The body manages these levels primarily through the kidneys, which is charged with the task of excreting or retaining fluids and electrolytes. When the kidneys sense an imbalance, they can adjust for it and ideally correct for it to restore normal body functions. The kidneys also play a key role in the body by filtering the blood of solutes, electrolytes, and other molecules (e.g. glucose) that can be excreted or retained as needed.

It’s important to understand some terminology when evaluating clients with a fluid imbalance. The balance of fluids and electrolytes mostly refers to the volume and concentration of solutes inside the cell referred to as intracellular fluid (ICF), and the volume and concentration outside the cell called extracellular fluid (ECF).

Clients may have too much or too little water in either of these parts of the body. When diagnosing the imbalance, practitioners generally look at the levels of the ECF where their labs are assessed. If fluid levels in the ECF are high it is called hypervolemic, and if the levels are low, it is called hypovolemic. If fluid levels are balanced it is called isovolumic.

The key electrolyte that lives within the ICS is potassium which is regulated by the sodium-potassium pump. The sodium-potassium pump is an important component of the cell membrane which acts to drive sodium out of the cell and potassium in using energy in the form of ATP (active transport) to do so. The ECF describes fluids that exist in blood vessels, the skin, spinal cord fluid (SCF), synovial fluid, pleural fluid, and digestive secretions.

The ECF contains six liters of water in the blood vessels, eleven to twelve liters in the interstitial fluids, and one liter in the transcellular spaces (between the cells).

The body may also lose water via sweating and breathing. Clients with diaphoresis or excessive sweating or those in heat stroke or with a fever may become dehydrated. Clients who are hyperventilating may also expire extra moisture from their lungs and outside of the body.

Other routes where fluid levels may become imbalanced are via vomiting and diarrhea where extra water will get excreted from the body.

Another key term to be aware of is osmosis, which describes the movement of fluid from lower solute concentrations to higher concentration. Osmolality describes the number of osmotically active particles per Kg of water in the body. The concentration of a solution in the body is measured as osmotic pressure as milliosmoles (mOsm).

Clients who are hypertonic have a higher concentration of osmotically active particles (> 300 mOsm/L). Hypotonic is a low concentration of these particles (< 270 mOsm/L).

Lastly, an important concept to understand is how much fluid the body’s various tissues can hold. Muscle contains the most water out of all tissues in the body while fatty tissue contains much less.

As a result, clients with larger muscle mass will require extra fluid intake to maintain their fluid balance. Clients who are obese will contain extra water but not as much per kg of muscle. Additionally, this implies that men tend to retain more water than women since men generally have a higher muscle mass than their female counterparts.

Causes of Fluid Imbalance

Dehydration:

Dehydration can be caused by several factors ultimately described as a greater loss of free water compared to intake or retention. Clients who are dehydrated may also have hypovolemia which more specifically refers to a decreased volume of circulating blood in the body.

Dehydration can be caused by over excretion of fluids which can be due to diuretic use as either medication (e.g. loop diuretics, thiazides) or substances (e.g. alcohol, caffeine). Clients with diabetes are at an increased risk for dehydration in the event of high blood sugar which draws extra water into the blood (from the cells) to be excreted via urine. Other causes of dehydration include excessive sweating (diaphoresis) and severe burns as the skin will draw water to itself as part of the healing process.

Overhydration:

Volume overload or fluid retention can be caused by a variety of conditions many of which can be very severe. Clients with kidney failure or heart failure may experience increased retention of water as a downstream consequence of their condition.

Other potential causes may be increased electrolyte consumption via diet or from IV fluids. Other causes can be hormonal signals via the renin angiotensin aldosterone system which generally act to increase the retention of water to adjust for low blood pressure. This system can become dysfunctional in clients with cardiovascular disease which ultimately have serious consequences down the line.

Signs, Symptoms, and Pathophysiology of Fluid Imbalance

Dehydration:

Dehydration Symptoms

• Flat neck and veins
• Dry/flat skin
• Increased skin turgor (slow, sluggish skin after getting pinched)
• Weight loss
• Difficulty breathing (dyspnea)
• Orthostatic hypotension (sudden drop of blood pressure after changing position)

Dehydration Pathophysiology

• Low blood pressure
• Increased heart rate (tachycardia)
• Decreased central venous pressure
• ECG abnormalities (due to potassium fluctuations)
• Increased respiratory rate (tachypnea)
• High lab values
  • High hemoglobin and hematocrit
  • High electrolyte panels
  • High serum osmolality
  • High BUN
  • Increased urine specific gravity

Overhydration:

Overhydration Symptoms

• Peripheral edema (especially in the limbs)
• Pulmonary edema (fluid in lungs)
• Crackling sounds in the lungs
• Bounding pulses
• Rapid weight gain

Overhydration Pathophysiology

• High blood pressure
• ECG abnormalities
• Jugular venous distension (JVD)
• Increased central venous pressure
• Heart damage
• Lab values
• Elevated BNP

Fluid Imbalance Treatment

Nursing Interventions for Fluid and Electrolyte Imbalance and Pharmacology

Fluid and Electrolyte Imbalance Pharmacology:

Fluid replacement is the main intervention that can be implemented for clients with electrolyte imbalances. There are many different types of solutions that can be used depending on the concentration of electrolytes in the ECF.

Understanding these measurements is critical to improve the client’s condition while also preventing side effects. It’s important to understand that all IV fluid replacements should be administered slowly to minimize the risk of fluid overload or exacerbating electrolyte abnormalities.

• Hypertonic solutions: Contains higher concentrations of solutes than what is observed in the body. These solutions are generally utilized when clients have low lab values (e.g. low sodium, low glucose, etc.) Hypertonic solutions can also draw water from the ICF to the ECF which can be useful for clients with edema. These solutions may also be used for clients with heat exhaustion (where too many electrolytes were wasted) or peritonitis (inflammation of the peritoneal cavity. Examples of hypertonic solutions includes…

  • 3% normal saline (3% NS)
  • 5% normal saline (5% NS)
  • 10% dextrose in water (D10W)
  • 5% dextrose in water with ½ normal saline (D5 ½ NS)
  • 5% dextrose with lactated ringers (D5LR)
  • 50% dextrose in water (D50W)
• Hypotonic solutions: Contains lower concentrations of solutes relative to the water in the bag. Hypotonic solution are used when clients already have high values of electrolytes especially hypernatremia (serum sodium > 145 mEq/L). Clients with elevated sodium and are given an isotonic or hypertonic solution this can exacerbate their hypernatremia and cause serious side effects. The main function of hypotonic solutions are to treat cellular dehydration which results from hyperosmolar conditions (e.g. hypernatremia, hyperkalemia, hyperglycemia, etc.)Diabetic clients may require this therapy in the event of uncontrolled blood sugar as the body will increase the excretion of glucose and water as a result. Clients with HHNS or diabetic ketoacidosis are prime examples of situations where hypotonic solutions may be administered. of Examples of hypotonic solutions includes…
  • 0.45% normal saline (½ NS)
  • 0.33% normal saline (½ NS)
  • 0.25% normal saline (¼ NS)
  • 2.5% dextrose in water and 5% dextrose in water (D5W)
    • Isotonic in the bag but hypotonic in the body after the cells consume the glucose
    • Should be used with caution for clients with hyperglycemia (e.g. diabetics)
    • Should not be use in clients with high intracranial pressure (ICP)
• Isotonic solutions: Contains approximately the same percentage of solute to solution as in the human body. These are used in situations where fluid levels need to be replenished without shifting the fluids in or out of the cell. Isotonic solutions are very commonly used as these are effective at rehydrating clients. Examples of isotonic solutions includes…
  • Normal saline (0.9% NS)
  • Lactated ringers
    • Use with caution in renal impairment
    • Contains potassium (can affect ECG)
    • Contraindicated in liver impairment (cirrhosis, hepatitis) as the liver is needed to metabolize lactate
  • D5W
    • Isotonic in the bag but hypotonic in the body

Other considerations should include an evaluation of the client’s medication regimen. Since many drugs can alter fluid or electrolyte levels it is imperative to determine if the medications that client is on is exacerbating their situation.

Examples of medications that can cause dehydration include diuretics, SGLT2 inhibitors, ACE inhibitors and ARBs. Clients in extreme conditions should be evaluated by the physician or pharmacy to determine if a medication may need to be discontinued.

Fluid Imbalance Nursing Interventions:

It’s imperative when administering IV fluids to never infuse the solutions too quickly as this can be harmful to the client. Hypertonic solutions are at an increased risk of causing fluid overload as it can draw water from the cells into the blood.

This can be dangerous when given to clients with heart failure or renal failure. Other side effects can include tachycardia or hypovolemia (increased risk in liver disease, trauma, or burns).

Clients who are being treated for fluid or electrolyte imbalances should have their weight monitored daily. Rapid weight gain or loss suggests problems with key organs in the body (e.g. the kidneys, digestive tract, lungs, skin). The ins and outs should also be monitored in these clients to track sensible water loss or gain.

It’s important to track urine output in this situation monitoring for excretions of 240 ml in three hours or 480 ml in six hours. Generally, urine output should be roughly a liter every twelve hours. If clients are not excreting at these levels may have a critical condition that requires immediate treatment. If blood urea nitrogen (BUN) or serum creatinine are elevated this suggests serious kidney problems – if only BUN is elevated the client may just be dehydrated.

One of the more important interventions to make for clients who frequently struggle with fluid management should involve a consultation on signs and symptoms of overhydration or dehydration. A key symptom of dehydration to be aware of is low blood pressure which can cause orthostatic hypotension, a condition where clients change positions too quickly and faint due to lack of blood supply to the brain.

Older clients who are prone to dehydration should be advised to increase their fluid and electrolyte intake as this can quickly lead to dehydration in addition to excessive vomiting. Clients who are on diuretics should also be instructed to increase water intake to ensure proper hydration.

IV Fluid Solutions Conclusion

It is very important that clients with fluid and electrolytes receive proper treatment. Although administering IV fluids is generally considered harmless – clients who are prone to these imbalances may already have underlying conditions that can be dangerous if the wrong solution is used or if it is given too quickly. Practitioners play a key role at managing these important levels in the client’s body which is why understanding these concepts fully is imperative when preparing for the NCLEX^® exam.