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NCM103: MED-SURG

FLUIDS AND ELECTROLYTES


All body fluids are dilute solutions that are
made up of water and dissolved substances
known as solutes
Water is the major component of the human
body (males approx. 60% and females approx.
50%)
The following are factors that affect body water:
o Fat Cells Fat cells contain very little water
so the more fat cells a person has, the less
water they have
o Age As a rule, body water decreases with
age and with muscle mass decline
o Female Gender Because of increased body
fat, women are inclined to have less water
mass (approx. 10% less)
SOLUTES
Either electrolytes or non-electrolyte substances
Electrolytes are substances that dissociate or
separate in solution and conduct electrical
current
o Cations
Sodium (Na+) is the primary cation in the
extracellular space
Potassium (K+) is the primary cation in the
intracellular space
Sodium/potassium pump responsible for
releasing these electrolytes
o Anions
Chloride (Cl-) & Bicarbonate (HCO3)
primary anion in the extracellular space
Phosphorus (PO3/4-) primary anion in the
intracellular space
Glucose and urea do not dissociate in solution
and are measured by weight
Other
important
electrolyte
substances:
createnine and bilirubin
Fluid Compartments:
Extracellular Fluid (ECF) found outside of the
cells; amount decreases with age
o In the newborn, approximately of the body
fluid is contained in the ECF. By the time the
infant has reached one year old; the ECF has
decreased to approximately 1/3 of the total
volume

In an average 70 kg adult the ECF is


approximately 15 liters of total volume. ECF
can further be divided into the following:
Interstitial Fluid surrounds the cells and
equals approximately 11 to 12 liters of fluid
in adults (lymph fluid is included in
interstitial fluid)
Intravascular Fluid within the blood vessels
(plasma volume)
The average adult blood volume is
approximately 5 to 6 liters or which
approximately 3 liters is plasma
The remaining 2 or 3 liters of volume
consists of red blood cells and erythrocytes
(which transport oxygen and important
body buffers)
Transcellular Fluid within specialized
cavities of the body and is also considered to
be part of the ECF
Examples of transcellular fluid include:
v Cerebral Spinal Fluid
v Pericardial Fluid
v Pleural Fluid
v Synovial Fluid
v Intraocular Fluid
v Digestive Secretions

Intracellular Fluid (ICF) contained within the


cell, also known as cellular soup
o In adults it is approximately 2/3s of the
bodys fluid (27 liters)
o Comprised mostly of potassium, organic
anions, proteins and other small cations and
anions

The 60-40-20 rule is that in total 60% of our


body weight is water with 40% of that being
intracellular with the remaining 20% being
extracellular

Factors That Affect Movement of Water and


Solutes:
Cell Membranes these membranes separate
intracellular fluid from interstitial fluid, and are
composed of lipids and proteins
Capillary Membranes these membranes
separate intravascular fluid from interstitial fluid
Epithelial Membranes these membranes
separate interstitial fluid and intravascular fluid
from transcellular fluid

Transport Process:
Diffusion random movement of particles in all
directions from an area of high concentration to
low concentration
o Movement of oxygen from the alveoli of the
lungs into the blood stream
o Another example of diffusions occurs when
cations follow anions and vice versa
o Substances may diffuse across the cell wall
(which is composed of lipids and proteins)
under the following conditions:
The substance is small enough to pass
through the protein pores (water, urea)
The substance is lipid soluble (oxygen and
carbon dioxide)
The substance is transported by a carrier
substance (e.g glucose is such a large
molecule it must combine on the outside of
the cell with a carrier substance to be moved
into the cell)
Factors that increase diffusion include:
Increased temperature
Increased concentration of solutes
Decreased size or weight of solutes
Increased surface area available for
diffusion
Decreased distance across which the solute
mass must diffuse

Active Transport a requirement for simple


diffusion, relies on the availability of carrier
substances
o Important solutes that require active transport
to move in and out of the cells are:
Sodium
Potassium
Hydrogen
Glucose
Amino-Acids

Filtration from an area of high hydrostatic


pressure to an area of low hydrostatic pressure
o Hydrostatic pressure is the pressure that is
created by the weight of fluid
o Allows the kidneys to filter plasma
(approximately 180 liters per day)

Osmosis across a semi-permeable membrane


from an area of lower solute concentration to an
area of higher solute concentration
o Osmosis can occur on either side of the
membrane when changes in concentration
occur
o The following are terms that are associated
with osmosis:
Osmotic pressure amount of hydrostatic
pressure required to stop the osmotic flow of
water
Oncotic pressure the osmotic pressure
exerted by colloids which are proteins such
as albumin
Osmotic diuresis increased urine output
caused by substances such as Mannitol,
glucose or contrast medium
Osmolality the ratio of solutes to water

Regulation of Vascular Volume:


Regulation occurs by a combination of renal,
metabolic and neurological functions
The following are examples of the bodys fluid
volume regulatory systems:
o The Sympathetic Nervous System (SNS)
provides the initial compensatory response to
rapid and short-term changes in the ECF
leading to changes in sympathetic tone (i.e.
cardiac output, arterial resistance and release
of renin by the kidneys)
o Renin-Angiotensin Renin is released from
the kidneys in response to decreased renal
perfusion
Renin acts on Angiotensin to produce
Angiotensin 1
Angiotensin 1 is converted by an enzyme to
Angiotensin 2 (potent vasoconstrictor)
Angiotensin 2 stimulates the release of
Aldosterone
Aldosterone is a mineralcorticoid hormone
released by the adrenal cortex and acts to
increase reabsorption of sodium
The reabsorption of sodium leads to water
retention making Aldosterone a potent and
important volume regulator
o Natriuretic Peptides influence fluid volume
and cardiovascular function through increased
excretion of sodium, direct vasodilation and
opposing the Renin-Angiotensin process

The following three natriuretic peptides have


been identified:
Type A produced by the atrial
myocardium
Type B produced by the ventricular
myocardium
Type C produced by the vascular
endothelium
Type A and B peptides are released in
response to increased pressure in the
myocardium while Type C peptide is
released in response to vascular bed changes
o Antidiuretic Hormone (ADH) produced by
the hypothalamus and secreted by the posterior
pituitary gland; ADH increases the
reabsorption of water and allow for the
excretion of concentrated urine and is
primarily regulated by plasma osmolality and
ECF volume
Factors that increase the release of ADH
include:
Increased plasma osmolality
Decreased extracellular fluid volume
Decreased blood pressure
Stress and pain
Medications such as Morphine and
Barbiturates
Surgery and certain anesthetics
Positive pressure ventilation
Factors that decrease the release of ADH
include:
Decreased plasma osmolality
Increased extracellular fluid volume
Increased blood pressure
Certain medications such as Dilantin
Medications that alter the action of ADH
include:
Lithium (suppresses)
Demeclocycline (suppresses)
Methoxyflurane (suppresses)
Chlorpropamide (enhances)
Indomethacin (enhances)
In addition to ADH, thirst also acts to
regulate extracellular fluid concentrations
and is essentially stimulated by the same
factors that stimulate ADH

Nursing Assessment for Patients at Risk for


Fluid/Electrolyte Imbalances:
Physiologic diabetes or ulcerative colitis
Developmental due to age or social situation
(an elder who lives alone)
Psychological anorexia or bulimia
Spiritual denial of blood products, religious
fasting
Sociocultural factors that are inhibiting the
client from complying with medical treatment
A. CLINICAL ASSESSMENT
Daily weights (one kg of weight represents one
liter of fluid)
Intake (oral fluids, IV fluids, tube feedings,
catheter irrigants)
Output (urine, feces, vomitus, NG and wound
drainage and using a rating system excessive
sweating)
Hemodynamic Monitoring (Cardiac Output,
CVP, PAP and PAWP)
B. VITAL SIGNS
Elevation of body temperature may lead to
increased insensible loss
Decreased body temperature may result from
hypovolemia
Increased respiratory rate and depth my lead to
increased insensible loss
Shortness of breath (crackles, rales, rhonchi)
may signal fluid build up
Increased heart rate may signal fluid volume
deficit
Bounding pulse may signal fluid volume
overload
Weak thready pulse may signal fluid volume
deficit
Elevated blood pressure may signal fluid
volume deficit
Decreased blood pressure may signal fluid
volume excess
Postural changes in blood pressure may signal
fluid volume deficit

C. INTEGUMENTARY SYSTEM
Flushed dry skin may signal fluid volume deficit
Changes in skin turgor/increased capillary refill
may signal fluid volume deficit
Edema may signal fluid volume excess
Increased furrowing of the tongue may signal
fluid volume deficit
Decreased moisture between cheek and gum
may signal fluid volume deficit

Nursing Diagnosis:
Alteration in nutrition
Fluid volume excess
Fluid volume deficit
Potential for skin impairment
Alteration in tissue perfusion (cardiovascular)
Alteration in tissue perfusion (renal)
Alteration in gas exchange
Knowledge deficit

D. CARDIOVASCULAR SYSTEM
Jugular vein distention may signal fluid volume
excess
Development of an S3 heart tone may signal
fluid volume excess
Dysrhythmias may occur with potassium,
calcium or magnesium imbalances
E. NEUROLOGIC SYSTEM
Altered LOC, restlessness and confusion may
signal fluid volume deficit
Positive Trousseaus sign or positive Chvosteks
signs
occur
with
hypocalcemia
and
hypomagnesemia
Neuromuscular irritability can occur with
metabolic and respiratory alkalosis
F. GASTROINTESTINAL SYSTEM
Anorexia, nausea, vomiting may occur with
either acute fluid volume excess or deficit
Thirst may be a signal for fluid volume deficit
G. LABORATORY ASSESSMENT
Tests to evaluate fluid status include:
Serum osmolality 280 to 300 mOsm/kg
Hematocrit
o MALES: 40% to 50%
o FEMALES: 37% to 47%
BUN 6 to 20 mg/dL
Urine osmolality
o TYPICAL 24 HOUR SPECIMEN:
300 to 900 mOsm/kg
o RANDOM URINE OSMOLALITY:
50 to 1200 mOsm/kg)
Urine specific gravity 1.001 to 1.040
Urine sodium 50 to 130 mEq/L

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