FLUIDS AND ELECTROLYTESIntroduction

To maintain good health, a balance of fluids and electrolytes, acids and bases must be normally regulated for metabolic processes to be in working state. A cell, together with its environment in any part of the body, is primarily composed of FLUID. Thus fluid and electrolyte balance must be maintained to promote normal function. Potential and actual problems of fluid and electrolytes happen in all health care settings, in every disorder and with a variety of changes that affect homeostasis. The nurse therefore needs to FULLY understand the physiology and pathophysiology of fluid and electrolyte alterations so as to identify or anticipate and intervene appropriately. Fluids -a solution of solvent and solute Solvent -a liquid substance where particles can be dissolved Solute -a substance, either dissolved or suspended in a solution Solution-a homogeneous mixture of 2 or more substances of dissimilar molecular structure usually applied to solids in liquids but applies equally to gasses in liquids Body Fluids A .Function 1. Transporter of nutrients , wastes, hormones, proteins and etc 2. Medium or milieu for metabolic processes 3. Body temperature regulation 4. Lubricant of musculoskeletal joints 5. Insulator and shock absorber B. Body Fluid Compartments C. Body Compartment Volumes neonates reach adult values by 2 yrs and are about half-way by 3 months average values ~ 70 ml/100g of lean body mass

percentage of water varies with tissue type, A. lean tissues ~ 60-80% B. bone ~ 20-25% C. fat ~ 10-15% D. Tonicity of Body Fluids Tonicity refers to the concentration of particles in a solution The normal tonicity or osmolarity of body fluids is 250-300 mOsm/L1. Isotonic Same as plasma 2. Hypotonic have a lesser or lowers solute concentration than plasma 3. Hypertonic higher or greater concentration of solutes Osmole the weight in grams of a substance producing an osmotic pressure of 22.4 atm. when dissolved in 1.0 litre of solution (gram molecular weight) / (no. of freely moving particles per molecule) Osmolality the number of osmoles of solute per kilogram of solvent Osmolarity the number of osmoles of solute per litre of solutionMole that number of molecules contained in 0.012 kg of C12, or, the molecular weight of a substance in grams = Avogadro's number = 6.023 x 1023 Molality the number of moles of solute per kilogram of solvent

Molarity Is the number of moles of solute per litre of solution THE Normal DYNAMICS OF BODY FLUIDS The methods by which electrolytes and other solutes move across biologic membranes are Osmosis, Diffusion, Filtration and Active Transport. Osmosis, diffusion and filtration are passive processes, while active transport is an active process. 1. OSMOSIS This is the movement of water/liquid/solvent across a semi-permeable membrane from a lesser concentration to a higher concentration Osmotic pressure is the power of a solution to draw water across a semi-permeable membrane Colloid osmotic pressure (also called oncotic pressure) is the osmotic pull exerted by plasma proteins 2. DIFFUSION Brownian movement or downhill movement The movement of particles/solutes/molecules from an area of higher concentration to an area of a lower concentration This process is affected by: a: The size of the molecules- larger size moves slower than smaller size b. The concentration of solution- wide difference in concentration has a faster rate of diffusion c. The temperature- increase in temperature causes increase rate of diffusion Facilitated Diffusion is a type of diffusion, which uses a carrier, but no energy is expended. One example is fructose and amino acid transport process in the intestinal cells. This type of diffusion is saturable. 3. FILTRATION This is the movement of BOTH solute and solvent together across a membrane from an area of higher pressure to an area of lower pressure Hydrostatic pressure is the pressure exerted by the fluids within the closed system in the walls of the container 4. ACTIVE TRANSPORT Process where substances/solutes move from an area of lower concentration to an area of higher concentration with utilization of ENERGY

It is called an uphill movement Usually, a carrier is required. An enzyme is utilized also. Types of Active Transport: a. Primarily Active Transport Energy is obtained directly from the breakdown of ATP One example is the Sodium-Potassium pump b. Secondary Active Transport Energy is derived secondarily from stored energy in the form of ionic concentration difference between two sides of the membrane. One example is the Glucose-Sodium co-transport; also the Sodium-Calcium counter-transport THE REGULATION OF BODY FLUID BALANCE To maintain homeostasis, many body systems interact to ensure a balance of fluid intake and output.A balance of body fluids normally occurs when the fluid output is balanced by the fluid input Overview of Fluid Regulation by the Body Systems A. Systemic Regulators of Body Fluids 1. Renal Regulation (RAS) This system regulates sodium and water balance in the ECF The formation of urine is the main mechanism Substance released to regulate water balance is RENIN. Renin activates Angiotensinogen to AngiotensinI, A-I i s enzymatically converted to Angiotensin-II ( a powerful vasoconstrictor) 2. Endocrine Regulation The primary regulator of water intake is the thirst mechanism, controlled by the thirst center in the hypothalamus (anterolateral wall of the third ventricle) Anti-diuretic hormone (ADH) is synthesized by the hypothalamus and acts on the collecting ducts of the nephron ADH increases rate of water reabsorption The adrenal gland helps control F&E through the secretion of ALOSTERONE- a hormone that promotes sodium retention and water retention in the distal nephron

ATRIAL NATRIURETIC factor (ANF) is released by the atrial cells of the heart in response to excess blood volume and increased wall stretching. ANF promotes sodium excretion and inhibits thirst mechanism 3. Gastro-intestinal regulation The GIT digests food and absorbs water The hormonal and enzymatic activities involved in digestion, combined with the passive and active transport of electrolyte, water and solutions, maintain the fluid balance in the body. B. Fluid Intake Healthy adult ingests fluid as part of the dietary intake. 90% of intake is from the ingested food and water 10% of intake results from the products of cellular metabolism Usual intake of adult is about 2, 500 ml per day The other sources of fluid intake are: IVF, TPN, Blood products, and colloids C. Fluid Output The average fluid losses amounts to 2, 500 ml per day, counterbalancing the input. the routes of fluid output are the following: SENSIBLE LOSS- Urine, feces or GI losses, sweat INSENSIBLE LOSS- though the skin and lungs as water vapor URINE- is an ultra-filtrate of blood. The normal output is 1,500 ml/day or 30-50 ml per hour or 0.5-1 ml per kilogram per hour. Urine is formed from the filtration process in the nephron FECAL loss- usually amounts to about 200 ml in the stool Insensible loss- occurs in the skin and lungs, which are not noticeable and cannot be accurately measured. Water vapor goes out of the lungs and skin. Water Metabolism Daily Balance: turnover ~ 2500 mla. Intake drink ~ 1500 ml food ~ 700 ml metabolism ~ 300 ml b. Losses

urine ~ 1500 ml skin ~ 500 ml insensible losses ~ 400 ml sweat ~ 100 ml lungs ~ 400 ml feces ~ 100ml Minimum daily intake ~ 500 ml with a "normal" diet Minimum losses ~ 1500 ml/dLosses are increased with;a. increased ambient T b. hyperthermia ~ 13% per Cc. decreased relative humidityd. increased minute ventilatione. increased MRO2 FLUID IMBALANCES Fluid Volume Deficit or Hypovolemia Definition: This is the loss of extra cellular fluid volume that exceeds the intake of fluid. The loss of water and electrolyte is in equal proportion. It can be called in various terms- vascular, cellular or intracellular Dehydration refers to loss WIthh increased solutes concentration and sodium concentration Pathophysiology of Fluid Volume Deficit Etiologic conditions include 1.Vomiting 2.Diarrhea 3.Prolonged GI suctioning 4.Increased sweating 5.Inability to gain access to fluids 6.Inadequate fluid intake 7.Massive third spacing Risk factors are the following :1.Diabetes Insipidus 2.Adrenal insufficiency 3.Osmotic diuresis 4.Hemorrhage

5.Coma 6.Third-spacing conditions like ascites, pancreatitis and burns PATHOPHYSIOLOGY: Factors inadequate fluids in the body decreased blood volume decreased cellular hydration cellular shrinkage weight loss, decreased turgor, oliguria, hypotension, weak pulse, etc.THE NURSING PROCESS IN FLUID VOLUME DEFICIT Assessment:1.Physical examination Weight loss, tented skin turgor, dry mucus membrane Hypotension Tachycardia Cool skin, acute weight loss Flat neck veins Decreased CVP 2.Subjective cues Thirst Nausea, anorexia Muscle weakness and cramps Change in mental state 3.Laboratory findings a.Elevated BUN due to depletion of fluids or decreased renal perfusion b.Hemoconcentrationc.Possible Electrolyte imbalances: Hypokalemia, Hyperkalemia, Hyponatremia, hypernatremiad.Urine specific gravity is increased (concentrated urine) above 1.020

4.NURSING DIAGNOSIS Fluid Volume deficit 5.PLANNING To restore body fluids 6.IMPLEMENTATION ASSIST IN MEDICAL INTERVENTION Provide intravenous fluid as ordered Provide fluid challenge test as ordered 7.NURSING MANAGEMENT 1. Assess the ongoing status of the patient by doing an accurate input and output monitoring 2. Monitor daily weights. Approximate weight loss 1 kilogram = 1liter! 3. Monitor Vital signs, skin and tongue turgor, urinary concentration, mental function and peripheral circulation 4. Prevent Fluid Volume Deficit from occurring by identifying risk patients and implement fluid replacement therapy as needed promptly 1.Correct fluid Volume Deficit by offering fluids orally if tolerated, anti-emetics if with vomiting,and foods with adequate electrolytes 2.Maintain skin integrity 3.Provide frequent oral care 4.Teach patient to change position slowly to avoid sudden postural hypotension FLUID VOLUME EXCESS: HYPERVOLEMIA Refers to the isotonic expansion of the ECF caused by the abnormal retention of water and sodium There is excessive retention of water and electrolytes in equal proportion. Serum sodiumconcentration remains NORMAL Pathophysiology of Fluid Volume Excess a.Etiologic conditions and Risks factors

Congestive heart failure with increased solutes concentration and sodiumconcentrationPathophysiology of Fluid Volume Deficit Renal failure Excessive fluid intake Impaired ability to excrete fluid as in renal disease Cirrhosis of the liver Consumption of excessive table salts Administration of excessive IVF Abnormal fluid retention b.PATHOPHYSIOLOGY Excessive fluid expansion of blood volume edema, increased neck vein distention, tachycardia, hypertension. The Nursing Process in Fluid Volume Excess ASSESSMENT Physical Examination 1.Increased weight gain 2.Increased urine output 3.Moist crackles in the lungs 4.Increased CVP 5.Distended neck veins 6.Wheezing 7.Dependent edema Subjective cue/s 1.Shortness of breath 2.Change in mental state

Laboratory findings 1.BUN and Creatinine levels are LOW because of dilution 2.Urine sodium and osmolality decreased (urine becomes diluted) 3.CXR may show pulmonary congestion NURSING DIAGNOSIS Fluid Volume excess IMPLEMENTATION ASSIST IN MEDICAL INTERVENTION Administer diuretics as prescribed Assist in hemodialysis Provide dietary restriction of sodium and water MANAGEMENT 1.Continually assess the patient s condition by measuring intake and output, daily weightmonitoring, edema assessment and breath sounds 2.Prevent Fluid Volume Excess by adhering to diet prescription of low salt- foods .3.Detect and Control Fluid Volume Excess by closely monitoring IVF therapy, administering medications, providing rest periods, placing in semi-fowler s position for lung expansion and providing frequent skin care for the edema 4.Teach patient about edema, ascites, and fluid therapy. Advise elevation of the extremities,restriction of fluids, necessity of paracentesis, dialysis and diuretic therapy.5.Instruct patient to avoid over-thecounter medications without first checking with the health care provider because they may contain sodium ELECTROLYTES Electrolytes are charged ions capable of conducting electricity and are solutes found in all body compartments. 1. Sources of electrolytes Foods and ingested fluids, medications; IVF and TPN solutions 2. Functions of Electrolytes Maintains fluid balance

Regulates acid-base balance Needed for enzymatic secretion and activation Needed for proper metabolism and effective processes of muscular contraction, nerve transmission 3. Types of Electrolytes CATIONS- positively charged ions; examples are sodium, potassium, calcium ANIONS- negatively charged ions; examples are chloride and phosphates] The major ICF cation is potassium (K+); the major ICF anion is Phosphates The major ECF cation is Sodium (Na+); the major ECF anion is Chloride (Cl-) DY Renal failure Excessive fluid intake Impaired ability to excrete fluid as in renal disease Cirrhosis of the liver Consumption of excessive table salts Administration of excessive IVF Abnormal fluid retention b.PATHOPHYSIOLOGY Excessive fluid expansion of blood volume edema, increased neck vein distention, tachycardia, hypertension. The Nursing Process in Fluid Volume Excess ASSESSMENTPhysical Examination1.Increased weight gain2.Increased urine output3.Moist crackles in the lungs4.Increased CVP5.Distended neck veins6.Wheezing7.Dependent edemaSubjective cue/s1.Shortness of breath2.Change in mental stateLaboratory findings1.BUN and Creatinine levels are LOW because of dilution2.Urine sodium and osmolality decreased (urine becomes diluted)3.CXR may show pulmonary congestion NURSING DIAGNOSIS o

Fluid Volume excessIMPLEMENTATIONASSIST IN MEDICAL INTERVENTION

Administer diuretics as prescribed

Assist in hemodialysis

Provide dietary restriction of sodium and water NURSING MANAGEMENT1.Continually assess the patient s condition by measuring intake and output, daily wei ghtmonitoring, edema assessment and breath sounds2.Prevent Fluid Volume Excess by adhering to diet prescription of low salt- foods.3.Detect and Control Fluid Volume Excess by closely monitoring IVF therapy, administeringmedications, providing rest periods, placing in semi-fowler s position for lung expansion and providing frequent skin care for the edema4.Teach patient about edema, ascites, and fluid therapy. Advise elevation of the extremities,restriction of fluids, necessity of paracentesis, dialysis and diuretic therapy.5.Instruct patient to avoid over-the-counter medications without first checking with the health care provider because they may contain sodium ELECTROLYTES

Electrolytes are charged ions capable of conducting electricity and are solutes found in all bodycompartments. 1. Sources of electrolytes

Foods and ingested fluids, medications; IVF and TPN solutions 2. Functions of Electrolytes

Maintains fluid balance

Regulates acid-base balance

Needed for enzymatic secretion and activation

Needed for proper metabolism and effective processes of muscular contraction, nerve transmission 3. Types of Electrolytes

CATIONS- positively charged ions; examples are sodium, potassium, calcium

ANIONS- negatively charged ions; examples are chloride and phosphates]

The major ICF cation is potassium (K+); the major ICF anion is Phosphates

The major ECF cation is Sodium (Na+); the major ECF anion is Chloride (Cl-) DYNAMICS OF ELECTROLYTE BALANCE1. Electrolyte Distribution NAMICS OF ELECTROLYTE BALANCE1. Electrolyte Distribution