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FLUIDS
60 %
Arterial Fluid
2%
Intravascular Interstitial
5% or 1/4 15% or 3/4
Venous
Fluid 3% Transcellular fluid 1-2%
ie csf, pericardial, synovial,
pleural,lymph system,
intraocular
•Movement of water from low solute to high •10% Dextran 40 in 5% Dextrose isotonic
solute concentration in order to maintain (252 mOsm/L)
balance between compartments. •Lactated Ringer’s Solution isotonic
•Osmotic pressure – amount of hydrostatic - Na 130 mEq/L
pressure needed to stop the flow of water by - K 4 mEq/L
osmosis -Ca 3 mEq/L
•Oncotic pressure – osmotic pressure - Cl 109 mEq/L
exerted by proteins - 273 mOsm/L
Rx:hypovolemia, burns, fluids lost as
Types of Fluid bile/diarrhea, acute blood loss
Tonicity CI: ph>7.5, lactic acidosis, renal
failure(cause HyperK)
•This is the concentration of solutes in a
solution
Hypotonic Fluid
•A solution with high solute concentration is - fluid will enter the cell, the cell
considered as HYPERTONIC will swell
•A solution with low solute concentration is Hypotonic Fluids
considered as HYPOTONIC
•0.45% NaCl (half strength saline)
•A solution having the same tonicity as that - provides Na, Cl and free water
of body fluid or plasma is considered - Na 77 mEq/L
ISOTONIC - Cl 77 mEq/L
- 154 mOsm/L
•In a HYPERTONIC solution, fluid will go Rx: hypertonic dehydration, Na and Cl
out from the cell, the cell will shrink. depletion, gastric fluid loss
CI : 3rd space fluid shifts and inc
•In a HYPOTONIC solution, fluid will enter ICP
the cell, the cell will swell.
•In an ISOTONIC solution, there will be no Hypertonic Fluid
movement of fluid. - fluid will go out from the cell, the
cell will shrink
Isotonic Fluid Hypertonic Fluids
- no movement of fluid.
Isotonic Fluids •3% NaCl (hypertonic saline)
•0.9% NaCl/ Normal Saline/NSS - no calories
-Na=154 - Na 513 mEq/L
-Cl=154 - Cl 513 mEq/L
-308 mOsm/L -1026 mOsm/L
- not desirable as routine maintenance Rx: critical situations to treat HypoNa, assist
solution in removing ICF excess
- only solution administered with blood CI: administered slowly and cautiously (IVF
products overload and pulmonary edema)
Rx: hypovolemia, shock, DKA,
metabolic alkalosis, hypercalcemia, mild NA •5% NaCl
deficit •D10W - 10% Dextrose in water hypertonic
CI: caution in renal failure, heart (505 mOsm/L)
failure and edema •D10W - 20% Dextrose in water hypertonic
(1011 mOsm/L)
•D5W - 5% Dextrose in water •D50W - 50% Dextrose in water hypertonic
- 170 cal and free water (1700 mOsm/L)
- 252 mOsm/L •D5NS - 5% Dextrose & 0.9NaCl
Rx: hypernatremia, fluid loss and hypertonic (559 mOsm/L)
dehydration •D10NS - 10% Dextrose & 0.9NaCl
CI: early post op when ADH inc d/t stress, hypertonic (812 mOsm/L)
sole treatment in FVD (dilutes plasma), head •D5LR - 5% Dextrose in Lactated Ringers
injury (inc ICP), fluid resuscitation hypertonic (524 mOsm/L
(hyperglycemia), caution in renal and
cardiac dse (fluid overload), px with NA Colloid solutions
deficiency (peripheral circulatory collapse
and anuria) •Dextran 40 in NS or 5% D5W
4
thirst: oral intake is controlled by thirst •ANP Promotes Sodium excretion and
center located in the hypothalamus : inhibits thirst mechanism
serum
osmolality 3. Gastro-intestinal regulation
or blood - GIT digests food and absorbs water
volume - Only about 200 ml of water is
excreted in the fecal material per day
stimulate thirst
center 4. Heart and Blood Vessel Functions
- pumping action of heart circulates blood
ADH - controls water excretion through kidneys
- determines concentration of urine
5. Lungs – insensible water loss through
4. osmoreceptors - located in the surface of respiration
hypothalamus Other Mechanisms
- sense changes in Na 1. Baroreceptors – carotid sinus and aortic
concentration arch
- causes vasoconstriction and increased
osmotic pressure (neurons become blood pressure
dehydrated)
Dec arterial pressure SNS inc
releases impulses to cardiac rate, contraction, contractility,
posterior pituitary to circulating blood volume, constriction of
renal arterioles and increased aldosterone
release ADH
2. Osmoreceptors – surface of hypothalamus
increases permeability of membrane to senses changes in Na concentration
–Urine SG is low
ADH (Antidiuretic hormone) –Hct is high
•Vasopressin RAAS (Renin-Angiotensin-Aldosterone
System)
•Water-retainer •To help maintain a balance of sodium and
•Hypothalamus produces ADH water, a healthy blood volume and blood
•Posterior pituitary gland stores and releases pressure, the juxtaglomerular cells near
ADH each glomerulus secrete RENIN
•Restores blood volume by reducing
•Leads to production of Angiotensin II, a
powerful vasoconstrictor
diuresis and increasing water retention
•Angiotensin II causes peripheral
ADH vasoconstriction, stimulating production of
Low blood volume/ Aldosterone
Pituitary gland •Both increase blood pressure.
Increased serum osmolality
secretes ADH Aldosterone Production
Decreased JG cells
into the bloodstream Renin travels
blood flow to the secrete
ADH causes the Water to the
retention glomerulus Renin
Kidneys to retain water increases liver
blood
volume/ decreases
Renin converts Angiotension 1
serum osmolality Angiotensin 1
ADH Regulation Angiotensin in travels to the
•ADH - produced by the Hypothalamus in the lungs is
the liver to lungs
- stored and secreted by the posterior
converted to
pituitary gland
Angiotensin 1
•less water in plasma,ADH secreted to Angiotensin II
conserve water by reducing urine output
•fluid overload in plasma, ADH secretion
stops to excrete fluid in the kidneys by Angiotensin II Angiotensin II
increasing urine output travels to the stimulates the
ADH Disorder Adrenal glands adrenal glands to
produce
•Abnormally high ADH concentration - Aldosterone
SIADH Aldosterone
reduced urine output (oliguria)
water retention (fluid overload)
Angiotensin II Aldosterone
•Abnormally low ADH – Diabetes Insipidus Sodium and
increased urine output (polyuria) stimulates the causes
water loss (fluid deficit) kidneys water retention
adrenal glands to to
ADH Disorder retain sodium leads to increased
produce Aldosterone and water
•SIADH fluid volume and
–Abnormally high ADH concentration
–urine output is reduced (oliguria)
–water retention (fluid overload) sodium level
–Urine SG is high (normal: 1.005 – 1.030)
–Hct is low (43-48%)
Aldosterone Disorders
•DI •Addison’s Disease
–Abnormally low ADH
–Abnormally low aldosterone
–urine output is increased (polyuria)
–water loss (fluid deficit) –Serum Na is low, serum potassium is high
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urine specific gravity: 1.010 - 1.025 •Urine sodium values: change with sodium
intake and status of fluid volume
Blood urea nitrogen - made up of urea, end
product of metabolism of protein - normal level ranges from 50 -
220mEq/24h
10-20mg/dl (3.5-7mmol/l) - used to assess volume status and
in the diagnosis of hyponatremia and acute
BUN: not most reliable indicator of renal renal failure
disease BUN:creatinine ratio better indicator
Normal 10:1. Fluid volume disturbances
•I and O must be equal
increased BUN due to:
•2.5 L per day
1. renal function •Fluid volume deficit (hypovolemia)
2. GI bleeding
3. dehydration
•Fluid volume excess (hypervolemia)
4. increased protein
intake
I&O Imbalance
5. fever and sepsis
Fluid Volume Deficit
decreased BUN due to : •↑output, normal intake
1. end-stage liver •Normal output, ↓ intake
disease •No intake
2. low protein
intake
3. starvation Fluid Volume Excess
4.condition that
expands fluid volume •↑ intake, normal output
ex. •Normal intake, ↓ output
pregnancy •No output
Creatinine
9
Edema FUNCTIONS:
•common manifestation of FVE 1. Regulate fluid balance and osmolality
2. Transmission of nerve impulse
•d/t inc capillary fluid pressure, decreased 3. Stimulation of muscle activity
capillary oncotic pressure, increased
interstitial oncotic pressure
•Localized or generalized
•ANIONS - negatively charged ions:
•Etiology: obstruction to lymph flow, Bicarbonate, chloride, PO4-, CHON
plasma albumin level < 1.5-2 g/dl, burns and
infection, Na retention in ECF, drugs
•CATIONS - positively charged ions:
Sodium, Potassium, magnesium, calcium
•Labs: Dec Hct, respiratory alkalosis and
hypoxemia, dec serum Na and osmolality,
inc BUN Crea, Dec Urine SG, dec urine Na Cations
level Sodium , Potassium , Calcium , Magnesium
, hydrogen ions
•Mgmt: diuretics, fluid restriction, elevation Anions
of extremities, elastic compression
Chloride, bicarbonate , phosphate, sulfate,
stockings, paracentesis, dialysis
proteinate ions
Laboratory (FVE)
•Dec BUN •Sodium - positively charged ions , major
•Dec Hct cation in the ECF
-important in regulating the volume
•CRF – serum osmolality and Na level dec of body fluids
•chest x-ray may reveal pulmonary -retention of Na- associated with
congestion fluid retention
Medical Management -loss of Na- decreased volume of
•Discontinue administration of Na solution body fluids
•Diuretics •Potassium - major cation in the ICF
ie Thiazide – block Na reabsorption
in
•Chloride - major anion in the ECF
distal tubule
Loop diuretics – block Na reabsorption
•Phosphate - major anion in the ICF
in ascending loop of Henle
•Restrict fluid and salt intake Regulation of Electrolyte Balance
•Dialysis 1. Renal regulation
•Occurs by the process of glomerular
Nursing Management filtration, tubular reabsorption and tubular
•Measure intake and output secretion
•Weigh patient daily •Urine formation
2 lb wt gain = 1 L fluid
11
–If there is little water in the body, it is Dx: inc serum sodium and Cl level, inc
conserved serum osmolality, inc urine sp.gravity, inc
–If there is water excess, it will be urine osmolality
eliminated
Mgmt:
Regulation:
K restriction (coffee, cocoa, tea, dried fruits,
beans, whole grain breads, milk, eggs) •GIT absorbs Ca+ in the intestine with the
diuretics help of Vitamin D
Polystyrene Sulfonate (Kayexalate) •Kidney Ca+ is filtered in the glomerulus
IV insulin and reabsorbed in the tubules
Beta 2 agonist •PTH increases Ca+ by bone resorption,
IV Calcium gluconate – WOF Hypotension inc intestinal and renal Ca+ reabsorption and
IV NaHCo3 – alkalinize plasma activation of Vitamin D
Dialysis
•Calcitonin reduces bone resorption,
Nsg consideration: increase Ca and Phosphorus deposition in
Monitor VS, urine output, lung bones and secretion in urine
sounds, Crea, BUN a. HYPERCALCEMIA
monitor K levels and ECG
observe for muscle weakness and •Serum calcium > 10.5 mg/dL
dysrythmia, paresthesia and GI symptoms
•Etiology: Overuse of calcium supplements
b. HYPOKALEMIA and antacids, excessive Vitamin A and D,
malignancy, hyperparathyroidism, prolonged
•K+ < 3.5 mEq/L immobilization, thiazide diuretic
•Inc Na reabsorption causes increased Cl •PTH inc bone resorption, inc PO4
reabsorption absorption from GIT, inhibit PO4 excretion
FUNCTIONS from kidney
1. major component of gastric juice aside •Calcitonin increases renal excretion of
from H+ PO4
2. together with Na+, regulates plasma
osmolality FUNCTIONS
3. participates in the chloride shift – inverse 1. component of bones
relationship with Bicarbonate 2. needed to generate ATP
4. acts as chemical buffer 3. components of DNA and RNA
a. HYPERCHLOREMIA
a. HYPERPHOSPHATEMIA
•Serum Cl > 108 mEq/L
•Serum PO4 > 4.5 mg/dL
•Etiology: sodium excess, loss of
bicarbonate ions •Etiology: excess vit D, renal failure, tissue
trauma, chemotherapy, PO4 containing
•s/sx: tachypnea, weakness, lethargy, deep medications, hypoparathyroidism
rapid respirations, diminished cognitive
ability and hypertension, dysrhytmia, coma •s/sx: tetany, tachycardia, palpitations,
anorexia, vomiting, muscle weakness,
hyperreflexia, tachycardia, soft tissue
•Dx: inc serum Cl calcification
dec serum bicarbonate
•Dx: inc serum phosphorus level
Mgmt: dec Ca level
Lactated Ringers soln xray – skeletal changes
IV Na Bicarbonate
Diuretics Mgmt:
diet – limit milk, ice cream, cheese,
Nsg mgmt: meat, fish, carbonated beverages, nuts, dried
monitor VS, ABGs, I and O, neurologic, food, sardines
cardiac and respiratory changes Dialysis
b. HYPOCHLOREMIA
Nsg mgmt:
•Cl < 96 mEq/l dietary restrictions
monitor signs of impending
•Etiology: Cl deficient formula, salt hypocalcemia and changes in urine output
restricted diets, severe vomiting and diarrhea
b. HYPOPHOSPHATEMIA
•s/sx: hyperexcitability of muscles, tetany, •Serum PO4 < 2.5 mg/dl
hyperactive DTR’s, weakness, twitching,
muscle cramps, dysrhytmias, seizures, coma •Etiology: administration of calories in
severe CHON-Calorie malnutrition
•Dx: dec serum Cl level (iatrogenic), chronic alcoholism, prolonged
ABG’s – metabolic alkalosis hyperventilation, poor dietary intake, DKA,
thermal burns, respiratory alkalosis, antacids
Mgmt: w/c bind with PO4, Vit D deficiency
Normal saline/half strength saline
diet ( tomato juice, salty broth, canned •s/sx: irritability, fatigue, apprehension,
vegetables, processed meats and fruits weakness, hyperglycemia, numbness,
avoid free/bottled water) paresthesias, confusion, seizure, coma
Nsg mgmt:
monitor I and O, ABG’s, VS, LOC, •Dx: dec serum PO4 level
muscle strength and movement
Phosphates (PO4) Mgmt:
oral or IV Phosphorus correction
•The MAJOR Anion in the ICF diet (milk, organ meat, nuts, fish,
•Normal range is 2.5-4.5 mg/L poultry, whole grains)
•Reciprocal relationship w/ Ca
15
•Electrolytes D2 Lung
•Acid-Base D3 -Control CO2 and Carbonic acid content of
ECF
•Burns D3
•Shock D4 1. METABOLIC ACIDOSIS
•GUT D5 - increased RR to eliminate CO2