Fluid and electrolyte balance play an important role in homeostasis, and critical care nurses

assume a vital role in identifying and treating the physiologic stressors experienced by critically
ill patients that disrupt homeostasis.
Electrolytes, found in body fluids, are electrically charged particles (ions). Cations are positively
charged ions; anions are negatively charged ions. Electrolytes play a crucial role in transmitting
impulses for proper heart, nerve, and muscle function. The number of positively and negatively
charged ions should be equal; when this balance is upset, electrolyte abnormalities can occur.
Electrolytes can further be classified as extracellular (EC, outside the cell) or intracellular (IC,
inside the cell). Sodium is the most abundant EC electrolyte; potassium is the most abundant IC
electrolyte. Just as too little or too much of any one electrolyte can become a problem in
maintaining a critically ill patient's stability, imbalances in fluid homeostasis can also present
unique challenges for both you and your patient.
Fluids are in constant motion in the body. Total body water (TBW) normally accounts for about
60% of an adult's body weight. Forty percent of TBW is in the IC space, and EC water accounts
for 20% of body weight: 14% in the interstitial space, and 5% in the intravascular space.
Transcellular fluid (cerebral spinal fluid and fluid contained in other body spaces such as joint
spaces, and the pleural, peritoneal, and pericardial spaces) make up about 1% of total body
weight.
To maintain homeostasis, fluids need to be stable in the intravascular, interstitial, and IC spaces.
The amount of IC fluid is rather stable in the body; intravascular fluid is the least stable and
fluctuates in response to fluid intake and loss. Interstitial fluid is the reserve fluid, replacing fluid
in the intravascular and IC spaces as needed.
Almost all pathologies affect the fluid balance within the body, especially in critically ill patients.
Fluid movement within the various body spaces depends on osmosis-movement of water through
a selectively permeable or semipermeable membrane from a solution that has a lower solute
concentration to one with a higher solute concentration-and diffusion, or the free movement of
molecules or other particles in solution across a permeable membrane from an area of higher
concentration to an area of lower concentration, resulting in an even distribution of the particles
in fluid. Fluid balance also is regulated by certain hormones:
* Aldosterone, the principal mineralcorticoid produced by the adrenal cortex, promotes sodium
retention by the distal tubules, while increasing urinary losses of potassium. This helps to prevent
water and sodium losses through the kidneys.
* Antidiuretic hormone (ADH), also known as vasopressin, is synthesized in the hypothalamus
and stored in and released by the posterior pituitary gland. ADH triggers the renal tubules to
reabsorb water and return it to the intravascular space.

* Natriuretic peptides, such as atrial natriuretic peptide, released from the heart in response to
cardiac chamber stretch and overfilling, increase sodium and water excretion by the renal distal
and collecting tubules.
Because the kidneys are the major organs involved in electrolyte and fluid homeostasis, the nurse
must determine the patient's renal function before attempting to correct a patient's electrolyte or
fluid imbalance. Also, a nurse must not let lab numbers or the numerous equations used for fluid
replacement override sound clinical judgment. If the patient's clinical condition doesn't support
the numbers, the nurse must perform a follow-up test-an error could have occurred in the lab,
blood draw, or be the result of blood sample hemolysis.

INTAKE AND OUTPUT

One of the most basic methods of monitoring a client's health is measuring intake and output ,
commonly called I and O. By monitoring the amount of fluids a client takes in and comparing
this to the amount of fluid a client puts out. The health care team can gain valuable insights into
the client's general health as well as monitor specific disease conditions.
INTAKE
- all those fluids entering the client's body such as water, ice chips, juice, milk, coffee and ice
cream. Artificial fluids include: parenteral, central lines, feeding tubes, irrigation and blood
transfusion.
OUTPUT
- all fluid that leaves the client's body such as: urine, perspiration, exhalation, diarrhea, vomiting,
drainage from all tubes and bleeding.

Equipment:
-

I & O form at bedside

I & O graphic record in chart

Pencil and paper

Calibrated drinking glass

Bedside pan, commode or urinal

Calibrated container to measure outputs

Weighing scale

Non-sterile gloves

Sign at bedside stating patient is for I & O monitoring

Ideal Daily fluid Intake and Output

Source

AMOUNT

| Route of excretion |

AMOUNT

H2O consumed as fluid

1500ml

1400-1500ml

H2O present in food

750ml

350ml

H2O produced by oxidation |

TOTAL

2600ml

urine

insensible losses |

350-400ml

lungs

350-400ml

skin

100ml

sweat

100-200ml

TOTAL

2300-2600ml

Purpose:
-

helps evaluate client's fluid and electrolyte balance

suggests various diagnosis

influence the choice of fluid therapy

document the client's ability to tolerate oral fluids

recognize significant fluid losses

Mandatory for clients with burns, electrolyte imbalance, recent surgical procedure, severe
vomiting or diarrhea, taking diuretics or corticosteroids, renal failure, congestive heart
failure, NGT, drainage collection device and IV therapy.

Deviations:
Other sources of fluid loss and excessive losses from normal routes:
-

drainage from catheter or tubes

vomitus

Diarrhea

Diaphoresis

Hemorrhage

ileostomy/colostomy

excessive urine output

Average daily water requirement by age and weight:

AGE
3days
1year
4years
10years
14years
18years
adult

ml/
250-350ml
1350-1500ml
1600-1800ml
2000-2500ml
2200-2700ml
2200-2700ml
2400-2600ml

ml/kg
80-100
115-125
100-110
70-85
50-60
40-60
20-30

Nursing Interventions:
Intervention/ Rationale:
1. Ideally intake and output should be monitored/ To obtain an accurate record
2. In critical situations, intake and output should be monitored on an hourly basis/ Urine
output less than 500ml in 24 hours or less than 30cc/hour indicates renal failure
3. Daily weights are often done/ Indicate fluid retention or loss
4. Identify if patient undergone surgery or with medical problem / May affect fluid loss
5. Make sure you know the total amount and fluid sources once you delegate this
task/To get an accurate measurement
6. Record the type and amount of all fluids and describe the route at least every 8 hours
7. If irrigating a nasogastric or another tube or bladder, measure the amount instilled and
subtract it from the total output/ To get exact amount
8. Keep toilet paper out of client urine output/ For an accurate measurement
9. Measure drainage in a calibrated container and observe it at eye level.
A significant change in a client's weight or a significant difference in a client's total intake and
output should be reported immediately to the physician.

WEIGHT CHANGES
-

mild dehydration- 2 to 5% loss

moderate dehydration- 6 to 9% loss

severe dehydration - 10 to 14% loss

death- 20% loss

mild volume overload- 2% gain

moderate volume overload - 5% gain

severe volume overload - 8% gain

Clinical Signs of Dehydration:

-

dry skin and mucous membrane

concentrated urine

poor skin turger

depressed periorbital space

sunken fontanel

dry conjunctiva

cracked lips

decreased saliva

weak pulse

Client's signs of fluid excess:

-

peripheral edema

puffy eyelids

sudden weight gain

ascites

rales in lungs

blurred vision

excessive salivation

distended neck vein

CLINICAL DO'S & DON'TS

INTAKE AND OUTPUT gauge fluid balance and give valuable information about your patient's
condition.
DO
-

Identify whether your patient has undergone surgery or if he has a medical condition
or takes medications that can affect fluid intake or loss.

Measure and record all intake and output. If you delegate this task, make sure you
know the totals and the fluid sources.

At least every 8 hours, record the type and amount of all fluids he's received and
describe the route as oral, parenteral, rectal, or by enteric tube.

Record ice chips as fluid at approximately half their volume.

Record the type and amount of all fluids the patient has lost and the route. Describe
them as urine, liquid stool, vomitus, tube drainage (including from chest, closed
wound drainage, and nasogastric tubes), and any fluid aspirated from a body cavity.

If irrigating a nasogastric or another tube or the bladder, measure the amount instilled
and subtract it from total output.

For an accurate measurement, keep toilet paper out of your patient's urine.

Measure drainage in a calibrated container. Observe it at eye level and take the
reading at the bottom of the meniscus.

Evaluate patterns and values outside the normal range, keeping in mind the typical
24-hour intake and output.

When looking at 8-hour urine output, ask how many times the patient voided, to
identify problems. For example, was a total of 300 and from 2 voids of 150 ml, or
from 10 voids of 30 ml each

Regard intake and output holistically because age, diagnosis, medical problem, and
type of surgical procedure can affect the amounts. Evaluate trends over 24 to 48
hours.

DON'T
-

Don't delegate the task of recording intake and output until you're sure the person
who's going to do it understands its importance.

Don't assess output by amount only. Consider color, color changes, and odor too.

Don't use the same graduated container for more than one patient.0

WEIGHT MONITORING

Percuss from the level of the umbilicus and repeat moving laterally towards one
side.

When the sound becomes dull, keep the fingers there to mark the spot and ask the
patient to move on to the opposite side.

Wait briefly for the fluid to sink and percuss again. If it is now resonant, that is a
positive sign. Percuss down until dullness is reached again.

Repeat on the other side.

False positives do occur, probably from dilated coils of small intestine reacting to
gravity.

At least 1500 ml of fluid must be present for a result. An ultrasound scan will
detect much less fluid with greater certainty.

Positive result: Probability of Ascites

Monitoring
Simple assessment of the progress of ascites may be made by:

Serial measurements of the abdominal girth - ensure the tape measure is placed in the
same position each time.

Serial measurement of weight - rapid changes indicate fluid gain or loss which are much
faster than gain or loss of fat or lean body mass.

When Weighing, the Patient Must:

1. Use the same scale every day.
2. Wear similar clothing each time he weighs himself.
3. Weigh himself at the same time each day (for example, when he gets up on the morning).
4. Weigh himself before eating and after urinating.
5. Record his weight in a diary or on a calendar.
6. Learn what his dry weight is. This is his weight without extra water (fluid).
7. Weigh himself in the morning after he is discharged from the hospital. One pound less than
this will be his dry weight. His goal is to keep his weight within four pounds of his dry weight.
8. Compare his actual daily weight to his dry weight

KIDNEYS, URETERS, AND BLADDER (KUB) X-RAY

A KUB is a plain frontal supine radiograph of the abdomen. It is often supplemented by an
upright PA view of the chest (to rule out air under the diaphragm or thoracic etiologies presenting
as abdominal complaints) and a standing view of the abdomen (to differentiate obstruction from
ileus by examining gastrointestinal air/water levels).
Despite its name, a KUB is not typically used to investigate pathology of the kidneys, ureters, or
bladder, since these structures are difficult to assess (for example, the kidneys may not be visible
due to overlying bowel gas.) In order to assess these structures radiographically, a technique
called an intravenous pyelogram was historically utilized, and today at many institutions CT
urography is the technique of choice.
KUB is typically used to investigate gastrointestinal conditions such as a bowel obstruction
and gallstones, and can detect the presence of kidney stones. The KUB is often used to diagnose
constipation as stool can be seen readily. The KUB is also used to assess positioning of
indwelling devices such as ureteric stents and nasogastric tubes. KUB is also done as a scout film
for other procedures such as barium enemas.
It should include on the upright projections both right and left visualizations of the diaphragm. In
at least one projection, the pubic symphysis must be present as the lower end of the area of
interest. If the patient is large, more than one film loaded in the Bucky in a "landscape" direction
may be used for each projection. This is done to ensure that the majority of bowel can be
reviewed.

INTRAVENOUS PYELOGRAM (IVP)

Historically, before the introduction and widespread adoption of computed tomography (CT)
imaging, the intravenous pyelogram, or IVP, was the most commonly utilized radiographic study
of the urinary tract. The IVP is an x-ray test in which a contrast agent (also termed "x-ray dye")
is injected into a patient's vein; the contrast agent acts to outline the patient's kidneys,ureters, and
bladder when x-rays are subsequently taken. Doctors would order an IVP for a number of
reasons, including the evaluation of pain in their side, blood in the urine (hematuria), or
other stone-related symptoms. In the present day, though, IVP is becoming less and less used
(although there are still certain cases where it may be a helpful study), primarily as a result of the
introduction of CT imaging. CT has become the x-ray study of choice for the evaluation of the
urinary tract, because it can rapidly (even in a single breath-hold) image the entirety of the
urinary tract. Since a CT scan presents its images as a cross-sectional view of the patient,
oftentimes CT provides a greater amount of information than an IVP does, making CT a more

cost-effective study. Furthermore, in many cases a CT imaging study does not require the
administration of a contrast agent.
An IVP is generally performed in a hospital radiology department or a physician's office by an
X-ray technologist and under the supervision of a radiologist or urologist. The patient will
commonly be placed on a restricted diet 24 hours prior to the test and will be asked to urinate
immediately prior to the test to ensure that the bladder is empty. The patient will then be asked to
lie on their back and to remain still. A preliminary film, also called a "scout" film, of the
abdomen and pelvis is obtained prior to the administration of intravenous contrast. The
preliminary film ensures that the x-ray machine is calibrated correctly for the patient's size, and
that there are no small stones present. Following intravenous injection of the contrast agent, a
series of x-rays will be obtained, following the contrast material as it filters through the kidneys.
Once the agent has filtered through the kidneys, it will pass down the ureters and into the
bladder. Again, x-rays are obtained throughout this process, following the course of the contrast
agent. The x-rays will be reviewed for evidence of tumors, cysts, stones or other structural and
functional abnormalities.
At the conclusion of the study, the patient will be asked to urinate, so that a final set of images
can be obtained to document how well the bladder empties. Once the IVP is over, the patient can
immediately resume their daily activities.

ULTRASOUND SPECIFIC TO CONDITIONS LEADING TO F&E IMBALANCE

o Abdominal ultrasound.
In abdominal ultrasound, the health care provider applies a gel to the persons abdomen and
moves a hand-held transducer over the skin. The gel allows the transducer to glide easily, and it
improves the transmission of the signals.
The procedure is performed in a health care providers office, outpatient center, or hospital by a
specially trained technician, and the images are interpreted by a radiologist; anesthesia is not
needed. An abdominal ultrasound can create images of the entire urinary tract. The images can
show damage or abnormalities in the urinary tract. Abdominal ultrasounds are also commonly
used to take pictures of fetuses in the womb and of a womans ovaries and uterus.

o Transrectal ultrasound with prostate biopsy

Transrectal ultrasound is most often used to examine the prostate. In a transrectal ultrasound, the
health care provider inserts a transducer slightly larger than a pen into the mans rectum next to
the prostate. The ultrasound image shows the size of the prostate and any abnormal-looking

areas, such as tumors. Transrectal ultrasound cannot be used to definitively diagnose prostate
cancer.
To determine whether a tumor is cancerous, the health care provider performs a biopsy. For the
biopsy, the health care provider uses the transducer and ultrasound images to guide a needle to
the prostate. The needle is then used to remove a few pieces of prostate tissue for examination
with a microscope. A transrectal ultrasound with prostate biopsy is usually performed in a health
care providers office, outpatient facility, or hospital by a doctor; light sedation and local
anesthesia are used. The biopsied prostate tissue is examined in a laboratory by a pathologista
doctor who specializes in diagnosing diseases. The biopsy can reveal whether prostate cancer is
present.

o MRI
Magnetic resonance imaging is a test that takes pictures of the bodys internal organs and soft
tissues without using x rays. MRI machines use radio waves and magnets to produce detailed
pictures of the bodys internal organs and soft tissues. An MRI may include the injection of
contrast medium. With most MRI machines, the person lies on a table that slides into a tunnelshaped device where the images are taken. The device may be open ended or closed at one end;
some newer machines are designed to allow the person to lie in a more open space. During an
MRI, the person is usually awake but must remain perfectly still while the images are being
taken. A sequence of images taken from different angles may be needed to create a detailed
picture of the urinary tract. During the sequencing, the person will hear loud, mechanical
knocking and humming noises. The procedure is performed in an outpatient center or hospital by
a specially trained technician, and the images are interpreted by a radiologist; anesthesia is not
needed, though light sedation may be used for people with a fear of confined spaces.

o Magnetic resonance angiogram (MRA).

An MRA is a type of MRI that provides the most detailed view of kidney arteriesthe blood
vessels that supply blood to the kidneys. An MRA can show kidney artery stenosis, which is the
narrowing of a kidney artery that restricts blood flow to the kidney. Kidney artery stenosis can
cause high blood pressure and lead to reduced kidney function and eventually kidney failure

o CT Scans
Computerized tomography scans use a combination of x rays and computer technology to create
three-dimensional (3-D) images. A CT scan may include the injection of contrast medium. CT

scans require the person to lie on a table that slides into a tunnel-shaped device where the x rays
are taken. The procedure is performed in an outpatient center or hospital by a specially trained
technician, and the images are interpreted by a radiologist; anesthesia is not needed. CT scans
can show stones in the urinary tract, obstructions, infections, cysts, tumors, and traumatic
injuries.

o Radionuclide Scans
A radionuclide scan is an imaging technique that relies on the detection of small amounts of
radiation after injection of radioactive chemicals. Because the dose of the radioactive chemicals
is small, the risk of causing damage to cells is low. Special cameras and computers are used to
create images of the radioactive chemicals as they pass through the urinary tract. Radionuclide
scans are performed at a health care providers office, outpatient center, or hospital by a specially
trained technician, and the images are interpreted by a radiologist; anesthesia is not needed.
Radioactive chemicals injected into the blood can provide information about kidney function.
Radioactive chemicals can also be put into the fluids used to fill the bladder and urethra for x ray,
MRI, and CT imaging.

Preparations for an imaging test mostly depend on the purpose and type of test. In general,
the health care provider will want to know whether the person is allergic to any foods or
medications, is pregnant, or has had any recent illnesses or medical conditions. Specific
preparations could include any of the following:
o fasting for 12 hours before the test
o drinking several glasses of water 2 hours before the test so the bladder is fullfor some
ultrasound tests
o taking a laxative, which is a medication that loosens stool and increases bowel
movements, to clear the colonfor a transrectal ultrasound
o taking an enema, which involves flushing water, laxative, or sometimes a mild soap
solution into the anus using a special squirt bottle, about 4 hours before the testfor a
transrectal ultrasound
o talking with the technical staff about any implanted devices that may have metal parts
that will affect MRI or MRA images, such as heart pacemakers, intrauterine devices
(IUDs), hip replacements, and implanted ports for catheterization; metal plates, pins,
screws, and surgical staples, as well as any bullets or shrapnel in the body, may also cause
a problem if they have been in place fewer than 4 to 6 weeks
o taking a sedative before an MRI or CT scan if the person feels anxious or has difficulty
holding still in enclosed spaces

BLOOD TESTS FOR DIAGNOSING F&E IMBALANCES

Blood tests can be used to diagnose and monitor a variety of urologic conditions. In many
cases, the results of blood work can help doctors determine if further lab tests or treatments are
necessary. Blood testing is a routine procedure. A blood test involves using a needle to collect
blood, usually from a vein in the arm. This blood sample is then sent to a laboratory for analysis.
Substances in the blood are measured in either milligrams per deciliter (mg/dL) or nanograms
per milliliter (ng/mL). Normal ranges are given as guidelines, but these levels can vary among
laboratories. Abnormal test results do not necessarily mean that the patient has a urologic
condition. Doctors confirm unusual results by repeating the blood test or performing a
combination of different diagnostic tests.
Here are some common blood tests that health care providers use to help diagnose urologic
conditions:
o Blood urea nitrogen (BUN)
This test, which is used to evaluate kidney function, diagnose kidney problems, and monitor
dialysis results, involves measuring the level of nitrogen in the urea of the blood. Urea is a waste
product that forms when protein breaks down. Usually, the kidneys filter urea and the substance
passes from the body in the urine. However, kidney problems can interfere with this filtering and
lead to higher levels of urea nitrogen. The normal range for this test is 7 to 20 mg/dL.

o Creatinine test
Creatinine (Cr) forms when a substance found in muscle tissue breaks down. Like urea nitrogen,
the kidneys filter out creatinine and let it pass through urine. A high level of creatinine in the
blood may indicate kidney damage caused by kidney infection, kidney stones, or decreased
blood flow to the kidneys. Abnormal test results also may suggest dehydration or a urinary
blockage. The normal range for this test is 0.8 to 1.4 mg/dL.

o Prostate-specific antigen (PSA) test

This test may be used in men to screen for prostate cancer (beginning at the age of 50 or at age
40 if at higher risk) and to monitor prostate cancer treatment. PSA is a protein produced by the
prostate gland. The PSA test also may be used to diagnose benign prostatic hyperplasia (BPH,
enlarged prostate) and or prostate infection (prostatitis) in men. Urinary tract infection (UTI) can
affect the results of this test and cause an abnormally high reading.

For most men, the normal range for the PSA test is lower than 4.0 ng/mL; however, there is no
specific normal or abnormal level. Men at increased risk for prostate cancer may be retested if
their level is higher than 2.5 ng/mL. High PSA levels do not mean that a patient has prostate
cancer, but may prompt further testing or a prostate biopsy.
The free PSA test is a variation of the usual PSA test. Normally, the protein PSA can be found in
two forms in the bloodeither attached to other proteins or "free" (unattached). The free PSA
test measures the amount of PSA that is unattached. The results of this test can provide further
clues on the likelihood of prostate cancera high level of overall PSA, but low level of free PSA
indicates a greater risk for cancer of the prostate.

o Calcium test
This test, which measures the level of calcium in the blood, can be used to screen patients for
kidney disease. The normal range for this test is 8.5 to 10.2 mg/dL. A lower-than-normal test
result might indicate kidney failure.

o Phosphate (phosphorus) test

Phosphate tests, which measure phosphate levels in the blood, are used to diagnose kidney
problems and monitor dialysis. The normal range for this test is 2.4 to 4.1 mg/dL. Levels that are
higher or lower-than-normal may indicate kidney disease.

o Alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) tests

These tests are used to help diagnose testicular cancer. AFP and beta-hCG are substances that are
produced in higher-than-normal amounts by testicular cancer cells.

REPUBLIC OF THE PHILIPPINES

Mariano Marcos State

University
COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac City, 2906, Ilocos Norte

Report

on

Fluid and
Electrolytes
Submitted by:
Danielle B. Quigao
Group 4 | BSNIII-A

Submitted to:
Ms. Judith P. Valenzuela
Clinical Instructor

July 2014