intake (Dairy products
(milk, cheese, and yogurt), vitamin D and
parathyroid hormone
 Magnesium (Mg2+) 4.5–5.5 Promotes regulation of
serum calcium, phosphorus, and potassium levels.
 Regulated through dietary intake (Green leafy
vegetables, whole grains, fish, and nuts).

 Anions:

 Chloride Cl−: Regulated through dietary intake and the

kidneys.
 Bicarbonate HCO3-: Essential to acid-base balance. It is
regulated by the kidneys.
 Phosphorus-phosphate (PO4-3): Assists in acid-base
regulation, bone and teeth development. Regulated by
dietary intake, renal excretion, intestinal and absorption.
Acid-Base Balance
 Acid-base: For an optimal functioning of cells, a balance
between acids and bases must be maintained.
 Acid-base: refers to the homeostasis of the hydrogen ion
concentration in extracellular fluid
 The slightest variation in the hydrogen ion concentration
causes marked alterations in the rate of cellular chemical
reactions.
 Normal pH range of extracellular fluid7.35 to 7.45
 As the number of hydrogen ions increases, the fluid
becomes acidic. Acidity of a solution increases as the pH
value decreases.
 An acid is a substance that donates hydrogen ions For
example, hydrochloric acid (HCl).
 A base is a substance that accepts hydrogen ions (proton
acceptor).
 Alkalinity of a solution increases as the pH value
increases.
 pH value becomes less than 7.35, the body is in a state
of acidosis.
 a pH value higher than 7.45 results alkalosis.
Regulators of Acid-Base Balance

The body has three main control systems that regulate

acid-base balance to counter acidosis or alkalosis:
1. buffer systems
2. respiration;
3. renal
These systems vary in their reaction time in regulating and
restoring balance to the hydrogen ion concentration of a
solution.
Buffer Systems:-

 (a solution containing two or more chemical

compounds that prevents marked changes in
hydrogen ion
concentration when either an acid or a base is
added to a solution).
 The buffer system reacts within a fraction of
a second to prevent excessive changes in the
hydrogen
ion concentration.
Respiratory Regulation
of Acid-Base Balance
 The respiratory buffering system helps to maintain acid
base balance by controlling the content of carbon
dioxide in extracellular fluid.
 With the increase of carbon dioxide in extracellular
fluids, respirations are increased in rate and depth so that
more carbon dioxide is exhaled. As the respiratory
system removes carbon dioxide, there is less carbon
dioxide in the blood to combine with water to form
carbonic acid.
 if the blood level of carbon dioxide is low, respirations
are depressed to maintain a normal ratio between carbonic
acid and basic bicarbonate.
Renal Control of
Hydrogen Ion Concentration
 The kidneys control extracellular fluid pH by
eliminating either hydrogen ions or bicarbonate ions
from body fluids.
 If the bicarbonate concentration in the extracellular
fluid is greater than normal, the kidneys excrete more
bicarbonate ions, making the urine more alkaline.
 function over a minutes the respiratory compensatory
mechanism
 Kidneys can function over a period of several hours or
days to correct an acid-base imbalance.
factors affecting fluid
and electrolyte balance
Age
 Body water distribution is relative to body size.
The
smaller the body, the larger the fluid content:
 Adult, 60% water
• Child, 60% to 77% water
• Infant, 77% water
• Embryo, 97% water
Lifestyle
 Diet
 stress, exercise
 Disturbances in electrolyte
In health, normal homeostatic mechanisms function to
maintain electrolyte and acid-base balance.
Sodium imbalance: Treatment depends on the cause.
Hyponatremia
Hyponatremia is a deficit in the extracellular level of
sodium.
 With hyponatremia, there is either a sodium deficit or a
water excess .
 The water moves out of the vascular space into the
interstitial space and then into the intracellular space,
causing edema.
Hyponatremia: May result from:
1. kidney disease
2. using diuretics
3. Low sodium intake
4. High water intake
5. Anorexia nervosa
Clinical Manifestations
Cognitive and sensory
 Headaches
 Apprehension
 Lethargy
 Confusion
 Depression
 Convulsion
 Muscular weakness
 Dry, pale skin
 Dry mucous membranes
Oxygenation and ECG
 Tachycardia
 Hypotension
Nutrition and metabolism
• Nausea
• Vomiting
• Diarrhea
Nursing Interventions:
 Administer comfort measures as needed.
 Monitor level of consciousness.
 Institute safety measures for seizures.
 Monitor serum sodium levels.
 Administer IV isotonic solution(0.9%
NaCl) per order.
 Monitor hourly vital signs and I&O
Hypernatremia
is an excess in the extracellular level of sodium.
With an excess of sodium or a loss of water.
 pulls fluid out of the cells into the extracellular
space.
Hypernatremia Causes:-
 High sodium intake
 Low water intake
 diabetes insipidus
 Severe GI loss (diarrhea and vomiting) and etc...
Clinical Manifestations
 Restlessness consciousness.
 Agitation.
 Delirium
 Twitching
 Convulsions
 Coma and etc...
Nursing Interventions:
 Monitor the client’s level of consciousness.
 Institute safety measures for seizures.
 Administer oral hygiene hourly.
 Monitor vital signs hourly.
Potassium
 slightest decrease or increase of Potassium can
cause serious or life-threatening effects on
physiological functions.
 A reciprocal relationship exists between sodium and
potassium; large sodium intake results in an
increased loss of potassium, and vice versa.
Hypokalemia
is a decrease in the extracellular level of potassium.
Causes of Hypokalemia :-
 Malnutrition
 Starvation
 Diabetes mellitus
 Laxative abuse
 Potassium-depleting diuretics (thiazide and
furosemide)
 Steroids and etc...
Hypokalemia
Clinical Manifestations
 Motility (hypoactive → absent bowel sounds)
 Abdominal distention
 Paralytic ileus
 Nausea
 Vomiting
 Malaise Disorientation
 Coma
 Muscle weakness
 Constipation
 Polyuria
 Tachycardia
 ↓ Peripheral pulses
Nursing Interventions:
 Administer potassium replacement as ordered .
 Monitor IV site for phlebitis and infiltration.
 Monitor I&O hourly.
 Monitor vital signs hourly.
 Monitor heart rate and rhythm.
NURSING ALERT
Hypokalemia can cause a cardiac arrest when:
The potassium level is less than 2.5 mEq/L.
 Hyperkalemia
Hyperkalemia
 Hyperkalemia is an increase in the extracellular
level of
potassium.
cause hyperkalemia:
 Acute and chronic renal failure
 Potassium-sparing diuretics
 Central nervous system agents
 Oral and intravenous replacement potassium salts
 Oral potassium supplement
Calcium
 Most of the body’s calcium (99%) is deposited in
bone
as phosphate and carbonate. The remaining 1% is in
the blood plasma (serum).
Hypocalcemia
Hypocalcemia is a decrease in the extracellular level
of
calcium.
causes of Hypocalcemia
 Inadequate dietary intake of calcium- rich foods
 Poor vitamin D intake and absorption
 Diarrhea
 Wound drainage
Clinical Manifestations

 Anxiety, irritability
 Tetany
 Convulsions
 Abdominal and muscle cramps
Nursing Interventions
 Administer 10% IV solution of
calciumgluconate, observe IV solutions with
calcium for infiltration.
 Teach a diet high in calcium with
 vitamin D supplement.
Hypercalcemia is an increase in the extracellular level
of calcium.
NURSING ALERT
Hypercalcemic Crisis
A rapid increase in the extracellular level of calcium
(above 8 to 9 mEq/L) can trigger a hypercalcemic
crisis. To prevent a hypercalcemic crisis, provide
adequate hydration and administer diuretics or
phosphate or both as prescribed by the health care
practitioner.
 Types of acid-base imbalances
 Respiratory acidosis: This is a condition in which decreased
respiration (hypoventilation) causes increased arterial carbon
dioxide and decreased pH. Causes include airway
obstruction, pneumonia, and respiratory failure.
 Respiratory alkalosis: This is a medical condition in which
increased respiration (hyperventilation) elevates the blood
pH. The PaCO2 is decreased. Causes include asthma,
anxiety, salicylate overdose.
 Metabolic acidosis: Results from high acid concentration in
the blood, which also causes a loss of sodium bicarbonate.
Causes include starvation, diabetes ketoacidosis (DKA), and
renal failure.
 Metabolic alkalosis: Results from heavy loss of acid from the
body or increased levels of bicarbonate. Causes include
vomiting and use of drugs (steroids, diuretics).
Common Types of Intravenous solutions
N Solution Comments

Isotonic It expands the extracellular fluid

0.9% NaCl volume, used in hypovolemic states,
Na+ 154 mEq/L resuscitative efforts, shock, and
Cl− 154 mEq/L DKA.
• It supplies an excess of Na+ and
Cl−; can cause fluid volume excess
if excessively used , particularly in
patients with compromised renal
function or heart failure.
• It may be administered with blood
products
N Solution Comments

1 Lactated Ringer An isotonic solution that

Na+ 130 mEq/L contains multiple electrolytes
K+ 4 mEq/L in roughly the same
Ca++ 3 mEq/L concentration as found in
Cl− 109 mEq/L plasma (note that solution is
lacking in Mg++): provides 9
calories/L
• Used in the treatment of
hypovolemia, burns, fluid lost
as bile or diarrhea, and for
acute blood loss replacement
N Solution Comments

2 Hypotonic Provides Na+, Cl−, and free water to aid

0.45% NaCl the kidneys in elimination of solute.
Na+ 77 • Used to treat hypertonic dehydration Na+
mEq/L and Cl− depletion, and gastric fluid loss.
Cl− 77 • Administer cautiously, as it can cause fluid shifts
mEq/L from vascular system into cells, resulting in
cardiovascular collapse and increased intracranial
pressure.
Hypertonic dehydration refers to a greater loss of
fluid than particles in the vascular space when the
body tries to maintain a normalized isotonic state by
pulling fluids from the intracellular space into the
vascular space; it occurs in diabetic ketoacidosis,
renal insufficiency, and with the administration of
hypertonic solutions.
N Solution Comments

3 Hypertonic Highly hypertonic solution used only

3% NaCl in critical situations to treat
Na+ 513 mEq/L hyponatremia manifested by anorexia,
Cl− 513 mEq/L nausea and vomiting, headache,
lethargy, confusion, muscle weakness,
seizures, dry skin, ↑ pulse, and↓ BP.
• Must be administered slowly and
cautiously, as it can cause
intravascular volume overload and
pulmonary edema
• Assists in removing intracellular
fluid excess
5% NaCL Highly hypertonic solution used to treat
symptomatic hyponatremia
Na+ 855 mEq/L • Administered slowly and cautiously, as it can
Cl− 855 mEq/L cause intravascular volume overload and
pulmonary edema
 Effect of Different Solutions on Blood
Cells
1. Isotonic solutions: (Sodium chloride concentration is
equal to that of blood, 0.9%). Cells in isotonic solution
are normal in size and shape because the same amount
of water is entering and leaving them.
2. Hypotonic solutions: (Sodium chloride concentration is
less than that of blood). In these solutions, water moves
into the cells, causing them to swell and burst.
3. Hypertonic solutions: (Sodium chloride concentration
is greater than that of blood). Cells in the hypertonic
solution are losing water because water moves from a
weaker concentration inside the cell to a greater
concentration outside the cell membrane.