Fluid and Electrolyte

By Abel. M(BSc, MSc)

1 02/15/2025
 Fundamental concepts
 The human body functions when certain conditions
are kept with in a narrow range of normal value.
These conditions include:-
 Body temperature
 Electrolytes
 Blood PH
 Blood volume

 Body fluid contains:

 water
 Electrolytes
 Non electrolytes (glucose, urine), and
 other substances
2 02/15/2025
Body fluid compartments

 Approximately 60-65% of a typical adult’s weight

consists of fluids.
 These fluids are distributed in to different
compartments:

 Intracellular fluid(ICF) compartment

 Is fluid with in the cells
 Located mainly (primarily) in skeletal muscle mass
 Contains approximately 2/3 of the total body fluid
 Constitute 45%of body weight
3 02/15/2025
Body fluid…
 Extra cellular fluid(ECF) compartment
 Is fluid outside cells
 Contains approximately 1/3 of body fluid

 further divided in to
 Intravascular space- fluids in the blood vessels
 Interstitial space- fluids that surround the cell
 Trans-cellular space- eg CSF, synovial, intraocular,
pericardial, pleural fluids
4 02/15/2025
 Exercise
 Question: show how the fluid is distributed in
the body of a 50kg male adult patient.
 Take 60% of his body weight is fluid.

5 02/15/2025
 Factors that influence the amount of body fluid
include:
 Age

 Gender

 Body fat

7 02/15/2025
 Functions of fluid
 Water provides about 90-93% of the volume in
the extra cellular compartment. Its functions
include:
 Acts as transport vehicle
 Aids in the hydrolysis of food
 Acts as medium and reactant for chemical reactions
 Acts as a lubricant
 Cushions and acts as shock absorber

8 02/15/2025
Gains and losses of body fluid (water)

The sources of fluid gains Routs of fluid losses

  Kidney (1ml/kg/hr in all

Absorption from GIT
age groups
 Parenterally administered  Insensible loss (without
fluids feeling or consciousness)
• Skin
 Metabolic oxidation of • Lungs

foods  Stool (GIT)

9 02/15/2025
 Average in take and out put of fluids in adults

 Intake Out put

Oral intake Urine-----1500ml

 As liquid -------------1500ml Stool------------200ml
 In food ---------------800ml Insensible

Metabolic oxidation ------300ml Lung-------300ml

Skin--------600ml
 Total gain--------------2600ml Total lose-----2600ml

10 02/15/2025
 Regulation of body fluids
 The body has many regulators that maintain fluid balance,
including fluid and food intake, skin, lungs,
gastrointestinal tract, and kidneys.
 When all organs are functioning normally, the body is able
to maintain homeostasis.

11 02/15/2025
Kidneys
 The kidneys play a major role in maintaining fluid balance
by excreting 1,200 to 1,500 ml/day in the adult.
 The excretion of water by healthy kidneys is proportional
to the fluid ingested and the amount of waste or solutes
excreted.
 When an extracellular fluid volume deficit occurs,
hormones play a key role in restoring the extracellular
fluid volume.
12 02/15/2025
 The release of the following hormones into circulation causes
the kidneys to conserve water:
 Antidiuretic hormone (ADH) from the posterior pituitary gland
acts on the distal tubules of the kidneys to reabsorb water.
 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.

13 02/15/2025
Cont…
 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.

14 02/15/2025
Cont…
 Sodium is the main electrolyte that promotes the retention
of water.
 An intravascular water deficit causes the renal tubules to
reabsorb more sodium into circulation.
 Because water molecules go with the sodium ions, the
intravascular water deficit is corrected by this action of
the renal tubules.

15 02/15/2025
 Fluid volume disturbances

16 02/15/2025
 Fluid volume deficit (FVD) Hypovolemia

 Occurs when water and electrolytes are lost in the same

proportion as they exist in normal body fluids,
 so that the ratio of serum electrolytes to water remains the
same.
 Should not be confused with dehydration (where only the
water is lost)

17 02/15/2025
 Causes

Inadequate fluid intake

Unconsciousness/coma or inability to express thirst
Oral trauma or inability to swallow
Impaired thirst mechanism (osmoreceptors)
Withholding of fluid for therapeutic reason

18 02/15/2025
 Causes…
Excessive fluid losses
 GI losses
Vomiting

Diarrhea

GI suctioning

 Urine losses
Diuretic therapy

19 02/15/2025
 Causes…
 Skin losses (salt water)
Fever
Exposure to hot environment
Burs and wounds that remove skin
 Third space losses
Intestinal obstruction
Edema, ascites, burns (for the firs several
days)
 Other risk factors
Hemorrhage

20 02/15/2025
 Clinical manifestations
 Acute weight loss
 Thirst, anorexia, nausea

 Urine out put(oliguria)

Urine osmolality

21 02/15/2025
Cont…

 Serum osmolality

 Vascular volume
 Tachycardia, weak thready pulse

 Postural hypotension

 Hypotension and shock

 Volume in extra cellular space

Depressed fontanel

Sunken eyes and soft eyeballs

22 02/15/2025
 Loss of ICF

Dry skin (skin turgor) and mucous membrane

Cracked and fissured tongue

Neuromuscular weakness and cramps

23 02/15/2025
 Diagnosis
Hx
Physical exam
Electrolyte changes may occur
Urine osmolality
 ed as kidney attempt to conserve water

24 02/15/2025
 Medical management

 Isotonic fluid replacement

 0.9%nacl solution, ringer’s lactate

 After the patient becomes normotensive, a

hypotonic solution
 0.45%nacl solution often used
 provide both electrolytes and water
 facilitates renal excretion of metabolic wastes

25 02/15/2025
 Nursing management
 Monitoring intake and out put at least
every 8 hours and sometimes every hour.
 Monitoring daily body weight (at the same
time of day)
 Monitoring vital signs

26 02/15/2025
Cont…
 Avoid orthostatic hypotension or possible syncope.

Do not allow the patient to sit or standup quickly

as long as circulation is compromised
 Monitoring skin and tongue turgor
 Skin color

27 02/15/2025
Fluid Volume Excess (FVE)/Hypervolemia

 Refers to an isotonic expansion of the ECF caused by

the abnormal retention of water and sodium in
approximately the same proportion in which they exist
in the total body fluid.

28 02/15/2025
 Causes/ contributing factors
 Excessive sodium and water in take
Dietary intake
Ingestion of medications containing sodium
 Inadequate renal losses
Renal disease (renal failure)
 Congestive heart failure

29 02/15/2025
 Clinical manifestations
 Acute weight gain
 Pitting edema of the extremities
 Pulmonary edema
 Shortness of breathing (dyspnea)
 Rales, wheezing
 Cough

30 02/15/2025
 Clinical…
 Tachycardia
 ed BP
 ed Urinary out put

31 02/15/2025
 Diagnosis
 Hx
 Physical exam
 ed Urine specific gravity (b/se of urine Na+level)
 ed Serum osmolality
 Chest X-ray reveals pulmonary congestion

32 02/15/2025
 Medical Management

Management is directed towards the

causes
If related to excessive administration,
discontinuing the infusion

Diuretics (thiazides/ loop diuretics)

Restricting fluid and sodium intake

Hemodialysis/peritoneal dialysis, if pharmacologic

and dietary management cannot act effectively
33 02/15/2025
Nursing management
Monitoring
Daily input and out put
Daily body weight
Degree of edema in most dependent
body parts
Feet and ankles in ambulatory

patients

34 02/15/2025
Nursing…
Promoting rest (bed rest favors diuresis
of edema fluid)
Restricting sodium intake
Regular positioning (to prevent skin
break down)
Teaching the patient about the edema
Ex. raising extremities.

35 02/15/2025
 Electrolyte Imbalances
 Electrolytes in body fluids are active chemicals (cations, which
carry positive charges, and anions, which carry negative
charges).

36 02/15/2025
 Alteration in Sodium Balance

Alteration in Sodium Balance

Alteration in Sodium Balance

 Sodium is the primary determinant of ECF

concentration because of its high concentration and
inability to cross the cell membrane easily.
 Alterations in sodium concentration can produce
profound CNS effects on cognition and sensory
perception and on the circulating blood volume.
 When the kidneys reabsorb sodium ions, chloride
and water are reabsorbed with the sodium to
maintain the body’s fluid volume.
37 02/15/2025
 Hyponatremia
 With hypo-natremia, there is either a sodium
deficit or a water excess; a hypo-osmolar
state exists because the ratio of water to
sodium is too high.
 Sodium level: less than 135 mEq/L (135
mmol/L)

38 02/15/2025
Cont…
 The water moves out of the vascular space
into the interstitial space and then into the
intracellular space, causing edema.
 The low extracellular serum sodium causes
water to enter the cells in the brain,
 thereby producing cerebral edema as
manifested by the cognitive and sensory
changes.
39 02/15/2025
 Hypernatremia
 Hypernatremia is an excess in the extracellular
level of sodium.
 With an excess of sodium or a loss of water, a
hyperosmolar state exists because the ratio of
sodium to water is too high.
 This ratio causes an increase in the
extracellular osmotic pressure, which pulls fluid
out of the cells into the extracellular space.
40 02/15/2025
 Potassium
 The normal range of extracellular potassium is
narrow (3.5–5.0 mEq/L).
 The slightest decrease or increase can cause
serious or life-threatening effects on physiological
functions.
 Potassium is important in neuromuscular function.
 Influences both skeletal and cardiac muscle
activity.

41 02/15/2025
Cont…
 A reciprocal relationship exists between
sodium and potassium; large sodium intake
results in an increased loss of potassium, and
vice versa.
 When potassium is lost from the cells, sodium
enters the cells.

42 02/15/2025
 Hypokalemia
 Hypokalemia is a decrease in the extracellular
level of potassium.
 GI tract disturbances and the use of diuretics
can place the client at risk for hypokalemia
 Potassium wasting diuretics can cause
hypokalemia.

43 02/15/2025
 Hyperkalemia
 Occur when the serum potassium level
exceeds 5.5 mmol/L.
 Seldom occurs in patients with normal renal
function.
 is often due to iatrogenic reasons
 less common, but more dangerous than
hypokalemia /cardiac arrest is more frequently
associated with high serum potassium levels/.
44 02/15/2025
 Alteration in Calcium
 More than 99% of the body’s calcium is
located in the skeletal system
 is a major component of bones and teeth.
 The normal total serum calcium level is
8.5 to 10.5 mg/dL(2.1–2.6 mmol/L).

45 02/15/2025
Cont…
 Absorbed from foods in the presence of
normal gastric acidity and vitamin D.
 Excreted primarily in the feces, the
remainder in urine.
 The serum calcium level is controlled by
PTH and calcitonin.

46 02/15/2025
 Hypocalcemia
 Hypocalcemia is a decrease in the
extracellular level of calcium.
 Causes: Hypoparathyroidism, the rapid
administration of citrated blood, Malabsorption,
chronic diarrhea

47 02/15/2025
 Hypercalcemia
 Hypercalcemia is an increase in the
extracellular level of calcium.
 The clinical symptoms result from a decrease
in neuromuscular activity, reabsorption of
calcium from bone.
 A rapid increase in the extracellular level of
calcium can trigger a hypercalcemic crisis.

48 02/15/2025
 Fluids and Electrolytes Therapy
 Goal of fluid therapy

 To maintain the normal volume and composition of body

fluids and correct abnormalities

 Indications of fluid therapy

 Replacement of abnormal fluid & electrolyte losses

[surgery, trauma, burns, GI bleeding and DHN]

 Maintenance of daily fluid & electrolyte needs

 Correction of fluid disorders

 Correction of electrolyte disorders

49
 Crystalloid Vs. Colloid
 Fluids with small “crystalizable” particles like NaCl are called
crystalloids
 Fluids with large particles like albumin are called colloids,
 these don’t (quickly) fit through vascular pores, so they stay in
the circulation and much smaller amounts can be used for same
volume expansion.
 (250ml Albumin = 4 L NS)

50
 Crystalloids
 Na+  main osmotically active particle
useful for volume expansion (mainly
interstitial space)
 Fluids for maintenance infusion
 Correction of electrolyte abnormality
 Require 3:1 replacement of volume loss

e.g. estimate 1 L blood loss, require 3 L of

crystalloid to replace volume
51
Crystalloids
1. Isotonic-

 has the same osmolarity as plasma. Osmolarity of 270-

310mOsm/L
 25% remain intravascularly
 (Used to expand ECF compartment
 e.g. Lactated Ringer’s, 0.9% NaCl,

52
Kinds of Cont’d
2.Hypotonic-Fluid has fewer solutes than plasma.
Osmolarity below 250mOsm/L
 Hydrates cells
 Depletes the circulatory system< 10% remain
intra-vascularly, inadequate for fluid resuscitation
 ECF to ICF shifts
 Water, 1/2 N/S (0.45% NaCl),

53
 Kinds of IV Fluid cont’d
3.Hypertonic-Fluid has more solutes than
plasma causes water from within a cell to
move to the ECF compartment
 Osmolarity of 375mOsm/l or greater
 Used to replace electrolytes
5 % Dextrose in Normal Saline (D5 N/S),
 3% saline solution, D5 in RL.
54
 2.Colloid Solutions
 Contain high molecular weight
substancesdo not readily migrate across
capillary walls
 Preparations

- Albumin: 5%, 25%

- Red cell concentrates
- platelets, plasma
 Replacement of lost volume

in 1:1 ratio
55
 Components to fluid therapy
 Maintenance therapy:
 Replaces the ongoing losses of water and
electrolytes (through urine, sweat, respiration,
and stool)
 Replacement therapy:
 Replaces water and electrolyte deficits that
result from abnormal gastrointestinal, urinary,
or skin losses, bleeding.

56
1.Maintenance therapy
 Maintenance therapy is usually undertaken when
the individual is not expected to eat or drink
normally for a longer time (eg, perioperatively or on
a ventilator).

Eg: Most people are “NPO” for 12 hours each day.

 Maintenance Requirements can be broken into
water and electrolyte requirements

57
 Maintenance vs. replacement
 Maintenance:
 Provide normal daily requirements:

Water: 2.5 L
Sodium ½ or ¼ NS
 Replacement:
 Replace abnormal losses with a fluid and
electrolytes similar to that which was lost.

58
Maintenance therapy cont’d

 Maintenance fluids are composed of a

solution of water, glucose, sodium, and
potassium.
 Patients lose water, sodium, and potassium
in their urine and stool; water is also lost
from the skin and lungs.
 Maintenance fluids replace these losses.
59
Maintenance Requirements increased
 Fever
 Restless/delirium
 Warm ambient temperature
 Hyperventilation

For example, water requirements increase by 100 to

150 mL/day for each C degree of body temperature
elevation.

60
Maintenance Requirements decrease
during
 Hypothermia
 High humidity
 Oliguria/anuria
 Retention/oedema
 Increased intracranial pressure

61
Calculation of Maintenance Fluids...
 For a 24 hr period, use 100/50/20 Rule
 100ml/kg for first 10kg
 50ml/kg for next 10kg
 20ml/kg for every kg over 20
 For hourly maintenance rate, use 4/2/1 Rule
 4ml/kg for first 10kg
 2ml/kg for next 10kg
 1ml/kg for every kg over 20
62
 Calculating Maintenance Fluid
Requirement

Putting these together, we come up with

this formula for daily maintenance water
requirements…
Per hour Per day Example: for wt 34kg

For each kg up to 10 4ml/hr 100ml/ 40ml/hr 1000ml/day

day
+ For each kg btw 10- 2ml/hr 50ml/day 20ml/hr 500ml/day
20
+ For each kg above 1ml/hr 20ml/day 14ml/hr 280ml/day
20
= 74ml/hr 1780ml/day

63
 2.Replacement Therapy
 A variety of disorders lead to fluid losses that
deplete the extracellular fluid .
 Lead to a potentially fatal decrease in tissue
perfusion.
 Fortunately, early diagnosis and treatment
can restore normovolemia in almost all
cases.
64
 Indications

 The gastrointestinal (GI) tract is potentially a

source of considerable water loss.
 GI water losses are accompanied by electrolytes
and thus may cause disturbances in intravascular
volume and electrolyte concentrations.
 GI losses(vomiting, Diarrhea and NG tube
drainage) are often associated with loss of
potassium, leading to hypokalemia.

65
Replacement therapy cont’d

 In the absence of vomiting, diarrhea, or NG

drainage, GI losses of water and electrolytes
are usually quite small.
 All GI losses are considered excessive, and
the increase in the water requirement is
equal to the volume of fluid losses.

66
Replacement therapy cont’d
 It is impossible to predict the losses for the
next 24 hr; it is better to replace excessive
GI losses as they occur.
 The losses should then be replaced after
they occur, using a solution with the same
approximate electrolyte concentration as
the GI fluid.
 The losses are usually replaced every 1–6
hr, depending on the rate of loss, with very
rapid losses being replaced more
frequently.
67
 Choice of fluids
1.Isotonic •
Ringer’s lactate
• Normal saline

Replace acute/
increases ECF abnormal
loss

ICF
ICF ISF
ISF Plasma
Plasma

68 800 ml 200 ml
 2. Hypotonic infusion
• 5% dextrose

increases ICF > ECF Replace Normal

loss (IWL + urine)

ICF
ICF ISF
ISF Plasma
Plasma

660
660 ml
ml 255
255 ml
ml 85
85 ml
ml
69
 THANK YOU

70 02/15/2025