FLUID ELECTROLYTE AND ACID BASE BALANCE.pptx

FLUID ELECTROLYTE AND
ACID BASE BALANCE

 approximately 60% of human body
consists of fluids
 major component of living organism

Fluid Compartments
There are two types of body fluid compartments:
Intracellular fluids or ICF and Extracellular
fluid or ECF. The intracellular fluid makes up
about 2/3 rd of the body water while the remaining
is extracellular

1. Intracellular Fluid (ICF): It is defined as the fluid
present inside the cells.
2. comprises 2/3 of the body's water
3. The ICF is primarily a solution of potassium and organic anions,
proteins, etc.

1. Extracellular Fluid (ECF): It is the fluid present outside the cells. It is the
remaining 1/3 of body's water.
a) ECF is about 20% of body's weight.
b) The ECF is primarily a NaCl and NaHCO3 solution.
The ECF is further subdivided into three sub compartments.
c) Interstitial Fluid (ISF) surrounds the cells, but does not circulate. It comprises about 3/4
of the ECF.
d) Plasma circulates as the extracellular component of blood. It makes up about 1/4 of the
ECF.
e) Transcellular fluid is a set of fluids that are outside the normal compartments. These 1-2
litres of fluids make up the CSF, digestive juices, mucus, etc

FLUID PRESSURE
 Body fluids shift between the interstitial space and the
intravascular space in the capillary as a result of differences in the
hydrostatic pressure and the oncotic pressure.
 Hydrostatic pressure is pressure caused by water volume in the
vessels.
 Oncotic pressure is pressure exerted plasma proteins.

FLUID AND ELECTROLYTE
BALANCE
 Homeostasis
 It is the process through which bodily equilibrium is maintained.

Fluid Balance
 The amount of water coming into the body each day must equal the
amount of water eliminated from the body over the same period of
time. If not, the body will have either a net water gain or a net water
loss.

Water Sources
a) Drinking water.
b) Water contained in food.
c) Metabolism to CO2 and H2O

Water Losses
a) Urinary loss.
b) Faecal loss.
c) Insensible Water loss: Evaporation from the respiratory tract
and the skin surface (not including sweat which is sensible
since it has a purpose).
d) Sweat losses: At normal room temperature, sweating accounts
for about 25% of heat losses. In cold environments, H2O losses
in sweat decrease. In warm environments or with exercise,
sweat losses increase.
e) Pathological losses include: Vascular bleeding, vomiting and
diarrhoea.

Water Requirements
 Requirements of water vary with climate, dietary constituents,
activities and surface area of the body. As a rule, a person
should take enough water to excrete about 1200-1500 mL of
urine per day.
 In tropics because of greater water loss through perspiration
increased water intake is required to maintain urine volume.
 Normal intake of water ranges between 8-10 glasses per day.

Daily Water Input
 In tropical countries like India, the daily water input amounts to 2400-3000 mL of
water through food, as fluid drinks and as metabolic water.
 As fluid drinks-water, tea, coffee, milk soups 1500-1750 ml.
 Water intake through solid food-600-900 mL
 Oxidation of carbohydrate, fat-300-350 mL
 Total 2400-3000 mL

Daily Output of Water
 Urine 1200-1500 mL (kidney)
 Perspiration 700-900 mL (skin)
 Respiration 400 mL (lung)
 Faeces 100-200 mL (intestine)
 Total 2400-3000 mL

New Born 80 to 100 ml
0-1 year 100 to 150 ml
1-2 years 100 to 125 ml
2-10 years 75 to 100 ml
11-18 years 50 to 75 ml
Adults 40 ml
Fluid Requirement
Fluid requirement per kg of body weight at different ages are:

1. Antidiuretics Hormone (ADH):
 water retainer called antidiuretic hormone (ADH) or vasopressin.
 The hypothalamus produces ADH, but the posterior pituitary gland stores and
releases it.
 function : to restore blood volume by reducing diuresis and increasing water
retention.
 Increased serum osmolality or decreased blood volume can stimulate the release of
ADH, which in turn increases the kidneys’ reabsorption of water. The increased
reabsorption of water results in more concentrated urine.
 Likewise, decreased serum osmolality or increased blood volume inhibits the release
of ADH and causes less water to be reabsorbed, making the urine less concentrated.
The amount of ADH released varies throughout the day, depending on the body’s
 needs.

2. Aldosterone:
 Secreted by the adrenal cortex
 regulates the reabsorption of sodium and water within the nephron.
 When blood volume drops, aldosterone initiates the active transport
of sodium from the distal tubules and the collecting ducts into the
bloodstream. That active transport forces sodium backinto the
bloodstream. When sodium is forced into the bloodstream, more
water is reabsorbed and blood volume expands.

Renin-Angiotensin
 is a chain of chemicals released to increase both BP and blood
volume.
 When the volume of arterial blood supplying the glomeruli is
reduced, a special cells (juxtaglomerular cells) near each
glomerulus secrete an enzyme called renin.
 Renin begins the transformation of angiotensinogen to angiotensin I
to angiotensin II.
 Angiotensin II causes vasoconstriction and raises BP;
 it also stimulates release of aldosterone from the adrenal cortex.
 Aldosterone causes the kidneys to reabsorb sodium, which in turn
increases blood volume and BP

Fluid Output Regulation
 1.Kidneys: Kidneys are the major regulatory organs of fluid balance, they receive
approximately 180 litres of plasma to filter each day and produce 1400 to 1500 ml of
urine.
 2. Skin: Water loss from the skin is regulated by the sympathetic nervous system which
activates the sweat glands; water loss from the skin can be a sensible or insensible
loss; an average of 500 to 600 ml of sensible or insensible fluids are lost via the skin
each day.
 3. Lungs: The lungs expire 300-400 ml of water daily; this insensible water loss may
increase in response to changes in respiratory rate and depth.
 4. GI Tract: GI Tract plays a vital role in fluid regulation, approximately 3 to 6 liters of
isotonic fluid is moved into the GI Tract. Under normal conditions, the average adult
loses only 100 to 200 ml each day through feces.

Electrolyte Balance
 Like H2O, we must consume and eliminate equal quantities of
electrolytes such as sodium (Na+) and potassium (K*).
Electrolyte Sources
a) Na* and K* normally enter the body mainly by ingestion in
food.
b) Clinically, electrolytes also can enter the body parenterally, e.g.
when a physician administers an intravenous(I.V.) solution.

Electrolyte Losses
a) Renal excretion.
b) Stool losses.
c) Sweating.
d) Abnormal routes, e.g. vomit and diarrhoea.

Regulation of Electrolytes
 Cations
 Major cations within the body fluids include sodium (Na),
potassium (K), calcium (Ca) and magnesium (Mg).
1. Sodium: Sodium is the most abundant cation (90%) in
ECF; sodium ions are the major contributors in maintaining
water balance through their effect on serum osmolality,
nerve impulses transmission, regulation of acid base
balance and participation in cellular chemical reactions.

 Potassium: Potassium regulates many metabolic activities and is
necessary for glycogen deposits in the liver and skeletal muscle,
transmission and conduction of nerve impulses, normal cardiac
conduction and skeletal and smooth muscle contraction.
 Calcium: Calcium is stored in bone, plasma and body cells, 99% of
calcium is located in bone and only 1% calcium is in ECF; . Calcium
is necessary for bone and teeth formation, blood clotting, hormone
secretions, cell membrane integrity, cardiac conduction, transmission
of nerve impulses and muscle contractions.

 Magnesium: Magnesium is essential for enzyme
activities, neurochemical activities, on a cardiac and
skeletal muscle excitability. Plasma concentration of
magnesium ranges from 0.7-0.95 mmol/L. About 50% to
60% of body magnesium is contained within the ECF
compartment, the rest is located inside the cell.

Anions
 Three major anions of body fluids are chlorine (CH),
bicarbonate (HCO3) and phosphate (PO) ions.
a. Chlorine is the major anion in ECF, normal concentration of chlorine
ranges from 98-106 mmol/L.
b.Bicarbonate is found in ECF and ICF, normal arterial bicarbonate
levels range between 23-32 mmol/L; venous bicarbonate is measured
as carbon dioxide concentration and the normal value is 24-34 mmol/L.
c. Phosphorus: Nearly all phosphorus in the form of phosphate (PO),
promotes normal neuromuscular action and participates in
carbohydrate metabolism.

Factors Affecting Fluid and Electrolyte
Balance
1. Age: It affects the body size, distribution of body fluids and electrolyte. Infant have
more body surface area and rapid respiration than adult which causes losses the fluid
loss where as in older adults, the kidney become less able to conserve water that will
affect the fluid balance.
2. Diaphoresis: Fluid and electrolyte balance is affected by the extreme temperature and
relative humidity. Hot and humid conditions can lead to increased fluid loss through
sweating, affecting electrolyte balance.
3. Renal diseases: the improper functioning of the kidneys due to acute or chronic illness
leads to electrolyte imbalance in the body.
4. Dehydration: Vomiting and diarrhoea leads to fluid and electrolyte loss from the body.
 Dehydration can affect electrolyte levels. Sodium level, in particular, can be adversely
affected.

 Diuretic therapy: During diuretic therapy, there is increased excretion of sodium and water
from the body in the form of increased urine output.
 Hormones: The antidiuretic hormone and aldosterone released from the kidneys are the main
hormone to control water content in the body. High levels of aldosterone one can result in
elevated levels of sodium and increased loss of potassium in the urine.
 Loss from abnormal routes: Nasogastric suction, wound or fistula drainage, paracentesis and
body irrigations will lead to electrolyte loss from the body. Burns are also abnormal route for
electrolyte excretion.
 Lifestyle: Diet, exercise, stress and alcohol consumption all affect the fluid and electrolyte
balance.
 Psychological Factors: Emotional stress and mental health conditions can impact hormonal
regulation, leading to changes in fluid and electrolyte balance.
 Trauma and Surgery: Surgical procedures and traumatic injuries can disrupt the body's
normal fluid balance due to increased fluid loss, inflammation, and stress responses.

 Hydration Status: The amount of fluid intake versus fluid output
through urine, sweat, and other bodily functions directly impacts
fluid balance. Insufficient fluid intake can lead to dehydration, while
excessive intake can strain the body's excretory systems.
 Dietary Habits: Diets high in processed foods, sodium, and low in
potassium-rich foods can disrupt electrolyte balance.
 Alcohol and Caffeine: Both alcohol and caffeine are diuretics that
can lead to increased fluid loss and affect electrolyte balance if
consumed excessively

FLUID AND ELECTROLYTE
IMBALANCE
FLUID VOLUME DEFICIT
 Hypovolemia
 Fluid Volume Deficit is a decrease in intravascular, interstitial or intracellular fluid in the
body. It occurs when loss of ECF volume exceeds the intake of fluid. It is the deficiency in
the amount of water and electrolytes in ECF but the water and electrolyte proportion
remains the same. The state is commonly known as hypovolemia. It is a relatively
common problem that may exist alone or in combination with other electrolyte or acid
base imbalances.

Causes of Fluid Volume Deficit
 The most common cause of fluid volume deficit is excessive loss of GI fluids from
vomiting, diarrhoea, GI suctioning, intestinal fistulas and intestinal drainage. Other
causes may include:
1. Excessive renal losses of water and sodium from diuretic therapy or renal disorders.
2. Water and sodium losses during sweating from excessive exercise or increased
environmental temperature
3. Haemorrhage.
4. Chronic use of laxatives or enemas.

Fluid volume deficit also takes place by inadequate
fluid intake may results from:
1. Lack of access to fluids
2. Inability to swallow
3. Oral trauma
4. Altered thirst mechanism

Clinical Manifestations
 With a rapid fluid loss manifestations of hypovolemia occur rapidly. When loss of
fluid occurs gradually, the client's fluid volume may be very low before symptoms
develop.
Mucous Membranes Dry, may be sticky.
Neurologic
 Altered sensorium, Anxiety, Restlessness, Diminished alertness, Possible coma.
Integumentary System
 Diminished skin turgor, Dry skin, Pale, Cool extremities.
Musculoskeletal System
 Fatigue

Cardiovascular System
 Tachycardia, Orthostatic hypotension, falling systolic/diastolic
pressure (severe FVD), Flat neck vein, decreased venous filling,
decreased capillary refill, Decreased haematocrit
Potential Complication
 Hypovolemic shock.
Urinary system
 decreased urinary output(400-500ml/day), Oliguria, Increased
specific gravity.
Sunken eyeball
Decreased jugular venous pressure

Diagnosis
 The patient with dehydration have elevated blood urea
nitrogen(BUN) level greater than 25 mg/dl and elevated
haematocrit greater than 55%. The BUN can be elevated due to
dehydration or decreased renal perfusion and function.
Haematocrit level is elevated because the red blood cells become
suspended in a decreased plasma volume. The specific gravity of
the urine also increases (greater than 1.030) as the kidneys
attempt to conserve water, resulting in more concentrated urine.

Assessment
 Collect assessment data through the health history, interview and physical
examination.
 Health History
a) Risk factors such as medications, acute or chronic renal or endocrine disease,
precipitating factor such as hot weather, extensive exercise, lack of access to fluids,
recent illnesses (fever vomiting and diarrhoea)
b) Physical Assessment
 Weight, vital signs, skin colour, temperature, turgor, level of consciousness, urine
output.
a) Diagnostic Tests
 Serum osmolality, electrolytes, haemoglobin and haematocrit, urine specific gravity
and osmolality, CVP readings.

Management of Fluid Volume Deficit
 The primary goal of care related to fluid volume
deficit is to prevent deficits in clients at risk and to
correct deficits and their underlying causes.
Treatment may include replacement of fluids and
electrolytes by IV, oral or enteral routes.

Fluid Management
1. Oral rehydration is the safest and most effective treatment in
adult clients who are able to take oral fluids.
2. For mild fluid deficits in which the loss of electrolyte has
been minimal, water alone may be used for fluid replacement
3. Severe fluid deficits in which electrolytes have also been lost
(e.g. vomiting, diarrhoea) electrolytes solutions such as sports
drinks, rehydrating solutions is more appropriate.
4. When the fluid deficit is severe and client is not able to ingest
fluids, the IV route is used to administer replacement fluids.

 Isotonic electrolyte solutions are used to expand plasma
volume in hypotensive clients or to replace abnormal losses.
 Normal saline (0.9% NaCl) tends to remain in the vascular
compartment, increasing blood volume. When administer
rapidly this solution can precipitate acid base imbalance so
balanced electrolyte solution such as ringer lactate solutions are
preferred to expand plasma volume

Nursing Management
1. Assess for presence or worsening of fluid volume deficit.
2. Administer oral fluids if indicated.
a. Consider the client's likes and dislikes when offering fluids.
b.b. If the client is reluctant to drink provide frequent mouth care
and offer fluids at frequent intervals.
c. Explain the need for fluid replacement to the client. d.
Administer medications if nausea is present.

1. Interventions for clients with impaired swallowing.
a. Assess gag reflex.
b. Position the client in an upright position with a head and neck flexed slightly
forward during feeding.
c. Provide thick fluids or semisolid foods.
2. Client unable to eat and drink, discuss possibility of tube feeding or TPN with
the physician.
3. Monitor response to fluid intake, either orally or parenterally.
4. Monitor clients with tendency for abnormal fluid retention for signs of
overload.
5. Turn client frequently, apply moisturizing agents to skin.

DEHYDRATION
 Dehydration is a condition that occurs when the body loses too much water and
other fluids that it needs to work normally. Diarrhoea can cause
dehydration. Dehydration is particularly dangerous in children and in older
people it must be treated promptly to avoid serious health problems.
 Signs of Dehydration
1. Thirst
2. Less frequent urination
3. Dry skin
4. Fatigue
5. Light headedness
6. Dark coloured urine

Signs of Dehydration in Children
1. Dry mouth and tongue.
2. No tears when crying.
3. No wet diapers for 3 hours or more.
4. Sunken eyes.
5. High fever.
6. restlessness or irritability.
7. Skin that does not flatten when pinched and released.

People at risk from dehydration
 Anyone can become dehydrated, but certain groups are particularly at risk. These
include:
 Babies and infants: They have a low body weight and are sensitive to even small
amounts of fluid loss.
 Older people: They may be less aware that they are becoming dehydrated and
need to keep drinking fluids.
 People with chronic illnesses: People with a long-term health condition- such as
diabetes or alcoholism. People who work or exercise outside: Athletes can lose a
large amount of body fluid through sweat when exercising for long periods.
 People on Low-Sodium Diets: Having the right amount of sodium in blood helps
to retain water in body. Sweating can deplete sodium and other electrolytes.

Diagnostic Tests
 Diagnostic tests to find the cause of diarrhoea may include
the following:
1. Medical history and physical examination
2. Monitor vital signs, such as blood pressure and pulse.
Fever, increased heart rate, decreased blood pressure, and
faster breathing are signs of potential dehydration and
other illnesses.
3. Irritability

1. Stool Culture: This test involves analysing a stool sample for the presence
of bacteria, viruses, or parasites that could be causing the diarrhoea. It's
commonly used to identify bacterial infections like Salmonella, Shigella,
and Campylobacter.
 Blood Tests: Assess blood for factors such as electrolytes and kidney
function. The amount of salts or electrolytes and glucose as well as
indicators of kidney function (BUN and creatinine) may be important to
evaluate the degree of dehydration and possible causes. Other blood tests,
such as liver function tests, may be indicated to find causes of the
symptoms.
• Fasting tests

 Checking urine for the level of dehydration or to find out what may be causing
dehydration. The colour and clarity of urine, the urine specific gravity, and the
presence of ketones in the urine may all help to indicate the degree of
dehydration.
 Colonoscopy: These procedures involve inserting a flexible tube with a camera
into the colon to directly visualize the lining of the intestines. They may be used
if the cause of diarrhoea is suspected to be related to inflammatory bowel disease
(IBD) or other gastrointestinal conditions
 Imaging tests
 Breath Tests: Certain breath tests can help diagnose conditions like lactose
intolerance or bacterial overgrowth in the small intestine.

Treatment
 In most cases of diarrhoea, replacing lost fluid to prevent
dehydration is the only treatment necessary.
 Medicines that stop diarrhoea may be helpful, but they are
not recommended for people where diarrhoea is caused by
a bacterial infection or parasite.
 Viral infections are either treated with medication or left to
run their course, depending on the severity and type of
virus.

Nursing Considerations
1. Administer an analgesic for pain and to decrease intestinal motility, unless the patient
has a possible or confirmed stool infection.
2. Ensure the patient's privacy during defecation and empty bedpans promptly.
3. Clean the perineum thoroughly and apply ointment to prevent skin breakdown.
4. Note the amount and characteristics of the patient's stool.
5. Monitor intake and output.
6. Obtain serum samples for electrolytes and treat imbalances.
7. Provide fluid replacement orally or I.V. as appropriate.
8. Ensure adequate rest.
9. If oral diet is tolerated, then small frequent feedings of bland food may be helpful to
meet the nutritional requirements of the patient.
10. Provide psychological support to the patient.
11. Avoid foods that cause allergy in patient.


Patient Teaching
1. Stress the need for medical follow-up to patients with inflammatory bowel disease
(particularly ulcerative colitis) who have an increased risk of developing colon
cancer.
2. Emphasize the importance of maintaining adequate hydration.
3. Explain food or fluids that should be avoided.
4. Discuss stress reduction techniques.
5. Explain the diagnosis and treatment plan.

FLUID VOLUME EXCESS
 Fluid overload
 Hypervolemia
 Fluid volume excess results when both water and sodium are retained in the body.
FVE may be caused by fluid overload (excess water and sodium intake) or by
impairment of the mechanisms that maintain homeostasis. The excess fluid can
lead to excess intravascular fluid (hypervolemia) and excess interstitial fluid
(edema).

 Fluid volume excess usually results from conditions that cause retention of both sodium
and water. These conditions include:
1. Compromised regulatory mechanisms like:
a. Renal failure.
b. Congestive heart failure.
c. Cirrhosis of liver.
d. Cushing's syndrome.
2. Corticosteroid administration.
3. Stress condition causing the release of ADH and aldosterone.
4. Excessive intake of sodium containing foods.
5. Drugs that cause sodium retention.
6. The administration of excess amounts of sodium containing IV fluids.

 Clinical Manifestations
 Excess extracellular fluid leads to hypervolemia and circulatory overload. Excess fluid in the
interstitial space causes peripheral or generalized edema. The following manifestations of fluid
volume excess relate to both the excess fluid and its effects on circulation are:
1. The increase in total body water causes weight gain over a short period of time.
2. Peripheral edema.
3. Excess of fluid in interstitial space.
4. Distended neck veins and peripheral veins.
5. Slow-emptying peripheral veins.
6. CVP over 11 cm H2O.
7. Crackles and wheezes in lungs.
8. Polyuria (if renal function normal).
9. Ascites, pleural effusion (when FVE is severe, fluid transudes into body cavities).
10. Decreased BUN (due to plasma dilution).
11. Decreased Haematocrit (due to plasma dilution).
12. Bounding, full-pulse.
13. Pulmonary edema, if severe.

Assessment
 Collect assessment data through the health history, interview
and physical examination.
 Health History
 Risk factors such as medications, heart failure, acute or chronic
renal or endocrine disease, precipitating factor such as recent
illness, change in diet or change in medication, recent weight
gain, complaints of persistent cough, shortness of breath, swelling
of feet and ankles or difficulty sleeping when lying down

 Physical Assessment
 Weight, vital signs, peripheral pulses, capillary refill, jugular neck
vein distention, edema, lung sounds (crackles or wheezes),
dyspnoea, cough and sputum, urine output, mental status.
 Diagnostic Tests
 Monitor serum osmolality, electrolytes, haemoglobin and
haematocrit, urine specific gravity and osmolality, CVP readings

Management
 Managing fluid volume excess focuses on prevention in clients at
risk, treating its manifestations and correcting the underlying cause.
Management includes limiting sodium and water intake and
administering diuretics.
 Fluid Management
 Fluid intake may be restricted in clients who have fluid volume
excess. The amount of fluid allowed per day is prescribed by
primary care provider. All fluid intake must be calculated, including
meals that used to administer medications orally or intravenous.

Dietary Management
 Sodium restricted diet is prescribed. A mild sodium
restriction can be achieved by instructing the client and
primary food preparer in the household to reduce the
amount of salt in recipes by half, avoid using the table salt
during meal.

Nursing Management
1. Assess the presence or worsening of FVE.
2. Encourage adherence to sodium restrictions to avoid over the counter drugs.
3. When indicated, encourage rest period.
4. Monitor the client's response to diuretics.
5. Monitor the rate of parenteral fluids and the client response.
6. Teach self-monitoring of weight and intake and output measurements (such
as in case of CCF, renal failure, cirrhosis of liver).
7. If dyspnoea or orthopnea is present position the patient in semi fowlers
position
8. Turn and position the patient frequently


EDEMA
 Edema is the medical term for swelling. It is caused by
excess fluid leaking from capillaries (tiny blood vessels)
into the surrounding tissue. When this extra fluid builds
up, the tissue swells. The swollen site may be red, painful,
inflamed, and warm or hot to the touch.

Physiological Review of Fluid Compartment
 Fluid compartments in the human body are divided between the intracellular and
extracellular spaces. The extracellular space constitutes about one-third of total body water,
which is further divided into intravascular plasma volume (25%) and the extravascular
interstitial space (75%). The fluid balance between these compartments is maintained by
hydrostatic pressures and oncotic pressures.
 The other two factors that play an important role in fluid balance are vessel wall permeability
and the lymphatic system. The lymphatic system collects fluid and filtered proteins from the
interstitial space and returns that back to the vasculature.
 Any disturbance in this delicate homeostasis that results in net filtration out of the vascular
space or impaired return of fluid by lymphatic's leads to the accumulation of fluid in the
interstitial space that is called edema.

Causes of Edema
1. Increased Capillary Hydrostatic Pressure
2. Regional venous hypertension (often unilateral) such as Deep vein thrombosis,
Compartment syndrome.
3. Systemic venous hypertension (often bilateral) Heart failure, Pericarditis,
Pulmonary hypertension, Liver failure/cirrhosis.
4. Increased plasma volume Pregnancy, Renal failure.
5. Increased Capillary Permeability, Burns, Insect bites, Cellulites, Allergic
reactions.
6. Lymphatic Obstruction, Filariasis and Malignancy involving lymph nodes leading
to obstruction.
 Others :Myxoedema in hypothyroidism

Types of Edema
 The following are the types of edema according to location and according to clinical findings:
 1. According to Location:
a) Localized edema: The presence of excess fluid in the interstitial spaces. If the hydrostatic pressure is
increased, particularly at the venular end of the capillary, the net movement of water will be disrupted.
This is caused due to a thrombus, obstruction from pressure in the abdomen, for example, obesity,
tumour, advanced pregnancy or immobility and lack of activity in the skeletal muscle for instance;
a. Pedal edema-affects lower legs, ankles, and feet. Possible causes: pregnancy, being older.
b. Peripheral edema/Lymphedema- affects the arms, legs, and feet. Possible causes: lymph nodes, kidneys or
cancer treatment.
c. Pulmonary edema-affects lungs, makes it hard to breathe, especially when lying down. Causes: fluid in the
lungs.
d. Cerebral edema- affects the brain. Causes: head trauma, blocked blood vessel, allergic reaction or tumour.
b) Generalized edema: Edema that is widespread may be caused by sodium retention or decreased
plasma proteins. Where sodium retention occurs, such as in Cushing's syndrome or advanced renal
failure. When the kidneys are unable to secrete sufficient sodium, excess sodium moves into the
interstitial space via diffusion. Water will follow, causing widespread edema. This is referred as
anasarca.

According to clinical findings:
 Pitting edema is described as an indentation that remains in the oedematous area after pressure
is applied. Its location, timing, and extent are determined for treatment response. It is mainly
assessed on the medial malleolus, the bony portion of the tibia and the dorsum of the foot
 Pitting edema can be demonstrated by applying pressure to the swollen area by depressing the
skin with a finger. If the pressing causes an indentation that persists for some time after the
release of the pressure, the edema is referred to as pitting edema. Any form of pressure, such as
from the elastic in socks, can induce pitting with this type of edema.
a) Non-pitting edema is seen in lymphedema, myxoedema, and lipoedema.
 In non-pitting edema, which usually affects the legs or arms, pressure that is applied to the skin
does not result in a persistent indentation. Non-pitting edema can occur in certain disorders of
the lymphatic system such as lymphedema, which is a disturbance of the lymphatic circulation
that may occur after a mastectomy, lymph node surgery, or congenitally.

Assessment of Edema
1. History collection: While collecting the history of the patient the following
points should be considered:
a) Timing of the edema.
b) Changes of edema with position
c) Unilateral or bilateral edema.
d) Medication history.
e) Assessment of systemic diseases.
1. Physical Examination: In physical examination, pitting, tenderness, skin
changes, and temperature are evaluated.

Methods of Assessment of Peripheral
Edema
 1. Girth measurements (with a tape measure) circumferential method is one of
the girth measurement techniques, For consistent measurements, each upper
extremity or lower extremity is marked with a semi-permanent marker at a certain
part with reference to the bony prominences.
 2. Pitting edema assessment is performed by pressing firmly with thumb for at
least 2 seconds on each extremity.
a. Over the dorsum of the foot.
b. Behind the medial malleolus.
c. Lower calf above the medial malleolus

 Pit depth and the time needed for the skin to return to its original
appearance (recovery time) are recorded. The grading of edema is
determined by pit depth (measured visually) and recovery time from
grade 0-4.
 The scale is used to rate the severity and the scores are as follows:
a. Grade 0: No clinical edema.
b. Grade 1: Slight pitting (2 mm depth) with no visible distortion that rebounds
immediately.
c. Grade 2: Somewhat deeper pit (4 mm) with no readily detectable distortion
that rebounds in fewer than 15 seconds,
d. Grade 3: Noticeably deep pit (6 mm) with the dependent extremity full and
swollen that takes up to 30 seconds to rebound.
e. Grade 4: Very deep pit (8 mm) with the dependent extremity grossly.

Management
 Edema can be temporary or permanent depending on its cause. Edema is treated according
to the underlying condition causing it.
 The most common treatment is a diuretic. Diuretics are drugs that raise the rate of
urination, providing a means of forced diuresis. Diuretics make the kidneys excrete excess
fluid from the body; which reduces the general fluid volume in the body. There are several
types of diuretics- they increase the excretion of water from the body in various different
ways such as loop diuretics and thiazide diuretics.

 Edema resulting from a blockage in fluid drainage can sometimes be treated by
eliminating the obstruction:
 A blood clot in the leg is treated with blood thinners, and the clot slowly breaks down.
 A tumor obstructing a blood vessel or lymph flow can sometimes be reduced in size or
removed with surgery, chemotherapy, or radiation.
 Allergic reactions causing edema may be treated with antihistamines and corticosteroids.
 Leg edema related to CHF or liver disease can be treated with a diuretic (furosemide).
 When urine output increases, more fluid drains from the legs back into the blood.
 Maintaining a sodium restricted diet will also help limit fluid retention associated with
heart failure or liver disease

 The treatment of fluid retention in these patients is to reduce the loss
of protein into the urine and to restrict salt in the diet. The loss of
protein in the urine may be reduced by the use of ACE inhibitors and
angiotensin receptor blockers (ARB's). Both categories of drugs,
which ordinarily are used to lower blood pressure, prompt the
kidneys to reduce the loss of protein into the urine.

Nursing Management
a) Instruct patient to put a pillow under legs when lying down. Keep legs elevated
above the level of heart for at least 30 minutes, three or four times a day.
b) Encourage to wear compression stockings, sleeves or gloves. These garments
keep pressure on limbs to prevent fluid from collecting in the tissue of legs and
ankles.
 Encourage the patient to do not sit or stand for long periods of time without
moving. Moving and using the muscles in the part of body that's affected by
edema may help pump the excess fluid back to heart

a) Instruct the patient to ask doctor about limiting salt intake. Follow doctor's
suggestions about limiting how much salt consume.
b) Massage and stroking the affected area toward heart using firm, but not
painful, pressure may help move the excess fluid out of that area.
c) Encourage the patient to protect any swollen areas from additional pressure,
injury, and extreme temperatures. Injury to the skin over swollen areas takes
longer to heal and is more likely to become infected.
d) Instruct the patient to avoid temperature extremes. Sudden temperature
changes and very hot and very cold temperatures can make edema worse.
Avoid hot baths, hot showers, hot tubs .dress warmly when going out in
cold temperature and take precautions to protect from frost bite

The serum electrolytes include:
 Sodium (Na): A positively charged electrolyte that helps to balance fluid levels in
the body and facilitates neuromuscular functioning.
 Potassium (K): A main component of cellular fluid, this positive electrolyte helps
to regulate neuromuscular function and osmotic pressure.
 Calcium (Ca): A cation or positive electrolyte, that affects neuromuscular
performance and contributes to skeletal growth and blood coagulation.
 Magnesium (Mg): Influences muscle contractions and intracellular activity.
 Chloride (CI): An anion or negative electrolyte, that regulates blood pressure.
 Phosphate (HPO,): Negative electrolyte that impacts metabolism and regulates
acid-base balance and calcium levels
 Bicarbonate (HCO3): A negatively charged electrolyte that assists in the regulation
of blood pH levels. Bicarbonate insufficiencies and elevations cause acid- base
disorders (i.e., acidosis, alkalosis

SODIUM
 Sodium is the most abundant electrolyte in ECF, with concentration range from
135 to 145 mEq/L. Sodium is the primary regulator of the volume, osmolality and
distribution of ECE Sodium imbalance affects osmolality of ECF and water
distribution between the fluid compartments. When sodium level is low water is
drawn into the cells of the body causing them to swell. In contrast, high levels of
sodium in ECF draw water out of body cells causing them to shrink. Sodium
moves easily between intravascular and interstitial spaces and moves across cell
membrane by active transport. It also acts as catalyst in reactions particularly in
nervous tissue cells and muscle tissue cells.

Functions of Sodium
1) It controls and regulates the volume of body fluids.
2) Sodium does not easily cross the cell wall membrane and its high concentration
accounts for controlling water balance distribution.
3) Primary regulator of ECF volume
4) It influences ICF volume.
5) It also functions in establishing the electrochemical state necessary for muscle
contraction and transmission of nerve impulses.
 Essential electrolyte in the sodium-potassium pump

Sources of Sodium
 Most of the sodium comes from the dietary intake.
 Although a sodium intake of 500 mg per day is usually sufficient to meet the
body's needs, the average intake of sodium by adult is about 6 to 15 g per day.
 Recommended Daily Allowance for sodium for adults 500 mg or 0.5 g.
 Other sources of sodium include prescription drugs and certain self-prescribed
remedies, particularly in mustard, processed cheese, canned vegetables, bread,
cereal and salted snack food, table salt (NaCl) (about 46% sodium).

Excretion of Sodium
 Sodium is primarily excreted by the kidneys. A small amount is excreted through
the skin and GI tract. The kidney is the primary regulator of sodium balance in the
body. The kidney excretes or conserves sodium in response to changes in the
vascular volume. A fall in blood volume promotes several mechanisms that lead to
sodium and water retention
1) Renin-angiotensin- aldosterone system.
2) ADH promotes sodium and water reabsorption in the distal tubules of the kidney,
reducing urine output and expanding blood volume.

Regulation of Sodium
 Sodium normally is maintained in the body within a relatively narrow range, and
deviations quickly result in a serious health problem
 Salt intake regulates sodium concentration
 Sodium is conserved through reabsorption in the kidneys, a process of stimulation
by aldosterone.
 The normal extracellular concentrations of sodium is 135 to 145 mEq/L
(mmol/L).

POTASSIUM
 Potassium is the primary intracellular cation, plays a vital role in cell metabolism and
cardiac and neuromuscular functions. The normal serum potassium level is 3.5 to 5.0 mEq/L
 Functions of Potassium
1) Potassium is very important in the human body. Along with sodium, it regulates the water
balance and the acid base balance in the blood and tissues.
2) In the nerve cells, sodium potassium flux generates the electrical potential that aids the
conduction of nerve impulses. When potassium leaves the cell, it changes the membrane
potential and allows the nerve impulse to progress. This electrical potential gradient, created
by the "sodium-potassium pump", helps to generate muscle contractions and regulates the
heartbeat.
3) Potassium is very important in cellular biochemical reactions and energy metabolism.

Sources of Potassium
 Normally potassium is supplied in food.
 Virtually all foods contain potassium, although some foods and fruits are richer sources
of this element than others.
 Most of the potassium is lost when processing or canning foods, while less is lost from
frozen fruits or vegetables.
 An average daily requirement of K is not known, but an intake of 50 to 100 meq daily
maintains potassium balance
 A well balanced diet contains adequate quantities of potassium
 Major sources include banana, peaches, kiwi, figs, dates, apricots, oranges, prunes,
melons, broccoli and potatoes.
 Meat and dairy products also provide adequate amounts of potassium

Excretion of Potassium
 The kidneys eliminate potassium very efficiently; even when potassium intake is
stopped, the kidneys continue to excrete it.
 Aldosterone helps regulate potassium elimination by the kidneys.
 Normally small amount of potassium are lost in the feces but substantial amounts
may be lost from the GI tract with diarrhoea or through drainage from the
ileostomy.

Regulation of Potassium
 Cellular potassium is conserved by the sodium pump when sodium
is excluded
 The kidneys conserve potassium when cellular K is decreased
 Aldosterone secretions trigger potassium excretion in urine The
normal range for serum potassium is 3.5 to 5 mEq/L.

CALCIUM
 Calcium is one of the most abundant ions in the body. The normal
adult total serum concentration in 8.5-10.0 mg/dL. It makes up
bones and teeth and is essential for the transmission of information
along the nerves and is used in the contraction of muscles. In the
blood, about half of all calcium is bound to proteins such as serum
albumin, but it is the unbound or ionized, calcium that the body
regulates. If a person has abnormal levels of blood proteins, then the
plasma calcium may be inaccurate.

Functions of Calcium
1. Calcium is responsible for construction, formation and maintenance of bone and
teeth. This function helps to reduce the occurrence of osteoporosis.
2. This is a vital component in blood clotting system and also helps in wound
healing.
3. It helps to control blood pressure, nerve transmission and release of
neurotransmitters.
4. It is an essential component in the production of enzymes and hormones that
regulate digestion, energy, and fat metabolism.
5. Calcium helps to transport ions (electrically charged particles) across the
membrane. It is essential for muscle contraction.
6. Calcium may be helpful to reduce the incidence of premature heart disease,
especially if adequate intakes of magnesium are also maintained.
7. It helps in vitamin B12 absorption and for its use by body cells

Sources of Calcium
 The average daily requirement of calcium is 1gm for adults. Higher amounts are required
according to body weight for children, for pregnant and lactating women and
postmenopausal women
 Calcium is obtained from dietary sources.
 The main sources of calcium in diets are dairy products.
 Many people are unable to digest milk and other dairy products due to a condition called
lactose intolerance, they use non-dairy sources of calcium such as legumes, green leafy
vegetables, tofu, nuts, seeds, peas and lentils and foods where the bones are consumed,
such as sardines and salmon.
 Lactose reduced milk and calcium supplements.
 Use of calcium is stimulated by vitamin D. the most active form of vitamin D (calciferol)
promotes calcium absorption and limits calcium excretion when levels are inadequate

Excretion of Calcium
 Only about 20% of the calcium ingested is
absorbed into the blood. The remainder is excreted
in feces. Extracellular calcium is excreted by the
kidneys. Approximately 99% of the total calcium
in the body is bound to phosphorus to form the
minerals in bones and teeth. The remaining 1% is
in extracellular fluid.

Regulation of Calcium
 When ECF calcium levels decrease, the parathyroid glands increase the
secretions of PTH, which acts on bones to increase the release of calcium
into the blood and acts on the kidney, tubules and the intestinal mucosa to
increase the absorption of calcium from the kidneys and the intestine
chloride
 A high serum phosphate concentration increases serum calcium; a low
serum phosphate concentration decreases serum calcium
 Calcitonin, a hormone secreted by the thyroid gland has an opposite effect
on calcium than PTH.Increase in calcitonin reduces the serum calcium
concentration primarily by opposing osteoclast bone resorption.

MAGNESIUM
 Only about 1% of the magnesium in the body is in extracellular fluid; the rest is
found within the cells and in bones. The normal serum concentration of
magnesium ranges from 1.6-2.6 mg/dL
 Functions of Magnesium
 Magnesium is vital to many intracellular processes including enzyme reactions
and synthesis of proteins and nucleic acid.
 It is essential ion for neuromuscular transmission and cardiovascular function.
 It is important for the metabolism of carbohydrates and proteins
 It maintains normal intracellular levels of potassium

Sources and Excretion of Magnesium
 Magnesium is obtained through the diet (green vegetables, grains, nuts, meats and
seafood) and excreted through kidney. The average daily adult requirement about
18 to 30 mEq/L.
 Regulation of Magnesium
 Magnesium is absorbed by the intestines and secreted by the kidneys
 Plasma concentration of magnesium range from 1.3 to 2.1 mEq/L with about one-
third of that amount bound to plasma proteins.

PHOSPHATE
 Most phosphate 85% is found in bones, it is primary intracellular anion. About 14% is in intracellular fluid and
the remaining 1% is in extracellular fluid. The normal serum phosphate (phosphorus) level in adult
is 2.5 to 4.5 mg/dl. Phosphorus levels vary with age, gender and diet
 Functions of Phosphate
1. Phosphate is essential to intracellular processes such as the production of ATP.
2. Phosphate is vital for red blood cell function and oxygen delivery to tissues; nervous system and
muscle function.
3. It also assists in maintaining acid base balance.
4. It is important for cell division and for the transmission of hereditary or hereditary traits.
5. Calcium and phosphate are inversely proportional and increase when one results in a decrease in
the other
 Sources and Excretion of Phosphate
 An average daily requirement of phosphate is similar to those of calcium. It is found in most foods
especially beef, pork and dried beans and peas. Phosphorus is ingested in the diet, absorbed in the
jejunum and excreted primarily by the kidneys. A relationship exists between phosphate and
calcium levels; when one increases the other decrease.

 CHLORIDE
 Chloride is the major anion found in the fluid outside of cells and in the blood.
Significant increases or decreases in chloride can have deleterious or even fatal
consequences. The normal serum range for chloride is 98-108 mEq/L.
 Functions of Chloride
1. Acts with sodium to maintain the osmotic pressure of the blood.
2. Vital role in the body's acid base balance.
3. Essential for the production of HCI.
4. Important in buffering action when o2 and co2 exchange in RBCs
 Sources
 It is found in foods rich in sodium in dairy products and meat

 Hyperchloremia
 Elevations in chloride may be seen in diarrhoea, certain kidney diseases and
sometimes in over activity of the parathyroid glands.
 Hypochloremia
 Chloride is normally lost in the urine, sweat and stomach secretions.
Excessive loss can occur from heavy sweating, Vomiting and adrenal gland
and kidney disease.

ACID-BASE IMBALANCE
 Homeostasis and optimal cellular functions require maintenance of the hydrogen
ion concentration of the body fluids within a relatively narrow range.
 Acids: Release hydrogen ion in solution.
 Bases: Accepts hydrogen ion in solution.
 The hydrogen ion concentration of a solution is measured as its ph. The pH of the
body fluids is slightly basic with normal ranging from 7.35-7.45.

 Respiratory System
 The respiratory system regulates carbonic acid in the body by eliminating or retaining carbon dioxide. When CO2
combined with water, it forms carbonic acid. Acute increase in CO2 or hydrogen ion in blood stimulate the respiratory
centre in the brain. As a result both rate and depth of respiration increases. The increased rate and depth of lung
ventilation eliminates carbondioxide from the body, carbonic acid levels fall, bringing the pH to a more normal range.
Alkalosis by contrast, depress the respiratory centre. Both rate and depth of respiration decrease and CO2 is retained.
The retained CO2 combines with water to restore carbonic acid levels and bring the pH back within the normal range.
 Renal System
 The renal system is responsible for the long term regulation of acid base balance in the body. Excess non-volatile acids
produced during metabolism normally are eliminated by kidneys. The kidneys also regulate bicarbonate levels in
extracellular fluid by regenerating bicarbonate ions as well as reabsorbing them in renal tubules. Although the kidney
respond more slowly to changes in pH, they can generate bicarbonate and selectively excrete or retain hydrogen ions as
needed. In acidosis, when excess hydrogen ion is present and pH falls, the kidneys excrete hydrogen ion and retain
bicarbonate. In alkalosis the kidneys retain hydrogen ions and excrete bicarbonate to restore acid base balance.


Types of Acid Base Imbalance
 It falls into two categories:
1. Acidosis: Occurs when the hydrogen ion concentration increase above normal
(pH below 7.35).
2. Alkalosis: Occurs when hydrogen ion concentration falls below normal (pH
above 7.45).

METABOLIC ACIDOSIS
 Metabolic acidosis is a clinical disturbance defined by a pH less than
7.35 and a low HCO3 level.
 Causes of Metabolic Acidosis
1. Excessive loss of bases in diabetic ketosis.
2. Severe diarrhoea.
3. Nephritic acidosis and hypoxic lactic acidosis.
4. Starvation.

Treatment
1. Aimed at correcting the metabolic defect.
2. Administer bicarbonate when necessary.
3. Haemodialysis or peritoneal dialysis as needed.

FLUID ELECTROLYTE AND ACID BASE BALANCE.pptx

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