2. Body Fluids
Water= most important nutrient for life.
Water= primary body fluid.
Adult weight is 55-60% water.
Loss of 10% body fluid = 8% weight loss SERIOUS
Loss of 20% body fluid = 15% weight loss FATAL
Fluid gained each day should = fluid lost each day
(2 -3L/day average)
What is the minimum output per hour necessary to
maintain renal function? 30ml/hr
3. Functions of Body Fluid
Medium for transport
Needed for cellular metabolism
Solvent for electrolytes and other
constituents
Helps maintain body temperature
Helps digestion and elimination
Acts as a lubricant
4. Mechanisms of
Fluid Gain and Loss
Gain
Fluid intake 1500ml
Food intake 1000ml
Oxidation of nutrients
300ml
(10ml of H20 per 100 Kcal)
Loss
“Sensible”
Can be seen.
Urine 1500ml
Sweat 100ml
“Insensible”
Not visible.
Skin (evaporation) 500ml
Lungs 400ml
Feces 200ml
5. Regulation of Fluids
Hypothalmus –thirst receptors (osmoreceptors)
continuosly monitor serum osmolarity (concentration). If
it rises, thirst mechanism is triggered.
+Vasopressin (AKA ADH )– increasing H20 reabsorption
Pituitary regulation- posterior pituitary releases
ADH (antidiuretic hormone) in response to increasing
serum osmolarity. Causes renal tubules to retain
H20.
Thirst is a late sign of water deficit
6. Regulation of Fluids (continued )
Renal regulation- Nephron receptors
sense decreased pressure (low
osmolarity) and kidney secretes RENIN.
Renin – Angiotensin I – Angiotensin II
Angiotensin II causes Na and H20
retention by kidneys AND…..
Stimulates Adrenal Cortex to secrete
Aldosterone which causes kidneys to
excrete K and retain Na and H20.
7. Consider This….
The Geriatric Client
-normal physiological aging results in
decreased thirst mechanism
decreased # of sweat glands
decreased renal function
-there also may be decreased mobility
and/or cognitive function which impacts
their ability to get adequate fluid intake.
8. Variations in Body Fluids
Elderly: Have lower % of total body fluid
than younger adults
Women: Have lower % total body fluid
than men
WHY DO YOU THINK THIS IS ?????
Muscle tissue has more H20 content THAN adipose tissue
9. Fluid Compartments
Intracellular
fluid (ICF)
Fluid inside the
cell
Most (2/3) of
the body’s H20
is in the ICF.
Extracellular Fluid
(ECF)
Fluid outside the cell.
1/3 of body’s H20
More prone to loss
3 types:
Interstitial- fluid
around/between cells
Intravascular- (plasma)
fluid in blood vessels
Transcellular –CSF,
Synovial fluid etc
10. Consider this….
Age variations exist in regards to
H20 content of fluid compartments
Infants =
60% of H20 is found in ECF
40% of H20 is found in ICF
What might this mean in regards to fluid
loss for an infant? Reverse of adults!
Infant MORE PRONE to fluid
LOSS!
11. Fluid Balance
Dynamic process
Balance between body fluids and
electrolytes
Attraction between ions
(electrolytes) and water (fluids)
causes fluids to move across
membranes and leave their
compartments.
12. Solvent (H20) Movement
Cell membranes are semipermeable
allowing water to pass through
Osmosis- major way fluids transported
Water shifts from low solute
concentration to high solute
concentration to reach homeostasis
(balance).
13. Osmolarity
Concentration of particles in solution
The greater the concentration (Osmolarity) of a
solution, the greater the pulling force (Osmotic
pressure)
Normal serum (blood) osmolarity = 280-295 mOSM/kg
A solution that has HIGH osmolarity is one that is >
serum osmolarity = HYPERTONIC solution
A solution that has LOW osmolarity is one that is <
serum osmolarity = HYPOTONIC solution
A solution that has equal osmolarity as serum =
ISOTONIC solution
14. Hypertonic Fluids
Hypertonic fluids have a higher
concentration of particles (high
osmolality) than ICF
This higher osmotic pressure
shifts fluid from the cells into the
ECF
Therefore Cells placed in a
hypertonic solution will shrink
15. Hypertonic Fluids
Used to temporarily treat hypovolemia
Used to expand vascular volume
Fosters normal BP and good urinary output
(often used post operatively)
Monitor for hypervolemia !
Not used for renal or cardiac disease.
16. Hypotonic Fluids
Hypotonic fluids have less
concentration of particles (low
osmolality) than ICF
This low osmotic pressure shifts
fluid from ECF into cells
Cells placed in a hypotonic solution
will swell
17. Hypotonic Fluids
Used to “dilute” plasma particularly in
hypernatremia
Treats cellular dehydration
Do not use for pts with increased ICP
risk or third spacing risk
18. Isotonic Fluid
Isotonic fluids have the same
concentration of particles (osmolality)
as ICF (275-295 mOsm/L)
Osmotic pressure is therefore the
same inside & outside the cells
Cells neither shrink nor swell in an
isotonic solution, they stay the same
19. Isotonic Fluid
Expands both intracellular and
extracellular volume
Used commonly for: excessive
vomiting,diarrhea
0.9% Normal saline
D5W
Ringer’s Lactate
20. Other Osmotic Factors
ALBUMIN ( a serum protein )
Albumin in the serum has osmotic properties called
colloid pressure
Albumin pulls H20 from the interstitial compartments
into the intravascular compartments (serum). Helps
to maintain BP.
Persons with low serum albumin levels tend to retain
fluid in their interstitial layers.
What abnormal assessments might you find in the
client with low serum albumin levels?
Edema, hypotension
21. Hmmm…….
What type of IV fluid
(hypotonic – isotonic – hypertonic)
might be of benefit to this client with low
albumin levels?
22. Consider this….
When tissue injury occurs, proteins
pathologically leak from the
intravascular space into the intersititial
space.
Termed: Third spacing
This explains __________ as a sign of
the inflammatory process.
EDEMA
23. Solute Movement -
Diffusion
Movement of solutes from high
concentration to low concentration
It is a PASSIVE movement DOWN the
concentration gradiant. (requires no energy)
Many body processes use diffusion.
Example: O2 and CO2 exchange
Rate is affected by: concentration gradiant,
permeability-surface area-thickness of
membranes, and size of particles.
(Fick’s Law)
24. Solute Movement –other
mechanisms
Active transport- requires energy (ATP)
to move from low concentration to high
concentration (uphill)
Example: Na / K pump
May be enhanced by carrier molecules with
binding sites on cell membrane
Example: Glucose
(Insulin promotes the insertion of binding
sites for Glucose on cell membranes).
25. Filtration
Solvent AND solute movement
Passage from an area of High Pressure to an area
of Low Pressure
Termed: Hydrostatic Pressure
Example:
Arterioles have higher pressure than ICF
Fluid, oxygen and nutrients move into cells
Venules have lower pressure than ICF
Fluid, carbon dioxide and wastes move out of cells
26. Definitions
An arteriole is a small diameter blood
vessel in the microcirculation that
extends and branches out from an
artery and leads to capillaries.
A venule is a very small blood vessel
in the microcirculation that allows blood
to return from the capillary beds to the
larger blood vessels called veins.
27. Fluid volume deficit FVD
(Hypovolemia)
Loss of both H20 and
electrolytes from ECF.
Causes include:
Increased output, Hemorrhage,
vomiting, diarrhea, burns,
OR
Fluid shift out of vascular space ( “third
spacing” ) into interstitial spaces
28. Dehydration
Isotonic dehydration = H20 & electrolyte
loss in equal amounts; diarrhea and
vomiting
Hypertonic dehydration = H20 loss
greater than electrolyte loss; excessive
perspiration, diabetes insipidus
29. Assessment
FVD - Hypovolemia
Cardiovascular:
Diminished peripheral pulses; quality 1+(thready)
Decreased BP & orthostatic hypotension
Increased HR
Flat neck & hand veins in dependent position
Elevated Hematocrit (Hct)
Gastrointestinal:
Thirst
Decreased motility; diminished bowel sounds,
possible constipation
31. Nursing Diagnosis - FVD
Deficient Fluid Volume
R/T loss of GI Fluids via vomiting
AEB elevated Hct, dry mucous
membranes, decreased output, thirst
32. Planning - FVD
Client will demonstrate fluid
balance aeb moist mucous
membranes, balanced I & O
measurements, Hct WNL, by ….
33. Interventions for
FVD - Hypovolemia
Prevent further fluid loss
Oral rehydration therapy
IV therapy
Medications; antiemetics, antidiarrheals
Monitor CV, Resp, Renal, GI status
Monitor electrolytes – possible supplement rx
MONITOR WEIGHT and I & O
34. Fluid Volume Excess
FVE - Hypervolemia
Fluid overload is an excess of body
fluid - overhydration
Excess fluid volume in the
intravascular area-hypervolemia
Excess fluid volume in interstitial
spaces edema
35. Fluid Volume Excess
Causes:
Increased Na/H2O retention
Excessive intake of Na (PO or IV)
Excessive intake of H2O ( PO or IV)
(Water intoxication)
Syndrome of inappropriate antidiuretic
hormone (SIADH)
Renal failure, congestive heart failure
38. Planning - FVE
Client will demonstrate fluid balance by
balanced I & O measurements, Serum
Na WNL, etc. by ….
39. Interventions
FVE - Hypervolemia
Restore normal fluid balance, prevent
further overload
Drug therapy; diuretics
Diet therapy; decrease Na & fluids
Monitor intake and output (I & O)
Monitor weights
Monitor electrolytes
Monitor CV, Resp, Renal systems
40. Electrolytes
Work with fluids to keep the body healthy and in
balance
They are solutes that are found in various
concentrations and measured in terms of
milliequivalent (mEq) units
Can be negatively charged (anions) or
positively charged (cations)
For homeostasis body needs:
Total body ANIONS = Total body CATIONS
43. Sodium Na+
135-145mEq/L
Major Cation
Chief electrolyte of the ECF
Regulates volume of body fluids
Needed for nerve impulse & muscle
fiber transmission (Na/K pump)
Regulated by kidneys/ hormones
44. Hmmm…
Hyper and Hypo Natremia are the most
common electrolyte disturbances. Why do
you think that is?
It is most abundant in the
EXTRACELLULAR FLUID and therefore
more prone to fluctuation.
45. Hyponatremia
Serum Na+ <135mEq/L
Results from excess of water or loss
of Na+
Water shifts from ECF into cells
S/S: abd cramps, confusion, N/V,
H/A, pitting edema over sternum
Tx: Diet/IV therapy/fluid restrictions
46. Lets think about …
Hyponatremia
What are some medical conditions that may cause a dilutional
hyponatremia?
CHF
Renal Failure
SIADH ( Cancer, pituitary trauma )
Addisons Disease ( hypoaldosteronism & Na loss )
What are some conditions that might cause actual loss of
sodium from the body?
GI losses – nasogastric suctioning, vomiting, diarrhea
Certain diuretic therapies
Permanent neurological damage can occur when serum Na
levels fall below 110 mEq/L. Why?
Hypotonic environment swells cells, increasing ICP – brain
damage
47. Hypernatremia
Serum Na+> 145mEq/L
Results from Na+ gained in excess of H2O
OR Water is lost in excess of Na+
Water shifts from cells to ECF
S/S: thirst, dry mucous membranes & lips,
oliguria, increased temp & pulse,flushed
skin,confusion
Tx: IV therapy/diet
48. Let’s think about….
Hypernatremia
What are some medical conditions that may cause elevated
serum Na?
Renal failure
Diabetes Insipidus
Diabetes Mellitus ( hyperglycemic dehydration)
Cushings syndrome (hyperaldosteronism)
What are some other patient populations at risk for
hypernatremia?
Elderly ( decreased thirst mechanism )
Patient’s receiving:
-tube feedings
-corticosteroid drugs
-certain diuretic therapies
Seizures, coma, death my result if hypernatremia is left
untreated. Why?
49. Potassium K+
3.5-5.0 mEq/L
Chief electrolyte of ICF
Major mineral in all cellular fluids
Aids in muscle contraction, nerve &
electrical impulse conduction, regulates
enzyme activity, regulates IC H20 content,
assists in acid-base balance
Regulated by kidneys/ hormones
Inversely proportional to Na
50. Hypokalemia
Serum level < 3.5mEq/L
Results from decreased intake, loss via
GI/Renal & potassium depleting diuretics
Life threatening-all body systems affected
S/S muscle weakness & leg cramps,
decreased GI motility, cardiac arrhythmias
Tx: diet/supplements/IV therapy
51. Lets think about …
Hypokalemia
What are some medical conditions that may cause a
hypokalemia?
Renal Disease / CHF (dilutional)
Metabolic Alkalosis
Cushings Disease ( Na retention leads to K loss )
What are some conditions that might cause actual loss of
potassium from the body?
GI losses – nasogastric suctioning, vomiting, diarrhea
Certain diuretic therapies
Inadequate intake – ( body cannot conserve K, need PO intake)
Cardiac arrest may occur when serum K levels fall below 2.5
mEq/L. Why?
Increased cardiac muscle irritability leads to PACs and PVCs,
then AF
53. Lets think about …
Hyperkalemia
What are some medical conditions that may cause
hyperkalemia?
Renal Disease=most common cause
Burns and other major tissue trauma
Metabolic Acidosis
Addison’s Disease ( Na loss leads to K retention )
What are some conditions that might cause potassium levels to
rise in the body?
Certain diuretic therapies
Excessive intake – ( inappropriate supplements)
Cardiac arrest may occur when serum K levels rise above
mEq/L. Why?
Decreased electrical impulse conduction leads to bradycardia
and eventual asystole.
54. Calcium Ca++
4.5-5.5mEq/L
Most abundant in body but:
99% in teeth and bones
Needed for nerve transmission, vitamin
B12 absorption, muscle contraction & blood
clotting
Inverse relationship with Phosphorus
Vitamin D needed for Ca absorption
57. Lets think about …
Hypocalcemia
What are some medical conditions that may cause
hypocalcemia?
Hypoparathyroidism (low PTH levels = decreased release of Ca
from bones)
S/P thryoid surgery ( low Calcitonin = decreased release of Ca
from bones) Acute pancreatitis
Crohns Disease
Hyperphosphatemia ( ESRF)
What are some other conditions that might cause low Ca?
GI losses – nasogastric suctioning, vomiting, diarrhea
Long term immobilization
Lactose intolerance
If hypocalcemia is prolonged, the body will utilize stored Ca
from bones.
What complication might arise?
58. Hypercalcemia
Serum Ca > 5.3mEq/L
Results from hyperparathyroidism,
some cancers, prolonged
immobilization
S/S muscle weakness, renal calculi,
fatigue, altered LOC, decreased GI
motility, cardiac changes
Tx: medication/ IV therapy
59. Lets think about …
Hypercalcemia
What are some medical conditions that may cause
hypercalcemia?
Hyperparathyroidism (high PTH levels = increased release of
Ca from bones)
Paget’s Disease
Some Cancers – Multiple Myleoma
Chronic Alcoholism ( with low serum phosphorus )
What are some other conditions that might cause low Ca?
Excessive intake of Ca OR Vitamin D
Excessive intake of OTC antacids
If hypercalcemia is uncorrected, AV block and cardiac arrest
may occur.
60. Magnesium Mg2+
1.5-2.5mEq/L
Most located within ICF
Needed for activating enzymes,
electrical activity, metabolism of
carbs/proteins, DNA synthesis
Regulated by intestinal absorption
and kidney
61. Hypomagnesemia
Serum < 1.5mEq/L
Results from decreased intake, prolonged NPO
status, chronic alcoholism & nasogastric
suctioning
S/S: muscle weakness, cardiac changes,
mental changes, hyperactive reflexes & other
hypocalcemia S/S.
Tx: replacement IV therapy
restore normal Ca levels ( Mg mimics Ca)
seizure precautions
62. Hypomagnesemia
Common in critically ill patients
Associated with high mortality rates
Increases cardiac irritability and ventricular
dysrhythmias - especially in patients with
recent MI
Maintenance of adequate serum Mg has
been shown to reduce mortality rates post MI
63. Hypermagnesemia
Serum>2.5mEq/L
Results from renal failure, increased
intake
S/S: flushing, lethargy, cardiac changes
(decreased HR),decreased resp, loss of
deep tendon reflexes
Tx: restrict intake
diuretic rx
64. Chloride Cl-
95-105mEq/L
Most abundant anion in ECF
Combines with Na to form salts
Maintains water balance, acid-base balance,
aids in digestion (hydrochoric acid) & osmotic
pressure (with Na and H20)
Regulated by kidneys
Follows Sodium (Na)
65. Hypochloremia
Serum level 96mEq/L
Results from prolonged vomiting &
suctioning
S/S metabolic alkalosis, nerve
excitability, muscle cramps, twitching,
hypoventilation, decreased BP if severe
Tx: diet/IV therapy
66. Hyperchloremia
Serum level > 106mEq/L
Results from excessive intake or
retention by kidneys – metabolic
acidosis
S/S Arrhythmias, decreased cardiac
output, muscle weakness, LOC
changes, Kussmauls’s respirations
Tx: restore fluid & electrolyte balance
67. Phosphate PO4-
2.5-4.5mg/dl
Needed for acid-base balance,neurological
& muscle function, energy transfer ATP &
affects metabolism of carbs/proteins/lipids,
B vitamin synthesis
Found in the bones
Regulated by intake and kidneys
Inversely proportional to Calcium
Therefore some regulation by PTH as well
68. Hypophosphatemia
Serum level < 1.8mEq/L
Results from decreased intestinal
absorption and increased excretion
S/S bone & muscle pain, mental
changes, chest pain, resp. failure
Tx: Diet/ IV therapy
69. Hyperphosphatemia
Serum level> 2.6mEq/L
Results from renal failure, low intake of
calcium
S/S: neuromuscular changes (tetany), EKG
changes, parathesia-fingertips/mouth
Tx: Diet; hypocalcemic interventions
Medications: phosphate binding
The body can tolerate hyperphosphatemia
fairly well BUT the accompanying
hypocalcemia is a larger problem!
70. Electrolyte homeostasis
This means to maintain balance…
to control by balancing the dietary
intake of electrolytes with the renal
excretion and reabsorption of
electrolytes
71. Interventions for F/E balance
Assess patient carefully- note changes
Monitor I & O (Intake & Output)
Monitor weight changes
Monitor urine
Monitor vs
Monitor lab results and dx test
Maintain proper IV therapy
72. Summary
Fluid compartments in the body must
balance
Body systems regulate F&E balance
Assessment of body fluid is important
to determine causes of imbalance
Interventions for imbalances are based
on the cause
Notas do Editor
What controls or regulates the fluids in our body? Thirst –simplest way to maintain fluid balance Thirst center failure- onconscious or confused pt. To not respond Which age group is most prone to dehydration because their body’s weight is mostly water?
What also is increased here?
Increased risk for fluid/electrolyte imbalance with decreased muscle since muscle cells hold more water
NOTE: Potter & Perry speaks to the “percentage of body weight” 40% of BODY WEIGHT = ICF fluid 20% of BODY WEIGHT = ECF fluid Transcellular fluid is a negligible amount
This is reverse of adults THEREFORE the infant is more susceptible to fluid loss
SEE NEXT SLIDES FOR IN-DEPTH
Water is a solvent Concentration of particles in solution (pulling action = osmolarity) Isotonic have almost same osmolarity as plasma therefore there is no pull
Osmosis, by the way, is the reason that drinking salt water will kill you. The HIGH osmolarity salt water in the GI system rapidly pulls water into the GI system and excretion – rapidly dehydrating cells SEE NEXT SLIDES FOR FURTHER DISCUSSION
Used for post op, decreases intracellular edema, fosters normal BP and good urinary output. D51/2NS, D5NS, D5RL Hyperal
ECF- extracellular fluids
ICF intracellular fluid - fluid inside the cell D5W isotonic / Normal saline solution is isotonic because it has almost the same concentration of sodium as blood. Used to replace Ecvlume
Hypertonic
EDEMA
Filtration- from pressure to low pressure
Dehydration : Fluid intake is not sufficient to meet the body’s needs. Dehydration- if water isn’t adequately replaced dehydration results Dx Tests Elevated HCT Elevated NA Sp. Gravity above 1.030 Monitor lab work Cause- unless unconscious Sudden wt. change is a major indicator of fluid loss
Oral- keep fluids at bedside, offer frequently IV fluids, blood & other parenteral measures Hyperal etc. Meds- depending on the cause Diarrhea give anti diarrhea meds Vomiting give anti emetics Vasopressors if pt. In shock cause vasoconstriction and increase BP
Increase in vascular blood Third spacing could be in the abd- ascites pleural effusion in the lungs
Retention- Intake- Poorly controlled IV therapy/ rapid hypertonic solution/ excessive sodium bicarb / excessive Na intake
Drug therapy- - diuretics for overhydration increases excretion of water and sodium Diet-- restricting fluid and sodium intake Monitor lab work
1 mEq MILLIEQUIVALENT = 1 MG OF HYDROGEN
Each will be discussed except Bicarbonate as that plays a role in acid base balance which will be covered in NR33
Na concentrations effected by water intake and salt untake Hormones -Aldsterone
Causes Poor IV therapy- IV therapy increased water in blood Na is diluted CHF Renal Failure GI: vomiting diarrhea drainage Skin: sweating burns diuretic drugs TX Diet- foods high in sodium - IV solutions ordered if hypovolemia (low volume) Fluid excess- osmotic diuretics ordered to promote excretion of water rather than sodium (mannitol) Fluid restriction till Na returns to norm Lop diueretics to to remove excess fluid Assess: VS skin integrity, seizures, I & O/ monitor lytes
Causes- increased Na intake- rapid infusion of saline solution/po intake loss of water – diarrhea/DM/decreased water intake/ impaired thirst center/can’t swallow Fluid shift from ICF to ECF ….(Na pulls h2o out of cells, kidneys excrete Na and water follows) Tx-if caused by fluid loss Need slow gradual return to normal Na+ by IV hypotonic solution 0.45%NS Pt. Teaching avoid high Na foods, canned soups, processed foods, ketchup AVOID antacids high in sodium bicarb I&O, review diet, meds, Moniotr weight, note change LOC
Effects skeletal/cardiac/smooth muscle Causes: Inadequate intake Alcoholism/ Diuretics Excessive Vomiting & diarrhea Tx ID cause High K diet, …oranges, broccoli, meat protein foods,banana, apricots PO supplements common IV therapy always diluted…
… (false rise due to tight tourniquet or hemolized specimen) occurs Poor elimination by kidneys Parathesia -tingling Tx-Depends on cause Hold Kmeds, low K diet orderd Kayexalate administered to increase excretion of K IV therapy add volume to dilute K+ Monitor for fluid overload.
8.5-10.5mg/deciliter dL Vit D needed for Ca absorption
Common after thyroid surgery Chovstek sign-Tap facial nerve in front of ear= facial spasm Trousseau- carpal spasm after BP cuff inflated due to increased neuromuscular excitability TX -Ca supplements…dietary. Dairy green veg, sardines salmon If severe-IV calcium gluconate
Remember it’s in the blood not the bones Causes-high intake TX-Depends on cause encourage mobility,immobilization causes demineralization of bones leading to fractures remove parathyroid tumors encourage fluids to prevent renal calculi Lower Ca by IV therapy causes diuresis encouraging kidney excretion Calcium binding meds given to promote excretion of calcium.
Flushing due to peripheral vasodilation Resp. deep shallow and slow
Tx: correct cause, diet increase Cl, vomiting reduce it, replacement thru IV therapy… can br given orally ie. Salty broth
Tx- treat underlying cause, VS, reorient if confused Kussmals –rapid and deep without pauses above 20/min
Tx- vs, assess resp, neuro status IV meds safety
Tx: Correct the under lying cause..renal failure, diet, decreased absorption, Iv fluids, vs Diet limit foods