1. Fluid and Electrolyte Imbalance Acid and Base Imbalance

2. Fluid and electrolyte Disturbance
Amount and Composition of Body Fluids:
- Approximately 60% of atypical adult’s weight consists of
fluid (water&electrolyte).
- Body fluid is located in tow fluid compartment:
1) Intracellular fluids (fluids in the cells) 2/3.
2) Extracelluler fluids :( fluids out side the cells) 1/3.
a-Intravascular space (fluids with in blood vessels)
contains plasma.(3L of the total blood).
b- Interstitial fluids: contain fluids that surround the cell
and total about 8L.eg. Lymph.
c- Trancellular space: contain approximately 1L.
eg. Cerebrospinal, Pericardial, Synovial.

3. Average daily intake and output in an adult:
Intake Output
Oral Liquids ml Urine ml
Water in foods ml Stool ml
Water produced Insensible lungs 300ml
by metabolism 300ml Skin ml
2600ml ml

4. Normal Lab Results: - Na→ 135−145mEq/L. - K+ → 3.5−5.5mEq/L.
- Ca++→ 8.5−10.5mEq/L.
- Cl → 96−106mEq/L.
- Mg→ 1.5−2.5mEq/L.

5. Fluid Volume Disturbance:
I-Hypovolemia (fluids volume deficit):
− Contributing Factors:
* Loss of water and electrolyte.
e.g.( vomiting,diarrhea,burns).
* Decrease intake. e.g. (anorexia, nausea, inability to
gain access to fluids).
* Some disease.e.g (D.M, Diabetic Insipidus).
− Sings and symptoms:
Weight loss, general weakness, dizziness, increase pulse.

6. Assessment Diagnostic evaluation
Health History & Physical examination
Serum BUN & Creatinin
Hematocrit level “great than normal”
Urine specific gravity
Serum electrolytes level
Hypokalemia in case of GI & renal loss
Hyperkalemia in case of adrenal insufficiency
Hypernatremia in case of ↑insensible losses & diabetic insepedus

8. ♣ Management
treatment of the causes of FVD should be go with treatment of FVD itself
factors influence the pt fluid needs should be taken in consideration
In case of sever or acute FVD IV replacement should be started
Isotonic solutions used to treat hypotension resulted from FVD
Renal function & hemodynamic status should be evaluated
♣Nursing Management
Monitor I&O as needed “urine”
Monitor V/S, skin turgor , mental status & daily weight
Extensive Hemodynamic CVP, arterial pressure
Mouth care & ↓ irritating fluids

9. Fluid Volume Disturbance:
II- Hypervolemia (fluid volume excess):
− Contributing Factors:
* Compromised regulatory mechanism such as renal failure, congestive heart failure, and cirrhosis.
* Administration of Na+ containing fluids.
* Prolong corticosteroid therapy.
* Increase fluid intake.
− Sings and Symptoms:
Weight gain, increase blood pressure, edema, and shortness of breathing.

10. Assessment & Diagnostic Evaluation
- Decreased BUN , Creatinin , Serum osmolality & hematocrete because of plasma dilution, &↓protein intake
- Urine sodium is increased if kidneys excrete excess fluid
- CXR may disclosed pulmonary congestion

12. Management Direct cause should be treated
Symptomatic treatment consist of :
- Diuretics
- restrict fluid & Na intake
- Maintained electrolytes balance
- Hemodialysis in case of renal impairment
- K+ supplement & specific nutrition
Nursing Management:
- Assess breathing , weight ,degree of edema regularly
- I & O measurement regularly
- Semifowlers position in case of shortness of breath
- Patient education

13. Electrolyte imbalance:
I- SodiumDeficit (Hyponatremia):
−Contributing Factors:
* Use of a diuretic.
* Loss of GI fluids.
* Gain of water.
− Sings and Symptoms:
Anorexia, nausea and vomiting, headache, lethargy, confusion, seizures.

15. Hyponatremia, continued
Treatment: correct underlying disorder
Fluid restrict, + diuretics
Hypertonic saline to increase level 2-3 mEq/L/hr and max rate 100cc of 5% saline/hr

16. Electrolyte imbalance:
II- Sodium Excess (Hypernatremia):
− Contributing Factors:
* Water deprivation in patient.
* Hypertonic tube feeding.
* Diabetes Insipidus.
− Sings and Symptoms:
Thirst, hallucination, lethargy, restless, pulmonary edema.

18. Hypernatremia, continued
Treatment: correct underlying disorder
Free water replacement: (0.6 * kg BW) * ((Na/140) – 1). Slow infusion of D5W give ½ over first 8 hrs then rest over next hrs to avoid cerebral edema.

19. Electrolyte imbalance:
III- Potassium Deficit (Hypokalemia):
− Contributing factors:
* Dirrhea, vomiting, gastric suctions.
* Corticosteroid administration.
* Diuretics.
− Sings and symptoms:
Fatigue, anorexia, nausea, vomiting, muscle weakness, change in ECG.
EKG: low, flat T-waves, ST depression, and U waves

20. Hypokalemia, continued
ECG changes in hypokalemia

21. Hypokalemia, continued
ECG changes in hypokalemia

22. Hypokalemia, continued
Treatment:
Check renal function
Treat alkalosis, decrease sodium intake
PO with mEq doses
IV: peripheral 7.5 mEq/hr, central 20 mEq/hr and increase K+ in maintenance fluids.

23. Electrolyte imbalance:
IV- Potassium Excess (Hyperkalemia):
− Contributing Factors:
* Renal Failure.
* Crush injury, burns.
* Blood transfusion.
* Administration of IV K+.
− Sings and Symptoms:
Bradycardia, dysarrythmia, anxiety, irritable.
- ECG: peaked T waves then flat P waves, depressed ST segment, widened QRS progressing to sine wave and V fib.

24. Hyperkalemia – ECG Changes

25. Hyperkalemia – ECG Changes

26. Hyperkalemia, continued
Treatment:
Remove iatrogenic causes
Acute: if > 7.5 mEq/L or EKG changes
Ca-gluconate – 1 gm over 2 min IV
Sodium bicarbonate – 1 amp, may repeat in 15min
D50W (1 ampule = 50 gm) and 10U regular insulin
Emergent dialysis
Hydration and diuresis, kayexalate g, in cc of 20% sorbitol q 4hrs or enema

27. Calcium Hypocalcemia: Seen in hypoalbuminemia. Check ionized Ca
Often symptomatic below 8 mEq/dL
Check PTH:
low may be Mg deficiency
High think pancreatitis, hyperPO4, low Vitamin D, pseudohypoparathyroidism, massive blood transfusion, drugs (e.g. gentamicin) renal insufficiency
S/Sx: numbness, tingling, circumoral paresthesia, cramps tetany, increased DTR’s, Chvostek’s sign, Trousseau’s sign
EKG has prolonged QT interval

29. ECG Changes in Calcium Abnormalities

30. Calcium, continued Hypocalcemia cont. Treatment:
Acute: (IV) CaCl 10 cc of 10% solution = 6.5 mmole Ca or CaGluconate 10cc of 10% solution = 2.2 mmole Ca
Chronic: (PO) gm CaCO3 = mg Ca.
Phosphate binding antacids improve GI absorption of Ca
Vit D (calciferol) must have normal serum PO4. Start 50,000 – 200,000 units/day

31. Calcium, continued

32. Calcium, continued Hypercalcemia
Usually secondary to hyperparathyroidism or malignancy. Other causes are thiazides, milk-alkali syndrome, granulomatous disease, acute adrenal insufficiency
Acute crisis is serum Ca> 12mg/dL. Critical at 16-20mg/dL
S/Sx: N/V, anorexia, abdominal pain, confusion, lethargy MS changes= “Bones, stone, abdominal groans and psychic overtones.”

33. Calcium, continued
Treatment: Hydration with NS then loop diuretic. Steroids for lymphoma, multiple myeloma, adrenal insufficiency, bone mets, Vit D intoxication. May need Hemodialysis.
Mithramycin for malignancy induced hyperCa refractory to other treatment. Give mcg/kg IVP
Calcitonin in malignant PTH syndromes

34. Magnesium Hypomagnesemia
Malnutrition, burns, pancreatitis, SIADH, parathyroidectomy, primary hyperaldosteronism
S/Sx: weakness, fatigue, MS changes, hyperreflexia, seizure, arrhythmia
Treatment: IV replacement of 2-4 gm of MgSO4 per day or oral replacement

35. Magnesium

36. Magnesium, continued Hypermagnesemia
Renal insufficiency, antacid abuse, adrenal insufficiency, hypothyroidism, iatrogenic
S/Sx: N/V, weakness, MS changes, hyporeflexia, paralysis of voluntary muscles, EKG has AV block and prolonged QT interval.
Treatment: Discontinue source, IV CaGluconate for acute Rx, Dialysis

37. Phosphate Hyperphosphatemia
Treatment: PO replacement (Neutraphos) or IV KPhos or NaPhos mM/kg over 6 hrs
Hyperphosphatemia
Renal insufficiency, hypoparathyroidism, may produce metastatic calcification
Treat with restriction and phosphate-binding antacid (Amphogel)

38. Acid−Base Disturbance:
Normal Values:
PH→
PCO2→ mmHg.
PO2→ mmHg.
HCO3→ mEq/L.
Respiratory Acidosis: → → → → ↑ PCO2.
Respiratory Alkalosis: → → → → ↓ PCO2.
Metabolic Acidosis: → → → → ↓ PH, ↓ HCO3.
Metabolic Alkalosis: → → → → ↑ PH, ↑ HCO3.

39. Types of IV solutions: * Serum plasma osmalarity (280-300 m osmol).
I- Isotonic Solutions:
A solution with the same osmalality as serum and other body
Fluids.
e.g. N/S 0.9%, Ringer Lactate, D5W.
II- Hypotonic Solutions:
A solution with an osmolality lower than that of serum
plasma.
e.g. half strength saline (0.45% sodium chloride).
III- Hypertonic Solution:
A solution with an osmalality higher than that of serum.
e.g. D/S 0.9%, D/S 0.18%, D/S 0.45%, D10W, D25W.

40. Types of IV solutions: *Hypotonic Solutions (0.45% saline)
Decreases intravascular osmolarity.
Results in intracellular expansion.
Used for cellular dehydration.
Complications include shock and increased ICP.
Contraindications include cerebral edema, and hypotension.

41. Types of IV solutions:
*Hypertonic Solutions (D5% .45% saline, D5% NS, D5%LR.)
Increases intravascular osmolarity.
Results in intracellular and interstitial dehydration.
Used for intravascular expansion by shifting intracellular and interstitial fluids.
Complications include circulatory overload.
Contraindications include intracellular dehydration and hyperosmolar states.

42. Types of IV solutions:
*Isotonic Solutions (NS, Lactated Ringers, D5%W.)
Does not change osmolarity.
Results in TBW expansion.
Used to increase intravascular space.
Complications include circulatory overload.
Contraindications include circulatory overload and LR in alkalosis and liver disease.