Assessing Fluid & Electrolytes Video

Homeostasis
Water & electrolyte balance
Assess water volume
Na & K concentrations
Body Water Distribution
Males: water 60% of total body weight
Females: water 50% of total body weight
Distributed in extracellular compartement (vascular & interstitial space) & intracellular
compartment (bodies cells)
Intracelluar & extracellular compartements separated by cell membranes which are semipermeable
(allow free movement of water into and out of cells, but impermeable to certain solutes)
Capillary membranes separate the interstitial and vascular spaces
When fluid balance is present 65% of total body water is contained in the intracellular
compartment, the remaining 35% is in the extracellular compartment
Intake & Output
Water is ingested via the GI tract where it is absorbed into the interstitial space
Water Intake
Liquids-1000 ml
Food-1000 ml
Metabolism-250ml
Total-2250 ml
Water Output
Urine-1250ml
Insensible water loss
Respiration-400ml
Persperation-600ml
Total-2250ml

If water not provided, insensible water losses will lead to a water deficit in the extracellular
compartment and an increase in the concentration of sodium and other solutes. This will lead to
an increased osmotic pressure. This increased pressure will pull water out of the cells until the
pressure is equal inside and outside of the cells.

Electrolyte Concentrations
Potassium located primarily in the intracellular compartment (140 mEq/L), 4mEq/L in
extracellular compartment
Sodium located primarily in the extracellular compartment (142 mEq/L), 10mEq/L in intracellular
compartment.
This distribution is maintained by the sodium-potassium pump located in the cell membrane which
actively transports sodium out of the cell and potassium into the cell.
Without the pump, sodium and potassium would be distributed equally in both compartments.
Because of the pump sodium:
Confined to extracellular compartment
Is osmotically active particle
-pulls water from cells
-holds ingested water
Determines volume in extracellular compartment
Osmotic Pressure

The force that moves water from the compartment of lower particle concentration to the
compartment of higher particle concentration

Example:
When water is lost from the extracellular compartment, the sodium concentration increases. This
creates an osmotic pressure gradient which pulls water out of the intracellular compartment into
the extracellular compartment. This movement leads to loss of intracellular fluid volume, causing
the cells to shrink. A new extracellular sodium concentration is established that is higher than
normal, but the total concentration of particles in both compartments is equal.
ADH which is produced in the hypothalamus and stored in the posterior pituitary gland; plays a
major role in maintaining blood osmolarity and total fluid volume. It is released into the
circulation in response to increased blood osmolarity or decreased blood volume. Although
changes in blood osmolarity are the primary regulators of ADH release a marked decrease in
extracellur fluid volume (10% or more) causes ADH to be released regardless of osmolarity.
Increase in ADH
Less water is excreted by the kidneys
Urine becomes concentrated
Blood osmolarity is decreased
Blood volume is increased
Decrease in ADH
More water is excreted by kidneys
Urine becomes diluted
Blood osmolarity becomes increased
Blood volume is decreased
When dehydration occurs; one type of cell that shrinks are the osmoreceptors located in the hypothalamus.
Osmoreceptors stimulate thirst and drinking if the person is able
Osmoreceptors cells have long axons connecting to posterior pituitary, where ADH is released and
circulates to the kidneys
ADH opens pores in the collecting ducts causing less water to be excreted, as a result of drinking
water and the kidneys concentrating the urine; the extracellular water volume increases and the
sodium concentration decreases. Consequently, the osmolarity of the extracellular fluid decreases
relative to the intracellular fluid. Osmotic pressure pulls water into the intracellular compartment,
rehydrating the cells and a new intracellur/extracellular balance is established.

Important concepts to remember:

-Sodium governs extracellular volume
-Water intake or loss governs sodium concentration
-Osmolarity varies minimally in a healthy person
-When extracellular osmolarity rises slightly because of a pure water loss; thirst is stimulated,
ADH release is increased, the kidneys retain water, and normal osmolarity is restored
-When a healthy person drinks water (a pure water gain) osmolarity decreases slightly, ADH
release is inhibited, and the kidneys secrete more dilute urine, bringing osmolarity back to normal.
Other Physiological Responses (to maintain homeostasis)
Juxtaglomerular apparatus of kidneys
Renin
Angiotensin converting enzyme
Aldosterone
Atrial natrueretic hormone
When arterial blood pressure decreases, the pressure of the blood flowing into the kidneys decreases as
well.

The juxtaglomerular apparatus interprets the decrease in pressure as a volume deficit in the
vascular space and responds by secreting renin into the blood.
Renin activates the angiotensiongen which changes into angiotensin I
Angiotensin converting enzyme (ACE) changes angiotensin I into angiotensin II

Angiotensin II
Increases peripheral vascular resistance
Raises blood pressure
Stimulates adrenal cortex to secrete aldosterone
Aldosterone
Causes kidneys to excrete potassium and retain sodium
Retained sodium pulls water with it to maintain osmolarity
Vascular volume increases
Urine output decreases
Volume Excess
Renin not released
-angiontensin II not formed
-aldosterone not secreted
Potassium excretion decreases
Sodium excreted along with enough water to maintain osmolarity
Vascular volume decreases
Urine output increases
When Heart Senses Volume Excess
Atria secrete atrial natruretic hormone
Kidney responds by excreting additional sodium
Vascular volume decreases
Urine output increases
Starling Forces
Regulates fluid volume between the vascular and interstitial spaces
A high concentration of negatively charged proteins such as albumin, are too large to pass through
the capillary wall pores and are repelled by the negative capillary wall charge.
Consequently, they remain in the plasma which causes the intravascular osmolarity to be greater
than the interstitial osmolarity
This normal difference in osmolarity is called colloidal oncotic pressure
To offset this holding force, blood pressure and the weight of the blood column in the arteries
exert a pushing force called capillary hydrostatic pressure
Filtration Pressure
Is the difference between the capillary hydrostatic pressure and the colloidal oncotic pressure
Regulates water movement between capillaries and interstitial spaces
Arterioles: capillary hydrostatic pressure is higher, so there is a positive filtration pressure which
pushes water and electrolytes out of the capillary into the interstitial space
Venules: capillary hydrostatic pressure is lower, so there is a negative filtration pressure which
pulls water and wastes back into the capillary

Diabetes Insipidus
(posterior pituitary problem)

Lack of ADH prevents kidneys from conserving water; consequently, water is excreted
Causes extracellular fluid compartment to lose water
Extracellular fluid becomes hypertonic and osmolarity increases, fluid shifts from intracellular to
extracellular compartment
Cellular dehydration results

Nursing Diagnosis
Actual fluid volume deficit related to failure of regulatory mechanisms due to pituitary surgery
and resultant decrease in ADH levels
Treatment Goal
Restore normal fluid volume and osmolarity
Antidiuaretic hormone (pitressin, vasopressin) is ordered for patients with DI, it replaces the natural
hormone and by increasing water permeability in the renal tubule and collecting duct which conservers
water
Conserves water
Increases urine osmolarity
Decreases urine output
Decreases blood osmolarity
Increases blood volume
Chlopropramide (Diabinase)
Potentiates action of ADH on renal tubule may also be ordered to help reduce water loss
Intranasal Desmopressin
Usually ordered when patient stabilized
Other Treatments
D5W IV
Accurate I&O essential, hourly urine output measurement
Water replacement must be gradual to prevent other complications (cerebral edema)
Monitor serum electrolytes
Measure urine specific gravity
Weigh patient daily
Assess for signs of dehydration

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

When ADH secretion increases, the kidneys respond by retaining body water
Extracellur fluid becomes hypotonic and the osmolarity decreases, this is known as dilutional
hyponatremia
To equalize extracellular and intracellular osmolarity, the water moves from the extracellular into
the intracellular compartment causing cellular swelling

Nursing Diagnosis
Alteration in fluid volume: excess related to compromised regulatory mechanism due to SIADH,
etiology unknown.
Treatment Goal: Eliminate excess water and increase serum osmolarity
Monitor I&O (hourly UOP measurement)
Fluid restriction (1000-1200ml/day or less)
Type of IV fluid depends on Na levels
If below 120 mEq/L, NS ordered (0.9% saline, isotonic fluid)
If very low and patient is critically ill, a hypertonic fluid will be ordered (0.3% NaCl)
Use IV pump
Diuretics
Monitor serum electrolytes
Weight patient daily
Assess mental status
Explain patient behavior to family