ANP SEMINAR CONTENT

ON
FLUID AND ELECTROLYTE
IMBALANCE

SUBMITTED TO: SUBMITTED BY:

Prof. Dr. MARIA THERESE Ms. NANDHINI S
PROFESSOR IN NURSING (MSN), I Year, M.Sc. Nursing,
MTPG&RIHS. MTPG&RIHS.

SUBMITTED ON:

19/02/2021
 TABLE OF CONTENT

Sl. No. CONTENT PAGE No.

1. INTRODUCTION 3

2. FLUID AND ELECTROLYTES – BALANCE AND IMBALANCE 4

3. BODY FULIDS COMPOSITION AND FUNCITONS 6

4. FUNDAMENTAL CONCEPTS 9

5. REGULATION OF BODY FLUID COMPARTMENTS 9

OSMOSIS AND OSMOLALITY

DIFFUSION

FILTERATION

SODIUM-POTASSIUM PUMP

6. HOMEOSTATIC MECHANISM 12

KIDNEY FUNCITON

HEART AND BLOOD VESSEL FUNCTION

LUNG FUNCTION

PITUITARY FUNCTION

ADRENAL FUNCTION

PARATHYROID FUNCTION

7. BARORECEPTOR 14

8. RENIN-ANGIOTENSIS-ALDOSTERONE SYSTEM 15

9. FLUID VOLUME DISTURBANCES 17

HYPOVOLEMIA

HYPERVOLEMIA 19

10. ELECTROLYTE IMBALANCE 22

 SODIUM

HYPERNATREMIA

HYPONATREMIA

POTASSIUM

HYPERKALEMIA

HYPOKALEMIA

CALCIUM

HYPERCALCEMIA

HYPOCALCEMIA

MAGNESIUM

HYPERMAGNESEMIA

HYPOMAGNESEMIA

PHOSPHOROUS

HYPERPHOSPHATEMIA

HYPOPHOSPHATEMIA

CHLORIDE

HYPERCHLOREMIA

HYPOCHLOREMIA

11. BIBLIOGRAPHY 43

12. JOURNAL REFRENCES 44

 FLUID AND ELECTROLYTE IMBALANCE

Learning Objectives:
● What is fluid and electrolyte balance and imbalance?
● Composition and function of body fluids
● Fundamental concepts.
● Regulation of Body Fluids.
● Homeostatic mechanism.
● Fluid volume disturbances.
● Electrolyte imbalances.

INTRODUCTION
● Body fluids are the liquids originating inside the bodies of living humans and plays a
vital role within our bodies.
● They are made up of proteins which are excreted or secreted from the body.
● Electrolytes are the minerals in your body that have an electric charge. They are in
the blood, urine, tissue, and other body fluids.
● Fluid and electrolyte balance – the equilibrium state between the fluids and
electrolytes within the body is fluid and electrolyte balance.
● Hence, when there is a change in this equilibrium state is termed is fluid and
electrolyte imbalance.
● The level of the electrolytes in the body can become too low or too high.
● This can happen when the amount of water in your body changes. The amount of
water that you take in should equal the amount you lose.
● If something upsets this balance, you may have too little water (dehydration) or too
much water (overhydration).

Fluid and Electrolyte - Balance and Imbalance:

● Fluids and electrolytes are the basic elements of life.
● All chemical reaction within the body takes place in fluids and the electrolytes react
because they have an electrical charge: Positive (+ve) or negative (-ve).
● The primary fluid of the body is water. It comprises of 70% of living cells and 60% of
an average adult’s total body weight (Barrett, Barman, Boitano & Brooks, 2010).
● An average healthy person needs about 2 to 2.5 liters of water per day to meet the
body’s fluid requirements.
 i.e., 1 to 1.5 ounces of water per kilogram of body weight per day to dissolve
and metabolize wastes. (Rives,2009).
● Fluids are lost continuously through respiration evacuation of urine and feces, and
perspiration. Most adults produce about 1500ml of urine per day.
● In another way, fluids are may be lost during illness through insensible fluid loss,
water that passes through skin, and from the respiratory tract by evaporation or also
with fever wound drainage, vomitus or diarrhea.
● Electrolytes – the positively charged cations are always accompanied by negatively
charged anions because of this attraction forces.
● The distribution of electrolytes between body compartments is influenced by their
electrical change, however, one cation may be exchanged for another and provided it
carriers the same charge.
● For e.g.: Positively charged H+ ion may be exchanged for a positively charged K+ ion.
● Ions do not move from one body compartment to another via the fluids and cause
movement of various body elements by electrochemical interactions.
● Fluids and electrolytes each have normal ranges in which the body functions well.
When elements or fluids are outside normal ranges, dysfunction or decreased
performance occur.

BODY FLUIDS COMPOSITION AND FUNCTION:

● Approximately 60% of a typical adult’s weight consists of fluid (water and
electrolyte)
● The amount of body fluids can be influenced by age, gender and body fat.
● In general, younger people have a higher percentage of body fluids than older people
and men have proportionately more body fluids than women
● Body fat: Obese people have less fluid that thin people because fat cells contains little
water.

COMPARTMENTS:
● The body fluids are located in 2 compartments.
1. Intra cellular space (Fluids in the cells)
2. Extra cellular space (Fluids outside the cells)
● The body fluids which accumulated in Intracellular space is termed as Intracellular
fluids (ICF). i.e., within the cell cytoplasm and nucleus and the fluid which
 accumulates in Extracellular space is termed as Extracellular Fluids (ECF). i.e.,
outside the cell membrane such as interstitial fluids between the cells, fluids in the
bloodstream (serum), cerebrospinal fluids (CSF) in the Central Nervous system, GI
Secretion, sweat, urine.
● Two-third of the body fluids is in the Intracellular space and one-third is in the
extracellular space (Felver,2009).
● Only 5% of body fluid is normally in the blood (Johnson,2011 Porth & Marfin,2009).
● Approximately 3L of the average 6L of blood volume is made up of plasma. The
remaining 3L is made up of erythrocytes, Leukocytes, Thrombocytes.
● The interstitial fluid is about 11 to 12L in adults.
Eg: Lymph.
● The transcellular space of the ECF compartment contains approximately 1L of Fluid
at any given time.
Eg: Cerebrospinal, Pericardial, Synovial, Intraocular, Pleural Fluids, Sweat and
digestive secretion.

FUNCTIONS OF BODY FLUIDS:

● Body fluids normally shifts between two major spaces in order to maintain the
equilibrium between the spaces and the loss of fluid from the body can disrupt this
equilibrium.
● Body fluids control or assist many bodily functions. They are:
1.Enzyme in saliva and mucus assist the passage of food into the gut and provide
mechanisms for hydrolyzing food into elements that the body can absorb.
2. ECF in blood and CSF serve as a transport mechanism to deliver electrolytes, oxygen,
nutrients and hormones to tissues.
3. Carry immune system cells to injury sites for the body’s defense.
4. ECF eliminates the body’s waste products through kidneys and bowel and
perspiration.
5. Helps in the movement of electrolytes from one body compartment to another ECF
plays an vital role in regulation of body temperature through perspiration and capillary dilation to give
off excess heat or conserve heat through skin.

6. Fluids provides form for body structure.

7. Acts as a lubricant.
8. often-multiple times per minute, to effect an electrochemical action.
 i.e., The heartbeat, secretion of hormone, or a neuromuscular transmission.

THE CONCEPTS OF FLUID AND ELECTROLYTES:

● They play an important role in maintaining homeostasis – the stable internal
environment of the body.
● Body fluids are in constant motion transporting nutrients, electrolytes and oxygen to
cell and carry and the waste products away from the cells.

REGULATION OF BODY FLUID COMPARTMENTS

i) OSMOSIS AND OSMOLALITY:

Osmosis is the process of water movement through a semipermeable membrane from an

area of low solute concentration to an area of high solute concentration.
Osmolality measures the number of dissolved particles contained in a unit of fluid
i.e., The number of milliosmoles per kilogram of water.
● Normal plasma osmolality is between 275 to 295mOsm/kg.
● If it goes beyond 295mOsm/kg indicates that the concentration of particles is too great
or that the water content is too little – water deficit.
● If it goes below 275mOsm/kg indicates to little solutes for the amount of water or too
much of water for the amount of solute – water excess.
● Osmolality of urine can range from 100 to 1300mOsm/kg depending on the fluid
intake and the amount of antidiuretic Hormone (ADH) in circulation and the renal
response to it.
● Hypotonic: The solution in which the solutes are less concentrated than in the cells
(hypo-osmolar).
● Hypertonic: the solutes are more concentrated in the fluids than in the cell (hyper-
osmolar).
● Isotonic: The solutes in the fluids are equally concentrated as in the cell. (Normal H2O
balance).

ii)

DIFFUSION:
 ● The natural tendency of a substances to move from an area of higher concentration to
one of the lower concentration.
● Eg: exchange of oxygen and carbon dioxide between the pulmonary capillaries
and alveoli.

iii) FILTERATION:

● The hydrostatic pressure in the capillaries tends to filter fluid out of the vascular
compartment into the interstitial fluid.
o Eg: The passage of water and electrolytes from the arterial capillary
bed to the interstitial fluid
● The hydrostatic pressure is furnished by the pumping action of the heart.

iv) SODIUM-POTASSIUM PUMP:

● The sodium concentration is greater in the ECF than in the ICF.

● Because of this sodium tends to enter into the cell by diffusion.
● To maintain this concentration difference, the cell uses active transport to move
sodium out of the cell and potassium into the cell.
● Active Transport – the process in the molecules moves against the concentration
gradient. An external energy is required for this process.
● The energy source for Sodium-Potassium Pump mechanism is Adenosine
triphosphate (ATP), which is produced in the cell’s maintained

HOMEOSTATIC MECHANISM:
 ● The following organs are involved in homeostasis.
● They are:
● Kidney
● Heart and blood vessel
● Lung
● Pituitary gland
● Adrenal gland
● Parathyroid gland

i) KIDNEY FUNCTION:

● The kidney normally filters 170 liter of plasma every day in the adult, while excreting
only 1.5L of urine. The act both autonomously and in response to blood borne
messenger.
Major functions of kidney in maintenance of normal fluid balance:
1. Regulation of ECF volume and osmolality by selective retention and excretion
of body fluids.
2. Regulation of electrolytes level in ECF by means of selective retention of
needed substances and excretion of unneeded substances.
3. Regulation of pH of ECF by retention of hydrogen ions.
4. Excretion of metabolic wastes and toxic substances.

ii) Heart and blood vessel function:

● The pumping action of the heart circulates blood through kidney under sufficient
pressure to allow for urine formation.
● Failure of this pumping action interferes with renal perfusion and thus with water and
electrolyte regulation.

iii) Lung function:

● Through exhalation, the lungs remove approximately 300ml of water daily in normal
adults.
● In abnormal condition i.e., Hyperpnea (deep respiration) or continuous coughing
increase the loss of water and in mechanical ventilation with excessive moisture
decrease it.

v) Pituitary function:
 ● The hypothalamus manufactures ADH (Anti-Diuretic Hormone), which is stored in
the posterior pituitary gland and released as needed.
● ADH is sometimes referred as water conserving hormone since it cause the body to
retain water.
● The function of the ADH is maintaining the osmotic pressure by controlling the
retention or excretion of water by the kidney and by regulating blood volume.

vi) Adrenal functions:

● Aldosterone, an hormone secreted by adrenal gland has a profound effect on fluid

balance.
● Increased secretion of aldosterone cause sodium retention (thus water retention) and
potassium loss.
● Decreased secretion leads to sodium and water loss and potassium retention.
● Cortisol – another adrenocortical hormone, when secreted in large quantities cause
sodium and fluid retention and potassium deficit.

vii) Parathyroid functions:

● The parathyroid hormone in the thyroid gland regulates the calcium and phosphate
balance by means of parathyroid hormones (PTH).
● PTH influences bone resorption, calcium absorption from the intestine and calcium
reabsorption from the renal tubules.

BARORECEPTORS:

● The baroreceptors are small nerve receptors located in carotid sinus and in the aortic
arch.
● This baroreceptors detects the changes in pressure within the blood vessels and
transmit this information to the central nervous system (CNS).
● The baroreceptors are responsible for monitoring the circulating volume and they
regulate the sympathetic and parasympathetic neural activity as well as endocrine
activities.
● As arterial pressure decreases, baroreceptor transmit fewer impulses from the carotid
sinus & the aortic arch to the vasomotor center.
 ● A decrease in impulses, stimulates the sympathetic and parasympathetic nervous
system which was inhibits by it.
● The outcome is an increase in cardiac rate, conduction, contractility and in circulating
blood volume.
● ●The sympathetic stimulation constricts renal arterioles and thus increase the release
of aldosterone, decrease glomerular filtration and increase the sodium and water
reabsorption.
● The outcome is an increase in cardiac rate, conduction, contractility and in circulating
blood volume.
● The sympathetic stimulation constricts renal arterioles and thus increase the release of
aldosterone, decrease glomerular filtration and increase the sodium and water
reabsorption.

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM

 Angiotensinogen is an hormone produced by the liver which was converted into

angiotensin I & angiotensin II by the hormone formed by the kidney called renin.
 An enzyme released within the lungs which converts angiotensin I into angiotensin II. The
angiotensin II with its vasoconstriction properties, it increases the arterial perfusion
pressure and stimulates thirst.
 As the stimulation of sympathetic nervous system, aldosterone is released in response to
an increased release of renin.
 Aldosterone is a volume regulator and is also released as serum potassium increases,
serum sodium decreases or adrenocorticotrophic hormone increases.
 This is Renin-Angiotensin-Aldosterone system.
 FLUID VOLUME DISTURBANCES

i) HYPOVOLEMIA:

● HYPO – Low or below normal

● VOLEMIA – Volume of circulating blood
● Hence, Hypovolemia means decreased volume of circulating blood or fluids in the
body.

Fluid Volume Deficit (Hypovolemia)

● Fluid volume deficit (FVD) results when the water and electrolytes are lost in the
same proportion as they exist in normal body fluids. Hence the ratio of serum
electrolytes to water remains the same. It should not be confused with the term
Dehydration, where it refers to loss of water alone with increased sodium level.

Causes:
● Increased insensible water loss or perspiration.
● Hemorrhage
● Osmotic diuresis
● GI losses: vomiting, Nasogastric Suction, Diarrhea.
● Inadequate fluid intake
● Diabetic insipidus
● Burns, intestinal obstruction.

Clinical manifestation:
● Restlessness, drowsy, lethargy, confusion
● Thirst, dry mucous membranes
● Decreased skin turgor, reduced capillary refill.
● Decreased urine output.
● Postural hypotension, increased pulse, decreased CVP.
● Increased respiratory rate.
 ● Weakness, dizziness.
● Weight loss.
● Seizure, coma.

Collaborative care:
● The goal is to correct the underlying causes and to replace both water and need of
electrolytes.
1. Balanced IV solution: Lactated Ringer’s Solution (Hartmann’s
Solution).
2. Isotonic (0.9%) sodium chloride is used when rapid volume
replacement is indicated.
3. Blood administration when the volume loss is due to blood loss.

Nursing Diagnosis:
1. Deficient fluid volume related to excessive fluid loss or decreased fluid intake.
2. Decreased cardiac output related to excessive fluid loss or decreased fluid intake.
3. Risk for deficient fluid volume
4. Potential complication: Hypovolemic shock.

ii) HYPERVOLEMIA:

● HYPER - More or above the normal

● VOLEMIA - Volume of circulating blood.
● Hence, Hypervolemia means Increased volume of circulating blood or fluids in the
body.

Fluid Volume Excess (Hypervolemia)

● Fluid volume excess may results from excessive intake of fluids, abnormal retention
of fluids or fluid shift from intracellular fluid into plasma fluid.
● This retention of water and sodium is in shame proportion in which it normally exists
in the extra cellular fluids (ECF).

Causes:
● Excessive isotonic or hypotonic IV fluids.
 ● Heart failure.
● Renal failure.
● Primary polydipsia.
● SIADH
● Long term use of corticosteroids.

Clinical manifestations:
● Headache, confusion, lethargy.
● Jugular venous distention.
● Bounding pulse, increased BP, Increased CVP.
● Polyuria (with normal urine function).
● Peripheral oedema.
● Dyspnea, crackles, pulmonary edema.
● Muscle spasm.
● Weight gain.
● Seizure, coma.

Collaborative care:
● The goal of treatment is to remove the excess fluids without making any abnormal
changes in electrolytes composition.
● Primary care:
● Fluid restriction.
● Discontinue the IV infusion when the fluid excess is related to excessive
administration of sodium containing fluids.
● Restriction of sodium intake.
Other measures:
● Diuretics are prescribed, when dietary restriction of sodium alone is insufficient to
reduce edema.
● The choice of diuretics are based on the severity of the hypervolemic state, the degree
of impairment of renal function & the potency of diuretic.

Hemodialysis:
 ● Hemodialysis or Peritoneal dialysis are advisable when the renal function is severely
impaired and so the pharmacological agents cannot act efficiently.

Abdominal Paracentesis:
● If fluid excess leads to ascites.

Thoracentesis:
● When fluid excess leads to pleural effusion.

Nursing Diagnosis:
1. Excess fluid volume related to increased water and/or sodium retention.
2. Activity intolerance related to increased water retention and fatigue, weakness.
3. Impaired gas exchange related to water retention leading to pulmonary edema.
4. Disturbed body image related to altered body appearance secondary to edema.
5. Risk for impaired skin integrity related to edema.
6. Potential complication: Pulmonary edema, ascites.

ELECTROLYTE IMBALANCES
● The electrolytes are minerals in the body with positive (+ve) or negative (-ve) charge.

CATIONS: Positive charge.

 Sodium (Na+).
 Potassium (K+).
 Calcium (Ca2+)
 Magnesium (Mg+).
 Hydrogen (H+).

ANIONS: Negative charge.

 Chloride (Cl-).
 Bicarbonate (HCo3-).
 Phosphate (PO₄³⁻).
 Sulphate (SO42−).
SODIUM
(Normal Range: 135 to 145mEq/L)
i) Hypernatremia (Sodium Excess)
● Hypernatremia, an elevated serum sodium may occur with water loss or sodium gain.
● Hypernatremia causes hyperosmolality because, the sodium is the major determinant
of the ECF osmolality.
● Hypernatremia is a higher than normal serum sodium level (>145mEq/L) with the
water loss, the patient loses more water that sodium; as a result the serum sodium
concentration increases and the increased concentration pulls fluid out of the cell.
● In sodium excess, the patient ingests or retains more sodium than water.

Causes:
1. Excessive sodium intake:
o IV fluids: Hypertonic NaCl, excessive Isotonic NaCl, IV Sodium
Bicarbonate.
o Hypertonic tube feeding without water supplements.

o Near drowning in the salt water

2. Inadequate Water Intake:

3. Excessive Water Loss:
(Increased sodium concentration)
o Increased insensible water loss (High fever, heart stroke, prolonged
hyperventilation)
o Osmotic diuretic therapy.

o Diarrhea.

4. Disease States:
1. Diabetes insipidus.
2. Cushing syndrome.
3. Uncontrolled diabetes mellitus.
4. Primary hyperaldosteronism.

Clinical manifestation:
1. Decreased ECF volume:
 o Restlessness, agitation, twitching, seizure, coma.

o Intense thirst, dry & swollen tongue, sticky mucous membrane.

o Postural hypotension, increased CVP, weight loss, increased

pulse.
o Weakness, lethargy.

2. Normal or increased ECF Volume:

1. Restlessness, agitation, twitching, seizure, coma.
2. Intense thirst, flushed skin.
3. Weight gain, peripheral and pulmonary edema, increased BP,
increased CVP.

Medical Management:
● Gradual lowering of the sodium level by the infusion of hypotonic electrolyte
solution.
o E.g.: 0.3% of NaCl.

● Isotonic solution – dextrose 5% in water (D5W).

● Diuretics – to excrete the excess sodium if the cause is diabetes insipidus.

Nursing Management:
● Monitor the serum sodium levels and the patient’s response to the therapy.
● Restrict the dietary intake of sodium.
● Prevent the ingestion of over-the-counter medications with high sodium content. Eg:
Alka-Seltzer.
● Note the patient’s thirst and elevated body temperature.
● Monitor for changes in behavior such as restlessness, disorientation and lethargy.

Nursing Diagnosis:
1. Risk for acute confusion related to electrolyte imbalance.
2. Risk for injury related to altered sensorium and decreased level of consciousness.
3. Risk for electrolyte imbalance related to excessive loss of sodium and or excessive
intake or retention of water.
4. Potential complication: Severe neurologic changes.

ii) Hyponatremia (Sodium Deficit)

 ● It refers to the serum sodium level that is below the normal range (< 135mEq/L).
● Hyponatremia may results from a loss of sodium containing fluids, water excess in
relation to the amount of sodium (dilutional hyponatremia).
● Hyponatremia causes hypo-osmolality with shift of water into the cells.

Causes:
1. Excessive sodium loss:
o GI Loss: Diarrhea, vomiting, fistulas, Nasogastric suction.

o Renal Loses: Diuretics, Adrenal insufficiency, Na+ wasting, renal

disease.
o Skin Loses: Burns, wound drainage.

2. Inadequate sodium Intake:

3. Excessive Water Gain:
(Decreased sodium concentration)
o Excessive hypotonic IV fluids.

o Primary Polydipsia.

4. Disease States:
o SIADH.

o Heart failure

o Primary hypoaldosteronism.

Clinical manifestation:
1. Decreased ECF volume:
o Irritability, confusion, dizziness, tremors, personality changes.

o Dry mucous membranes.

o Postural hypotension, decreased hypotension, decreased CVP,

decreased jugular venous filling, increased Pulse.
o Cold, clammy skin

2. Normal or increased ECF Volume:

1. Headache, apathy, confusion, muscle spasm seizure, coma.
2. Nausea, vomiting, diarrhea, abdominal cramps.
3. Weight gain, increased BP, increased CVP.
Medical Management:
● Sodium replacement therapy:
o Oral intake of sodium by eat or drink.

o Administration of small amount of IV hypertonic saline solution (3% of

NaCl).
o Lactated Ringer’s solution (0.9% of NaCl is prescribed).

● The correction of serum sodium must not increase greater than 12mEq/L in 24 hours
to avoid neurological damages.
● The drug Tolvaptan and conivaptan are given to block the activity of ADH which
increases the urine output without the loss of electrolytes such as sodium and
potassium

NURSING MANAGEMENT:
● Monitor the serum sodium levels and the patient’s response to the therapy.
● Advise to add up salt in diet.
● Record the lab value and inform to the physician.

NURSING DIAGNOSIS:
1. Risk for fluid volume deficit related to excessive intake of sodium and or excessive
loss of water.
2. Risk for electrolyte imbalance related to excessive intake of sodium and or excessive
loss of water.
3. Potential complication: Seizure, coma brain damages.

POTASSIUM
(Normal Range: 3.5 to 5.5mEq/L)
● Potassium is major intracellular fluid (ICF) cation, with 98% of the body potassium
being intracellular.
● Diet is the source of potassium. The typical wester diet approximately contains 50 to
100mEq of potassium daily, which are mainly from fruits, dried fruits and vegetables.
● The kidney are the primary route for potassium loss, eliminates about 90% of daily
potassium intake.
● There is an inverse relationship between sodium and potassium reabsorption in the
kidney.
i) Hyperkalemia (K+ > 5.5mEq/L)
(High serum potassium):
● It results from impaired renal excretion, a shift of potassium from ICF to ECF and a
massive intake of potassium or combination of these factors.
● The most common cause of hyperkalemia is renal failure, retention of potassium ions.

Causes:
1. Excessive potassium intake:
o Excessive or rapid parenteral administration.

o Potassium containing drugs. Eg.: Potassium Penicillin.

o Potassium containing salt substitute.

2. Shift of potassium out of cells:

o Acidosis.

o Tissue catabolism.

Eg: Fever, sepsis, burns.

o Crush Injury.

o Tumor lysis syndrome.

3. Failure to eliminate potassium:

o Renal disease.

o Potassium-sparing diuretics.

Eg: amiloride
o Adrenal insufficiency.

o ACE inhibitors.

o NSAIDS

Clinical manifestation:
1. Irritability, anxiety
2. Abdominal cramping, diarrhea.
3. Weakness of lower extremities.
4. Paresthesia's.
5. Irregular pulse.
 6. Cardiac arrest.

ECG changes in hyperkalemia:

o Tall, peaked T wave.

o Prolonged PR interval.

o ST segment depression

o Loss of P wave.

o Widening QRS.

o Ventricular fibrillation.

Medical Management:
● Immediate ECG should be obtained to detect the changes.
● Restriction of dietary potassium.
● Potassium containing diuretics.
● Calcium gluconate administered in serum potassium level are dangerously elevated.

Nursing Management:
● Identification and close monitoring of patients who are at risk of hyperkalemia.
● Observes the sign of muscle weakness and dysrhythmias.
● To avoid false reports of hyperkalemia, the blood samples are taken to laboratory as
soon as possible.

Nursing Diagnosis:
1. Risk for activity intolerance related to lower extremity muscle weakness.
2. Risk for electrolyte imbalance related to excessive retention or cellular release of
potassium.
3. Risk for injury related to altered sensorium and decreased level of consciousness.
4. Potential complication: Dysrhythmias.

ii) Hypokalemia (K+ < 3.5mEq/L)

(Low serum potassium):
● It results from increased loss of potassium, from an increased shift of potassium from
ECF to ICF or rarely from deficient dietary potassium intake.
● The most common cause are abnormal losses from either the kidney or GI tract.
Causes:
1. Potassium loss:
o GI Loss: Diarrhea, vomiting, fistulas, Nasogastric suction.

o Renal Loses: Diuretics, hyperaldosteronism, magnesium depletion.

o Skin Loses: Diaphoresis, Dialysis.

2. Shift of potassium into cells:

1. Increased insulin Eg: Dextrose load
2. Alkalosis.
3. Tissue repair.
4. Increased epinephrine Eg: Stress.
3. Lack of Potassium intake:
o Starvation.

o Diet low in potassium.

o Failure to include potassium in parenteral fluids, if NPO.

Clinical manifestation:
1. Fatigue.
2. Muscle weakness, leg cramps.
3. Nausea, vomiting, paralytic ileus.
4. Soft, flabby muscle
5. Paresthesia’s, decreased reflexes.
6. Weak irregular pulse.
7. polyuria.
8. Hyperglycemia

ECG changes in hypokalemia:

o Flattened T wave.

o Presence of U waves.

o ST segment depression

o Bradycardia.
 o Prolonged QRS.

o Ventricular dysrhythmias.

Medical Management:
● Treated with oral or IV replacement therapy.
● Administer 40 to 80mEq/L day of potassium.
● IV route is indicated if oral K+ therapy is not feasible.
● Potassium rich diet for patients at risk of hypokalemia.

NURSING MANAGEMENT:
● Monitor for the presence of hypokalemia in patients at risk.
● Encourage the patients for potassium rich diet (bananas, melon, citrus, fresh and
frozen vegetables, fresh meats).
● Monitor the patients who are taking digitalis which may cause potassium deficiency.

NURSING DIAGNOSIS:
1. Risk for electrolyte imbalance related to excessive loss of potassium.
2. Risk for injury related to muscle weakness and hyporeflexia.
3. Potential complication: Dysrhythmias.

CALCIUM
(Normal Range: 8.5 to 10.5mg/dL)
● More than 99% of the body’s calcium is present in the skeletal system, where it is a
major component of bones and teeth.
● About 1% of skeletal calcium is exchanged with blood calcium.
● Calcium plays a major role in transmitting nerve impulses and helps to regulate
muscle contraction and relaxation, including the cardiac muscle.
● Calcium helps in activating the enzymes that stimulate many essential chemical
reactions in the body, and also plays a vital role in blood coagulation.
● Calcium is absorbed from food in the presence of normal gastric acidity and vitamin-
D.
● Calcium is excreted primarily in feces, the remaining in urine.

i) Hypercalcemia (Ca2+ > 10.5mg/dL)

(High serum calcium):
● Hypercalcemia refers to an excess of calcium in the plasma.
 ● The most common cause of hypercalcemia are malignancies and
hyperparathyroidism. The excessive PTH secretion associated with
hyperparathyroidism cause increased release of calcium from the bones and increased
intestinal and renal absorption of calcium.

Causes:
1. Increased total calcium:
o Malignancies with bone metastasis.

o Prolonged immobilization.

o hyperparathyroidism.

o Vitamin D overdose.

o Thiazide diuretics.

o Milk-alkali syndrome.

o Multiple myeloma.

2. Increased ionized calcium:

o Acidosis.

Clinical manifestation:
1. Lethargy, weakness.
2. Depressed reflexes.
3. Decreased memory.
4. Confusion, personality changes.
5. Psychosis.
6. Anorexia, nausea, vomiting.
7. Bone Pain, fractures.
8. Polyuria, dehydration.
9. Stupor, coma.

ECG changes in hypercalcemia:

o Shortened ST segment,

QT interval
o Ventricular dysrhythmias.
 o Increased digitalis effect.

Medical Management:
● Administration of fluids to dilute serum calcium and promote its excretion by the
kidney.
● IV administration of 0.9% NaCl solution temporarily dilutes the serum calcium level.
● Administering furosemide increases calcium level.
● Calcitonin administered to lower the serum calcium level.
Nursing Management:
● Monitor the patients who are at risk of hypercalcemia.
● Increasing the patient mobility and encouraging fluids to prevent hypercalcemia.
● Fluids containing sodium should be administered unless contraindicated by other
conditions, because sodium favors calcium excretion.
● Patients are encourage to drink 3 to 4 quarts of fluid daily.

ii) Hypocalcemia (Ca2+ < 8.5mg/dL)

(Low serum calcium):
● Hypocalcemia refers to lower than normal serum concentration of calcium.
● Any condition that causes a decreased production of PTH [Parathyroid Hormone]
may result in the development of hypocalcemia.

Causes:
1. Decreased total calcium:
o Chronic kidney disease.

o Elevated phosphorus.

o Primary hypoparathyroidism.

o Vitamin D deficiency.

o Magnesium deficiency.

o Acute pancreatitis.

o Chronic alcoholism.

o Diarrhea.

2. Decreased ionized calcium:

o Alkalosis.
Clinical manifestation:
1. Easy fatigability.
2. Depression, anxiety, confusion.
3. Numbness, tingling in extremities & region around mouth.
4. Hyperreflexia, muscle cramps.
5. Chvostek’s sign.
6. Trousseau’s sign.
7. Laryngeal spasm, tetany, seizure.

Positive Chvostek’s sign: Contraction of facial muscle when light tapping of

facial nerve in front of the ear.

Positive Trousseau’s Sign:

Induction of carpopedal spasm by inflation of sphygmomanometer above SBP for 3 minutes.

ECG changes in hypercalcemia:

o Elongation of ST segment.

o Prolonged QT interval

o Ventricular tachycardia.

Medical Management:
● IV administration of calcium like:
o Calcium gluconate.

o Calcium chloride.

o Calcium gluceptate.

● Vitamin D administration to increase the absorption of calcium from GI tract.

● Increase the dietary intake of calcium at least 1000 to 1500mg/day.

Nursing Management:
● Monitor the patients who are at risk of hypocalcemia.
● Seizure precautions are initiated if hypocalcemia is severe.
● People at high risk for osteoporosis are instructed about the need for adequate dietary
intake of calcium.
MAGNESIUM
(Normal Range: 1.5 to 2.5mEq/L)
● Magnesium is the second most abundant intracellular cation, next to potassium.
● It plays an major role in cellular process and it acts as a co-enzyme in the metabolism
of carbohydrates and protein and also required for the synthesis of nucleic acids and
proteins.
● It helps in maintenance of normal calcium and potassium balance.

i) Hypermagnesemia (Mg+ > 2.5mEq/L)

(High serum magnesium):
● It refers to a greater than normal serum concentration of magnesium.
● It occurs only with an increase in magnesium intake accompanied by renal
insufficiency or failure.
● A patients with chronic kidney disease who ingests products containing magnesium
(Eg: Milk of magnesia) will have problem with excess magnesium.
● Hypermagnesemia depresses the neuromuscular and CNS functions.

Causes:
1. Renal failure.
2. Adrenal insufficiency.
3. Excessive administration of magnesium, especially for treatment of eclampsia.
4. Tumor lysis syndrome.
5. Diabetic ketoacidosis.

Clinical manifestation:
1. Lethargy, drowsiness.
2. Nausea, vomiting.
3. Diminished deep tendon reflexes.
4. Flushed, warm skin.
5. Decreased pulse, decreased blood pressure.
6. Muscle weakness.
7. Dysphagia.

Medical Management:
 ● Avoiding administration of magnesium to patients with renal failure.
● In severe hypermagnesemia, all parenteral and oral magnesium salts are discontinued.
● In respiratory depression or defective cardiac conduction ventilatory support and IV
calcium are indicated.
● Hemodialysis.

Nursing Management:
● Careful monitoring of patients with high risk of hypermagnesemia.
● Interpretation of lab results and inform to the physician and follow up the orders.

ii) Hypomagnesemia (Mg+ < 1.5mEq/L)

(Low serum magnesium):
● It refers to below normal serum concentration of magnesium.
● It commonly occurs in patients with limited magnesium intake or increased renal
losses.
● Hypomagnesemia produces neuromuscular and CNS hyperirritability.

Causes:
1. Diarrhea, vomiting.
2. Chronic alcoholism.
3. Malabsorption syndrome.
4. Prolonged malnutrition.
5. Increased urine output.
6. Poorly controlled diabetes mellitus.

Clinical manifestation:
1. Confusion.
2. Tremors, seizures.
3. Hyperactive deep tendon reflexes.
4. Insomnia.
5. Increased pulse, Increased blood pressure.
6. Muscle cramps.

Medical Management:
● Oral supplement and increase the dietary intake of foods high in magnesium.
 ● IV administration of magnesium (Eg: Magnesium Sulfate) is given in case of severe
hypomagnesemia or hypocalcemia is present.
● For mild deficiency – intake of magnesium rich foods or by suing oral magnesium
supplement (Eg: Magnesium containing antacids).
● Foods rich in magnesium:
● Green leafy vegetables.
● Legumes.
● Whole grains.
● Bananas, oranges, grape fruits.
● Dairy products.
● Meat, sea foods.

PHOSPHOROUS
(Normal Range: 2.4 to 4.4mg/dL)
● Phosphorous is the primary anion in ICF and the second most abundant element in the
body, second to calcium.
● Most phosphorous is in the bones and teeth as calcium phosphate. The remaining
phosphorous is metabolically active and essential in the function of muscle, red blood
cells (RBCs) & the nervous system.

i) Hyperphosphatemia (PO₄³⁻ > 4.4mg/dL)

(High serum phosphate):
● It refers to the serum phosphorous level that exceeds normal level and is commonly
caused by acute kidney injury (AKI) or chronic renal disease (CKD), which results in
altered ability of the kidney to excrete phosphate.

Causes:
1. Renal failure.
2. Chemotherapy drugs.
3. Enemas containing phosphorous [Eg: Fleet enema].
4. Excessive ingestion of phosphorous [Eg: Milk].
5. Phosphate containing laxatives.
6. Hypoparathyroidism.
7. Sickle cell anemia.
Clinical manifestation:
1. Hypocalcemia.
2. Numbness and tingling in extremities and region around mouth.
3. Hyperreflexia, muscle cramps.
4. Tetany, seizures.
5. Deposition of calcium phosphate precipitates in skin, soft tissue, cornea, viscera,
blood vessels.

Medical Management:
● The ingestion of high phosphorous rich foods and fluids are restricted. [Eg: Dairy
Products].
● Phosphate binding agents or gels [Eg: Calcium Carbonate] which limit intestinal
phosphate absorption and thus increase phosphate secretion into the intestine.
● Hemodialysis.
● Insulin or glucose infusion can rapidly decrease the levels.

ii) Hypophosphatemia (PO₄³⁻ <2.4mg/dL)

(Low serum phosphate):
● Hypophosphatemia is below normal serum concentration of inorganic phosphorous.
● It is rare, but may occur in the patient who is malnourished or has a mal-absorption
syndrome.

Causes:
1. Malabsorption syndrome.
2. Recovery from malnutrition or refeeding.
3. Glucose or insulin therapy.
4. Total parenteral nutrition.
5. Alcohol withdrawal.
6. Recovery from diabetes ketoacidosis.
7. Respiratory alkalosis.

Clinical manifestation:
1. CNS depression – confusion, coma.
2. Muscle weakness.
3. Polyneuropathy, seizures.
 4. Cardiac problems – dysrhythmias, decreased stroke volume.
5. Osteomalacia.
6. Rhabdomyolysis.

Medical Management:
● Oral supplementation and ingestion of foods high in phosphorous. [Eg: Dairy
Products].
● IV administration of sodium phosphate or potassium phosphate.

● Frequent monitoring of serum phosphate and calcium levels is necessary to guide IV

therapy.
CHLORIDE
(Normal Range: 96 to 106mEq/L)
● Chloride is the major anion of the ECF.
● They found more in interstitial and lymph fluid compartments than in blood.
● Chloride also contained in gastric and pancreatic juices as well as in sweat.
● The sodium and chloride in water makes up the composition of the ECF.

i) Hyperchloremia (Cl⁻ > 106mg/dL)

(High serum chloride):
● Hyperchloremia occurs when the serum concentration level of chloride exceeds the
normal range.
● With increase in the chloride level, hypernatremia, carbonate loss, and metabolic
acidosis can also occur.

Causes:
● Loss of Bicarbonate ions via the kidney or through GI tract with a corresponding
increase in chloride ions.

Clinical manifestation:
1. Tachycardia.
2. Diminished cognitive ability.
3. Hypertension.
4. Rapid respiration.
5. Weakness.
6. Deep respiration.
Medical Management:
● Lactated Ringer’s solution to convert lactate to bicarbonate in the liver, which will
increase the base bicarbonate level and correct the acidosis.
● Sodium bicarbonate in IV infusion to increase the bicarbonate levels, which leads to
the renal excretion of chloride ions as bicarbonate and chloride compete for
combination with sodium.
● Diuretics to eliminate chloride as well sodium fluids and chloride are restricted.

Nursing Management:
● Monitoring arterial blood gas (ABG) values, intake and output (I/O), Vitals.
● Assess the respiratory, neurological, cardiac system & document the changes to
discuss with the physician.
● Teach the patients about the diet that should be followed to manage hyperchloremia.

ii) Hypochloremia (Cl⁻ <69mg/dL)

(Low serum chloride):
● Chloride control depends on the intake of chloride and the excretion and reabsorption
of its ions in the kidney.
● Chloride is produced in the stomach as hydrochloric acid, a small of chloride is lost in
feces.

Causes:
1. Salt restricted diet.
2. GI tube drainage, and severe diarrhea.
3. Volume depletion.
4. Accumulation of HCo3 in ECF.

Clinical manifestation:
1. Metabolic alkalosis.
2. Hyper-excitability of muscles.
3. Tetany, hyperactive.
4. Deep tendon reflexes, weakness.
5. Twitching, muscle cramps.
6. Dysrhythmias.
Medical Management:
● 0.9% of sodium chloride or 0.45 % of sodium chloride of normal saline IV infusion to
replace the chloride.
● Discontinue or change of diuretics.
● High chloride rich foods are provided.
oTomato juice

oSalty broth.

oCanned vegetables.

oProcessed meats.

oFruits.

● Ammonium chloride, an acidifying agent to treat metabolic alkalosis.

Nursing Management:
● Monitoring arterial blood gas (ABG) values, intake and output (I/O), serum
electrolytes.
● Monitor patient’s level of consciousness, muscle strength and movement.
● Vital signs are monitored.
● Educate about the high chloride rich diet.

BIBLIOGRAPHY
JOURNAL REFRENCES
1. Fluid and electrolyte imbalance: Interpretation and assessment – Mandi D. Walker
(Journal of infusion nursing), 2016.
2. Fluid and electrolyte imbalances related intracranial abnormality (2013), international
journal of paediatric endocrinology- by Frida soesanti, Bambang Tridjaja, Aman
Pulungan.
3. General characteristics of patients with electrolyte imbalance admitted to emergency
dept. by Arif Kadri Balc, Ozlem Koksal, Nuran Oner world, Journal of emergency
medicine.
4. Overview of fluid and electrolyte imbalances by Norma Metheny R.N (1981), Journal
of national intravenous therapy association.