Chapter 39 Fluid, Electrolyte, and Acid Base Balance

KEY TERMS
acid: substance containing a hydrogen ion that can be liberated or released
acidosis: condition characterized by a proportionate excess of hydrogen ions in the extracellular
fluid, in which the pH falls below 7.35
active transport: movement of ions or molecules across cell membranes, usually against a
pressure gradient and with the expenditure of metabolic energy
agglutinin: an antibody that causes a clumping of specific antigens
alkalosis: condition, characterized by a proportionate lack of hydrogen ions in the extracellular
fluid concentration, in which the pH exceeds 7.45
anions: ion that carries a negative electric charge
antibody: immunoglobin produced by the body in response to a specific antigen
antigen: foreign material capable of inducing a specific immune response
autologous transfusion: occurs when a patient donates one’s own blood for a transfusion
base: substance that can accept or trap a hydrogen ion; synonym for alkali
blood typing: the laboratory examination to determine a person’s blood type
buffer: substance that prevents body fluid from becoming overly acid or alkaline
capillary filtration: passage of fluid across the wall of the capillary; results from the force of
blood “pushing” against the walls of the capillaries
cation: ion that carries a positive electric charge
colloid osmotic pressure: pressure exerted by plasma proteins on permeable membranes in the
body; synonym for oncotic pressure
cross-matching: act of determining the compatibility of two blood specimens
dehydration: decreased water volume in body tissue
diffusion: tendency of solutes to move freely throughout a solvent from an area of higher
concentration to an area of lower concentration until equilibrium is established
edema: accumulation of fluid in extracellular spaces
electrolytes: substance capable of breaking into ions and developing an electric charge when
dissolved in solution
Extracellular fluid (ECF): fluid outside the cells; includes intravascular and interstitial fluids
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

hydrostatic pressure: force exerted by a fluid against the container wall

hypercalcemia: excess of calcium in the extracellular fluid
hyperchloremia
hyperkalemia: excess of potassium in the extracellular fluid
hypermagnesemia: excess of magnesium in the extracellular fluid
hypernatremia: excess of sodium in the extracellular fluid
hyperphosphatemia: above-normal serum concentration of inorganic phosphorus
hypertonic: having a greater concentration than the solution with which it is being compared
hypervolemia: excess of plasma
hypocalcemia: insufficient amount of calcium in the extracellular fluid
hypochloremia
hypokalemia: insufficient amount of potassium in the extracellular fluid
hypomagnesemia: insufficient amount of magnesium in the extracellular fluid
hyponatremia: insufficient amount of sodium in the extracellular fluid
hypophosphatemia: below-normal serum concentration of inorganic phosphorus
hypotonic: having a lesser concentration than the solution with which it is being compared
hypovolemia: deficiency of blood plasma
intracellular fluid (ICF): fluid within the cell; synonym for cellular fluid
ion: atom or molecule carrying an electric charge in solution
isotonic: having about the same concentration as the solution with which it is being compared
osmolarity: concentration of particles in a solution, or a solution’s pulling power
osmosis: passage of a solvent through a semipermeable membrane from an area of lesser
concentration to an area of greater concentration until equilibrium is established
pH: expression of hydrogen ion concentration and resulting acidity of a substance
solutes: substance dissolved in a solution
solvents: liquid holding a substance in solution

PRINCIPLES OF FLUID, ELECTROLYTE, AND ACID BASE BALANCE

 Body Fluids
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Transporting nutrients to cells and wastes from cells

 Transporting hormones, enzymes, blood platelets, and red and white
blood cells
 Facilitating cellular metabolism and proper cellular chemical functioning
 Acting as a solvent for electrolytes and nonelectrolytes(glucose and
uria)
 Helping maintain normal body temperature
 Facilitating digestion and promoting elimination
 Acting as a tissue lubricant
o Body Fluid Compartments
 Intracellular fluid (ICF): fluid within cells (70%)
 Potassium
 Phosphorus
 Extracellular fluid (ECF): fluid outside cells (30%)
 Intravascular; plasma
 interstitial fluids; surrounds cells, lymph
o Variations in Fluid Content
 Healthy person: total body water is 50% to 60% of body weight
 An infant has considerably more body fluid and ECF than an adult; more
prone to fluid volume deficits
 Gender and amount of fat cells affect body water; women and obese
people have less body water
o Fluid Balance
 Ingested liquids, average is 2600mL/day
 1300mL water
 Food
 1000mL
 Metabolism
 300mL
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Losses: 2500-2900mL; 2600 average

 Kidneys: urine
o 1500mL
 Intestinal tract: feces
o 200Ml
 Skin: perspiration
o 600mL
 Insensible water loss
o Lungs: 300mL

 Electrolytes
MAJOR ECF
o SODIUM: chief electrolyte; controls and regulates volume of body fluids
 135-145 mEq/L
 Muscle contraction
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Nerve impulses
 Regulate acid-base as sodium bicarb
o CHLORIDE: maintains osmotic pressure in blood, produces hydrochloric acid
 97-107 mEq/L
o CALCIUM: nerve impulse, blood clotting, muscle contraction, B12 absorption
 8.6-10.2 mg/dL
o BICARBONATE: body’s primary buffer system READ UP AND KNOW
 25-29 mEq/L
 Regulates acid-base
 Kidneys
MAJOR ICF
o PHOSPHATE: involved in important chemical reactions in the body, cell division,
and hereditary traits
 2.5-4.5 mg/dL
 Hydrogen buffer
 Promotes energy storage
 Eliminated by kidneys
 Regulated by parathyroid
o POTASSIUM: chief regulator of cellular enzyme activity and water content;
HEART
 Most abundant ICF
 3.5-5.0 mEq/L
 Regulates acid-base: exchange of H+
o MAGNESIUM: metabolism of carbohydrates and proteins, vital actions
involving enzymes
 1.3-2.3 mEq/L
 2nd most abundant ICF
 Regulation and Homeostatic Mechanisms of Fluid and Electrolyte Base
o Organ Body Systems
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

o Osmosis
 Water (the solvent) passes from an area of lesser solute
concentration and more water to an area of greater solute
concentration and less water until equilibrium is established.
 ISOTONIC: close to that of ECF
 0.9% normal saline: close to blood transfusions
 Lactated Ringers: same as plasma
 HYPERTONIC: greater concentration of particles than plasma
 HYPOTONIC: lesser concentration of particles than plasma
 0.45% normal saline
 Primary Organs
 Kidneys normally filter 180 L of plasma and excrete 1.5 L of
urine.
 The cardiovascular system pumps and carries nutrients and
water in body.
 Lungs regulate oxygen and carbon dioxide levels of the blood.
 Adrenal glands help the body conserve sodium, save chloride
and water, and excrete potassium.
 The pituitary gland stores and releases ADH.
 The thyroid gland increases the blood flow in the body and
increases renal circulation.
 The nervous system inhibits and stimulates mechanisms
influencing fluid balance.
 Parathyroid glands regulate the level of calcium in ECF.
 The GI tract absorbs water and nutrients that enter the body
through this route.
o Diffusion
o Active Transport
o Capillary Filtration
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

o Acid-Base Balance
 Acid: substance containing hydrogen ions that can be liberated or
released
 Think of Lungs
 Base: substance that can trap hydrogen ions
 Think kidneys
 Normal pH
 Blood: 7.35-7.45
 Below 7.35 acidic
 Above 7.45 alkoltic
o Chemical Buffer Systems
 CARBONIC ACID-SODIUM BICARBONTE BUFFER SYSTEM
 Carbonic acid; most common acid in body
 Bicarbonate; most common base in the body
 Normal ECF: 20 part bicarb to 1 part carbonic acid
 PHOSPHATE BUFFER SYSTEM
 PROTEIN BUFFER SYSTEM
o Respiratory Regulation of Hydrogen Ions
o Renal Regulation of Hydrogen Ions
DISTURBANCES IN FLUID, ELECTROLYTE, AND ACID BASE BALANCE
 Fluid Imbalances
 Involve either volume or distribution of water or electrolytes
o Fluid Volume Deficit
 Hypovolemia: deficiency in amount of water and electrolytes in ECF
with near-normal water/electrolyte proportions; intravascular
 Dehydration: decreased volume of water and electrolyte change
 Third-space fluid shift: distributional shift of body fluids into potential
body spaces
o Fluid Volume Excess
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Hypervolemia: excessive retention of water and sodium in ECF;

 too much plasma in blood, too much water;
 JVD
 Overhydration: above-normal amounts of water in extracellular spaces
 Edema: excessive ECF accumulates in tissue spaces
 Where??
 Interstitial-to-plasma shift: movement of fluid from space surrounding
cells to blood
 Electrolyte Imbalance
o Hyponatremia and Hypernatremia: sodium
 Hyper: Swelling of cells; confusion, hypotension, edema, muscle cramps,
weakness, and dry skin
 Cerebral edema = seizures
 Hypo: Water loss
 Restlessness, weakness, disorientation, delusion, hallucinations
o Hypokalemia and Hyperkalemia: potassium
 Hypo: Muscle weakness, muscle cramps, fatigue, paresthesias,
dysrhythmias
 Hyper: dangerous, muscle weakness and paralysis
 NSAIDS, ACE inhibitors, potassium chloride
o Hypocalcemia and Hypercalcemia: calcium
 Hypo: numbness, tingling,
 Hyper:
o Hypomagnesemia and Hypermagnesemia: magnesium
 1.5-2.5 mEq/L
 Hypo: <1.5
 Hyper: >2.5
 diarrhea
o Hypophosphatemia and Hyperphosphatemia: phosphorus
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Normal: 2.4-4.5mg/dL or mEq/L

 Hypo: <2.5 mg/dL or 1.8 mEq/L
o Hypochloremia and Hyperchloremia: chloride
 Normal: 96 – 106 mEq/L
 Acid-Base Imbalances: Occur when carbonic acid or bicarbonate levels become
disproportionate.
o pH is what you always look at FIRST!!
o Metabolic Acidosis and Alkalosis
 Metabolic acidosis: proportionate deficit of bicarbonate in ECF
 Bicarb low
 pH low
 Metabolic alkalosis: primary excess of bicarbonate in ECF
 Bicarb: high
 pH high
o Respiratory Acidosis and Alkalosis
 Respiratory acidosis: primary excess of carbonic acid in ECF
 pH: low
 CO2: high
 Respiratory alkalosis: primary deficit of carbonic acid in ECF
 pH: high
 CO2: low
THE NURSING PROCESS FOR FLUID, ELECTROLYTE, AND ACID BASE BALANCE
 Assessing
 Identify patients at risk for imbalances.
 Elderly
 Infants
 Kidney and Lung diseases. issues
 Determine that a specific imbalance is present and its severity, etiology,
and characteristics.
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Determine the plan of care, nursing diagnoses or collaborative

problems.
 Identify specific outcomes and associated interventions.
 Determine effectiveness of the plan of care.
o Nursing History
 Risk Factors for Imbalance
 Pathophysiology underlying acute and chronic illnesses
 Abnormal losses of body fluids
 Burns
 Trauma
 Surgery
 Therapies that disrupt fluid and electrolyte balance
o Physical Assessment
o Fluid Intake and Output
o Daily Weights
 2.2lbs=1kg=1L of fluid
o Lab Studies
 Complete Blood Cell Count
 Increased hematocrit values: found in severe fluid volume deficit
and shock  (when hemoconcentration rises considerably)
 Decreased hematocrit values: found with acute, massive blood
loss, and with hemolytic reaction after transfusion of
incompatible blood or with fluid overload
 Increased levels of hemoglobin: found in hemoconcentration of
the blood
 Decreased levels of hemoglobin: found with anemia states,
severe hemorrhage, and after a hemolytic reaction
 Serum Electrolyte, BUN, and Creatinine Levels
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Below normal or above normal levels of sodium, potassium,

calcium, magnesium, phosphate, and chloride. Refer to the
electrolyte imbalance discussion earlier in the chapter.
 Below normal or above normal levels of bicarbonate ions. Refer
to the acid–base discussion earlier in the chapter.
 Increased BUN: found with impaired renal function (such as
associated with shock, heart failure, salt and water depletion),
diabetic ketoacidosis, burns
 Increased creatinine: found with impaired renal function, heart
failure, shock, dehydration
 Urine pH and Specific Gravity
 Range: 4.6 – 8.2
 pH: Lower than normal urinary pH can occur with metabolic
acidosis, diabetic ketosis, and diarrhea. Higher than normal
urinary pH can occur with respiratory alkalosis, potassium
depletion, and chronic renal failure. 
 Specific Gravity: Normal values range from 1.005 to 1.030
(concentrated urine:  ≥1.025; dilute urine:  ≤1.001–1.010).
 Increased urine specific gravity can occur with dehydration,
vomiting, diarrhea, and heart failure. Decreased urine specific
gravity can occur with renal damage.
 Arterial Blood Gas
 Adequacy of oxygenation and ventilation
 Treatment of acid-base
 Diagnosing
o Fluid, Electrolyte, and Acid-Base Disturbances as the Problem
 Excess fluid volume
 Deficient fluid volume
 Risk for Deficient Fluid Volume
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Risk for imbalanced fluid volume

o Fluid and Electrolyte Disturbances as the Etiology
 Outcome Identification and Planning
o Maintain approximate fluid intake and output balance (2,500-mL intake and
output over 3 days).
o Maintain urine specific gravity within normal range (1,010–1,025).
o Practice self-care behaviors to promote balance.
 Implementing: look at Table 39-9!!
o Preventing Fluid and Electrolyte Imbalances
o Developing a Dietary Plan
o Modifying Fluid Intake KNOW
 Increase Fluids
 Restricting Fluids
o Administering Medications
 Mineral-electrolyte preparations
 Diuretics
o Administering IV Therapy, KNOW DIFFERENCE fluids
 TABLE 39-11
 Equipment
o Vascular Access Devices
 Peripheral Venous Catheters
 Midline Peripheral Catheters
 Central Venous Access Devices
 Change every 48hrs
 Sterile technique
 In large vessel
 Imported ports
o Peripheral Venous Catheter Site Selection
 Accessibility of a Vein
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Hand first then move towards heart

 Condition of the Vein
 Palpate
 look
 Types of Fluid to be Infused
 Anticipate duration of infusion

o Initiation of an IV Infusion
 Infusion Regulation and Monitoring
 Solution and Tubing Changes
o Complications of IV Therapy TABLE 39-12
 Infiltration: escapes into the sub-q
 Swollen,Pain
 Stop IV, take IV out, start diff site
 Elevate extremity, warm compress
 Venous Access Device-Related Infection
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Improper hand decon/hygiene

 Erythema, edema, fever, malaise
 Phlebitis: inside vein irritated
 Local, acute tenderness, red, warm, red streak
 Discontinue, notify Dr,
 Thrombus
 Speed Shock
 Fluid Overload
 Air Embolus: air in circulatory system
 Resp distress, increased HR, cyanosis, low BP, Altered LOC
 Pinch tubing off, put into Trendelenburg, call for assistance,
monitor VS and Pulse Ox
o Venous Access Site Care
o Capping a Primary Line for Intermittent Use
o Discontinuation of the Infusion
o Home Infusion
 Administering Blood and Blood Products
o Blood Typing and Cross Matching
 Blood Types
 Rh Factor
o Blood Donors
o Blood Components
o Initiation of Transfusion
 Cant run for more than 4 hrs
o Transfusion Reactions
 Administering of Parenteral Nutrition
o Giving nutrition through IV
o Thick
o Great medium for bacterial growth, only hang for 24hrs
Chapter 39 Fluid, Electrolyte, and Acid Base Balance

 Allaying patient anxiety as needed

 Appropriate patient and family teaching
 Evaluating
PrepU
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's
laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the
removal of the parathyroid gland?

  calcium and phosphorus

Which client will have more adipose tissue and less fluid?

  A woman

How is control over the extracellular concentration of potassium within the human body is
exerted?

  aldosterone.

The nursing instructor is explaining how the respiratory system is involved in hydrogen ion
regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has
increased, resulting in increased respirations to eliminate CO2.

  H2CO3 level in the blood decreases

  pH becomes more alkaline
  Blood level of CO2 decreases
  Decreased respirations
  Carbon dioxide retention
  Carbonic acid formed

The nurse writes a nursing diagnosis of “Fluid Volume: Excess.” for a client. What risk factor
would the nurse assess in this client?

  renal failure

Which statement most accurately describes the process of osmosis?

  Water moves from an area of lower solute concentration to an area of higher solute
concentration.

The passageways of the kidney permit the urine to flow to the bladder and:

  selectively reabsorb or secrete substance to maintain fluids and electrolytes.

Chapter 39 Fluid, Electrolyte, and Acid Base Balance

During a blood transfusion, a client displays signs of immediate onset facial flushing,
hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?

  Hemolytic transfusion reaction: incompatibility of blood product