Fluids

By:
Sonny M. Moreno, RN
 Board Question
 Body weight of an adult
represents how many percent of
water?
A. 40%
B. 50%
C. 60%
D. 70%
 Board Question
 Most accurate test to determine
fluid status would be?
A. BP readings
B. HR and RR readings
C. CVP readings
D. all of the above
 Board Question
 It is movement of particle from
low to high area of
concentration, with the help of
ATP (energy)
A. Active transport
B. Passive transport
C. Osmosis
D. Diffusion
 Board Question
 In response to FVD, RENIN
secretions will:
A. increase
B. decrease
C. remain normal
D. increase and decrease
 Intake and Output
 I and O must be
equal
 2.5 L per day
 Essential,
Measurable,
Sensible
 Non essential,
Not Measurable,
Insensible
 I&O Imbalance
Fluid Volume Excess
 ↑ intake, normal output
 Normal intake, ↓ output
 No output

Fluid Volume Deficit

 ↑ output, normal intake
 Normal output, ↓ intake
 No intake
 Facts About Fluids
 Body weight of an adult
represents 60%
 Infants = ↑60% (more water)
 Elderly = ↓60% (less water)
 More fats = ↓water
 More muscles = ↑water
 Infants and elderlies are prone
to fluid imbalance
 1% fluid loss triggers thirst
mechanism
 Water Auto Regulation
 THIRST
 ADH
 ANP
 RENIN
 BARORECEPTOR
 ALDOSTERONE
Decreased Blood Volume
 THIRST mechanism
 ADH secretion is increased
 ANP secretion is decreased
 RENIN secretion is increased
 BARORECEPTOR vasoconstricton
 ALDOSTERONE secretion is
increased
Increased Blood Volume
 NO THIRST mechanism
 ADH secretion is decreased
 ANP secretion is increased
 RENIN secretion is increased
 BARORECEPTOR vasodilation
 ALDOSTERONE decreased
 ADH Regulation
 ADH is produced by the
Hypothalamus
 ADH is stored and
secreted by the
posterior pituitary gland
 With less water in the
plasma ADH is secreted,
to conserve water by
reducing urine output
 With fluid overload in
the plasma ADH
secretion stops, to
excrete fluid in the
 ADH Antidiuretic
Hormone

↓ H20 IN T HE P LAS MA ↑ H20 IN T HE PL ASMA

↓ ↓
↑ADH ↓ ADH

↓ ↓
↑ H20 RE ABS ORP TION ↓ H20 RE AB SORP TIO N
IN T HE KID NE YS IN T HE KIDN EYS
↓ ↓
↑ BLO OD VO LUME ↓ BLO OD VO LUME
 ADH Disorder
 SIADH
 Abnormally high ADH concentration
 urine output is reduced (oliguria)
 water retention (fluid overload)
 Urine SG is high (normal: 1.005 – 1.030)
 Hct is low (43-48%)
 DI
 Abnormally low ADH
 urine output is increased (polyuria)
 water loss (fluid deficit)
 Urine SG is low
 Hct is high
 ANP Atrial Natriuretic
Peptide

↓ H20 IN T HE P LAS MA ↑ H20 IN T HE PL ASMA

↓ ↓
↓ AN P ↑AN P
↓ ↓
↓ URIN E FORMAT ION ↑ URIN E F ORMAT ION
OLIG URI A POLYU RIA
↓ ↓
↑ BLO OD VO LUME ↓ BLOO D VO LUME
 Aldosterone

↓ H20 IN T HE P LAS MA
↓ ↑ H20 IN T HE PL ASMA

↑ ALDO STE RONE ↓

↓ ↓ ALDOS TERONE

↑ Na RE ABS ORP TIO N ↓

↑ SERUM Na ↑ Na and H20 E XC RE TION
H20 R ETENT ION
↓
↓ ↓ BLO OD VO LUME
↑ BLO OD VO LUME
 Aldosterone Disorders
 Addison’s Disease
 Abnormally low aldosterone
 Serum Na is low, serum potassium
is high
 FVD

 Cushing’s Disease
 Abnormally high aldosterone
 Serum Na is high, serum potassium
is low
 FVE
 Renin Angiotensin
Aldosterone
System
Stimulates JGA RENIN Angioten-
Dec RTP JGA Releases combines sinogen LIVER
RENIN

Increasing Stimulates ANGIO-

Na and H20 To release Adrenal TENSIN
in the Aldosterone Cortex 1
BLOOD

↑ BV
↑ BP
 Renin Angiotensin
Aldosterone
System
Stimulates JGA RENIN Angioten-
Dec RTP JGA Releases combines sinogen LIVER
RENIN

ANGIO-
TENSIN
1

↑ BV
↑ BP
BV ANGIO- Converted
CONSTRIC- LUNGS TENSIN To
TION 2
 Renin Angiotensin
Aldosterone
System
Stimulates JGA RENIN Angioten-
Dec RTP JGA Releases combines sinogen LIVER
RENIN

Increasing ANGIO-
To release Stimulates
Na and H20 TENSIN
Aldosterone Adrenal
in the Cortex 1
BLOOD
↑ BV
↑ BP
BV ANGIO- Converted
CONSTRIC- LUNGS TENSIN To
TION 2
 60% of Body Weight is
Water
Fluid Compartments:
1. ICF Intracellular Fluid = 40L
2. ECF Extracellular Fluid = 20L
IVF Intravascular Fluid = 5L
Arterial Fluid = 2L
Venous Fluid = 3L
ITF interstitial fluid = 15L

3. Transcellular Fluid
Pleural Fluid
Peritoneal Fluid
Pericardial Fluid
CSF
Distribution of Body
Weight
 Assessment of Fluid
Imbalance
1. ICF compartment (cells)
 FVE
 cellular edema = ↓LOC
 pulmonary edema = crackles (bibasilar)

 FVD
 cellular dehydration = Acid = Acidosis
 Assessment of Fluid
Imbalance
2. ITF compartment (skin)
 FVE
 skin = pitting edema
 feet (bipedal) = ANASARCA (periorbital
edema)
 FVD
 skin = poor skin turgor
 Assessment of Fluid
Imbalance
3. IVF compartment (blood
volume)
 FVE
 artery = ↑BP, pulse (rapid bounding)
 vein = ↑CVP, ↑PAWP

 FVD
 artery = ↓BP, pulse (rapid thready)
 vein = ↓CVP, ↓PAWP
 Assessment of Fluid
Imbalance
4. 3rd space
Pleural sac = Pleural
Effusion
Pericardial sac = Pericardial
Effusion
Peritoneal sac = Ascites
 Fluid status can be
assessed through:
 Mucus membrane
 Skin integrity
 Body weight
 Jugular vein
 BP, PAWP 6-12 mm Hg
 CVP (most accurate) 0-7 mm Hg or 5-10 cm
of H2O
 I&O
 Pulse
 Temperature
 Lung sound and heart sound
 Urine output
 Urine SG 1.005-1.030
 Hematocrit 48%
 Plasma osmolality

 Transport Mechanism
 Take note that fluids from
different compartments will
always move from one
compartment to another
compartment to maintain
balance.
 That movement is dictated by
the transport mechanism
principle.
PASSIVE
 Active Transport
 It is movement of particles from low
to high area of concentration, with
the help of ATP (energy)
EXAMPLE:
glucose
amino acids
potassium pump
 PISO “potassium in sodium out”
 Endocytosis = to the cells
 Exocytosis = out of the cells
 Passive Transport
 It is movement from high to low
area of concentration
 Dictated by pressure gradient
(DALTON’S LAW)
EXAMPLE:
Osmosis
Diffusion
Ultrafiltration
 Osmosis
 Movement of water from high to
low pressure in order to maintain
balance between compartments.
 Diffusion
 Movement of
solute from
high to low
concentratio
n in order to
maintain
balance
between
compartment
 Ultrafiltration
Dictated by COP and HP
 COP = colloidal osmotic pressure
(holds water)
 HP = hydrostatic pressure (water
pressure)
 EDEMA FORMATION:
1. Increased HP
Ex: CHF, CRF
2. Decreased COP
Ex: proteinuria, kwashiorkor,
marasmus
3. Lymphatic Obstruction
Ex: Filariasis, Hodgkin’s and
Non Hodgkins
 Types of Fluids
 Isotonic = increases BV
 Hypotonic = hydrates the cells
 Hypertonic = attracts water from
cells into the IV space
Isotonic Fluid
Hypotonic Fluid
Hypertonic Fluid
 Isotonic Example
 D5W - 5% Dextrose in water isotonic
(252 mOsm/L)
 10% Dextran 40 in 5% Dextrose
isotonic (252 mOsm/L)
 Ringer’s Solution isotonic (309
mOsm/L)
replaces K, Na, Cl. and Ca
does not contain lactate
 Lactated Ringer’s Solution isotonic
(273 mOsm/L)  
 NS - 0.9% NaCl isotonic (308mOsm/L)
replaces NaCl deficit
 Hypotonic Example
 5% dextrose is hypotonic relative
to extracellular fluid
 Half strength saline is a
hypotonic solution. It is
infrequently used by 1/2 NS
 0.45%NaCl hypotonic (154
mOsm/L)
 Hypertonic Example
 D10W - 10% Dextrose in water hypertonic
(505 mOsm/L)
 D10W - 20% Dextrose in water hypertonic
(1011 mOsm/L)
 D50W - 50% Dextrose in water hypertonic
(1700 mOsm/L)
 D5NS - 5% Dextrose & 0.9NaCl hypertonic
(559 mOsm/L)
 D10NS - 10% Dextrose & 0.9NaCl hypertonic
(812 mOsm/L)
 3%NS hypertonic (1026 mOsm/L)
 D5LR - 5% Dextrose in Lactated Ringers
hypertonic (524 mOsm/L
 FVD or Hypovolemia

 Isotonic fluid loss including

solutes
 Body’s compensation is to
↑ ADH and Aldosterone level,
OLIGURIA
↓ ANP atrial natriuretic peptide,
OLIGURIA
(produced from atrial muscle of
the heart)
 FVD
 Children and older patients are
vulnerable
 If not detected early it may lead
to hypovolemic shock
(most common type of shock)
 FVD
Due to:
 ECF loss
(abdominal surgery, DM, DI, diuretics,
laxative, ↑ sweating, fever, NGT,
vomiting/diarrhea)
 3rd space shifting
(acute intestinal obstruction, acute
peritonitis, burns during initial phase,
↓ COP)
 FVD
How FVD is treated?
 Look for the cause and manage
it.
(apply direct pressure if there is
bleeding)
 Replace lost fluids with fluids of
the same concentration
(NSS or LR followed by plasma
proteins)
 FVD
Fluid and hemodynamic derangements
↓ H2O:↑ solute = hyperosmolality →
sluggish blood flow → ↑ coagulation
→ thrombosis
 ↓ H2O:↑ RBC = ↑ hematocrit → easy
to coagulate (hemoconcentration)
 ↓ blood volume → ICF moves out from
the cell to ↑ blood volume = cellular
dehydration
 FVE or Hypervolemia
 Is an excess of isotonic fluid and
sodium in the ECF
 Body’s compensation is to
↓ ADH and Aldosterone level,
POLYURIA
↑ ANP atrial natriuretic peptide,
POLYURIA
(produced from atrial muscle of
the heart)
 Elderly and patients with kidney
or heart problems are prone to
 FVE
 ↑ H2O=↑ HP → cerebral edema →
↑ ICP and pulmonary edema →
respiratory arrest
 ↑ blood volume → venous
congestion → CHF
 ↑ H2O:↓ RBC → hemodilution or
pseudoanemia
FVE
Due to:
 Excessive intake of Na and H2O (diet,
IV replacement, blood or plasma
transfusion)
 ARF, CRF and CHF
 Liver Cirrhosis
 Nephrotic Syndrome
 Hyperaldosteronism
 SIADH
 Low intake of dietary CHON
 Remobilization of fluid after burn
treatment
(1ST PHASE)
 FVE
How FVE is treated?
 Look for the cause and manage it.
(restrict Na and H20 intake)
 Diuretics or dialysis if kidneys are not
working properly
 Morphine and NTG to dilate blood
vessels
 Dopamine & Dobutamine (diuresis
effect & ↑ CO)
 Digoxin for CHF (+inotropic, -
chronotropic)
 Mannitol for cerebral edema (monitor
 Related Disorders
 ARDS = intravascular fluid excess
 Cerebral Edema = swelling of the cells
 ARF/CRF = fluid accumulation
 Burns = IVF to outside from it VICE VERSA
 Blood Pooling = lower extremities
 3rd space fluid shift = burns
 Lymphatic vessel obstruction = Hodgkins
 CHF = blood pooling
 Portal Hypertension = congestion of
abdominal organs
 QUIZ
 1. ↑ ADH A. INCREASED URINE
 2. ↓ ADH B. DECREASED URINE
 3. ↑ ANP
 4. ↓ ANP
 5. ISOTONIC AXN A. HYDRATE
 6. HYPOTONIC AXN B. ↑ BV
 7. HYPERTONIC AXN C. ↓ EDEMA

 8. OSMOSIS A. USES ATP

 9. DIFFUSION B. WATER
 10. ACTIVE C. SOLUTES
 11. SPECIFIC TEST FOR FLUID
STATUS?
 12. ABNORMAL ACCUMULATION
OF FLUID IN THE PERITONEAL
CAVITY?
 13. TWO MAIN ACTIONS OF
DIGOXIN?
 14. MOVEMENT OF FLUID FROM
INTRAVASCULAR SPACE TO
TRANSCELLULAR SPACE IS
 EDEMA FORMATION:
16. HP increased or decreased?
17. COP increased or decreased?
 18. extravasated fluid from filtrate will be
collected initially by
A. lymphatic
B. venous
C. artery
D. all of the above
19. Cushings Disease
A. FVE
B. FVD
20. Addisons Disease
A. FVE
B. FVD
21. SIADH
a. Polyuria and FVE
b. Polyuria and FVD
c. Oliguria and FVE
d. oliguria and FVD
22. Diabetes Insipidus
a. Polyuria and FVE
b. Polyuria and FVD
c. Oliguria and FVE
d. oliguria and FVD
23. Isotonic will swell the cell?
True or false
24. Hypertonic will lead to cellular
edema?
True or false
25. Hypotonic will improve cellular
edema s/sx?
True or false
Tnk u Po…