ABNNORMALITIES OF WATER BALANCE

Water Balance Water balance refers to the balance between the amount of water consumed and the amount of water excreted. The body's water content needs to be constant for optimal functioning. Cells are bathed in interstitial fluids (fluids from between cells) that contain nutrients. These fluids also carry metabolic wastes away from the cells. Intracellular fluids facilitate chemical reactions inside the cells, and they help maintain cell structure by adhering to the cell's larger molecules, such as proteins and glycogen . Body fluids contain solutes (chemical compounds that are soluble in water), which separate into charged particles, or ions, when dissolved in water. Intracellular fluids are high in potassium and phosphate ions, while interstitial fluids are high in sodium and chloride ions. These ions help to maintain the amount of fluids both within and outside the cells. Water molecules follow the solutes moving across cell membranes from a lower to higher solute concentration to maintain homeostasis.

Water facilitates a number of critical body functions, from lubricating joints to carrying away cellular waste. Physical activity speeds fluid loss via perspiration. Athletes who do not drink enough water can easily become dehydrated, which can impair physical and mental functioning. Here, soccer star David Beckham drinks from a water bottle during a practice session. [AP/Wide World Photos. Reproduced by permission.] Overhydration

Definition
Overhydration, also called water excess or water intoxication, is a condition in which the body contains too much water.

Description
Overhydration occurs when the body takes in more water than it excretes and its normal sodium level is diluted. This can result in digestive problems, behavioral changes, brain damage, seizures, or coma. An adult whose heart, kidneys, and pituitary gland are functioning properly would have to drink more than two gallons of water a day to develop water intoxication. This condition is most common in patients whose kidney function is impaired and may occur when doctors, nurses, or other healthcare professionals administer greater amounts of water-producing fluids and medications than the patient's body can excrete. Overhydration is the most common electrolyte imbalance in hospitals, occurring in about 2% of all patients. Infants seem to be at greater risk for developing overhydration. The Centers for Disease Control and Prevention has declared that babies are especially susceptible to oral overhydration during the first month of life, when the kidneys' filtering mechanism is too immature to excrete fluid as rapidly as older infants do. Breast milk or formula provide all the fluids a healthy baby needs. Water should be given slowly, sparingly, and only during extremely hot weather. Overhydration,

which has been cited as a hazard of infant swimming lessons, occurs whenever a baby drinks too much water, excretes too little fluid, or consumes and retains too much water.

Causes and symptoms

Drinking too much water rarely causes overhydration when the body's systems are working normally. People with heart, kidney, or liver disease are more likely to develop overhydration because their kidneys are unable to excrete water normally. It may be necessary for people with these disorders to restrict the amount of water they drink and/or adjust the amount of salt in their diets. Since the brain is the organ most susceptible to overhydration, a change in behavior is usually the first symptom of water intoxication. The patient may become confused, drowsy, or inattentive. Shouting and delirium are common. Other symptoms of overhydration may include blurred vision, muscle cramps and twitching, paralysis on one side of the body, poor coordination, nausea and vomiting, rapid breathing, sudden weight gain, and weakness. The patient's complexion is normal or flushed. Blood pressure is sometimes higher than normal, but elevations may not be noticed even when the degree of water intoxication is serious. Overhydration can cause acidosis (a condition in which blood and body tissues have an abnormally high acid content), anemia, cyanosis (a condition that occurs when oxygen levels in the blood drop sharply), hemorrhage, and shock. The brain is the organ most vulnerable to the effects of overhydration. If excess fluid levels accumulate gradually, the brain may be able to adapt to them and the patient will have only a few symptoms. If the condition develops rapidly, confusion, seizures, and coma are likely to occur. Risk factors Chronic illness, malnutrition, a tendency to retain water, and kidney diseases and disorders increase the likelihood of becoming overhydrated. Infants and the elderly seem to be at increased risk for overhydration, as are people with certain mental disorders or alcoholism.

Diagnosis
Before treatment can begin, a doctor must determine whether a patient's symptoms are due to overhydration, in which excess water is found within and outside cells, or excess blood volume, in which high sodium levels prevent the body from storing excess water inside the cells. Overhydration is characterized by excess water both within and around the body's cells, while excess blood volume occurs when the body has too much sodium and can not move water to reservoirs within the cells. In cases of overhydration, symptoms of fluid accumulation do not usually occur. On the other hand, in cases of excess blood volume, fluid tends to accumulate around cells in the lower legs, abdomen, and chest. Overhydration can occur alone or in conjunction with excess blood volume, and differentiating between these two conditions may be difficult.

Treatment

Mild overhydration can generally be corrected by following a doctor's instructions to limit fluid intake. In more serious cases, diuretics may be prescribed to increase urination, although these drugs tend to be most effective in the treatment of excess blood volume. Identifying and treating any underlying condition (such as impaired heart or kidney function) is a priority, and fluid restrictions are a critical component of every treatment plan. In patients with severe neurologic symptoms, fluid imbalances must be corrected without delay. A powerful diuretic and fluids to restore normal sodium concentrations are administered rapidly at first. When the patient has absorbed 50% of the therapeutic substances, blood levels are measured. Therapy is continued at a more moderate pace in order to prevent brain damage as a result of sudden changes in blood chemistry.

Prognosis
Mild water intoxication is usually corrected by drinking less than a quart of water a day for several days. Untreated water intoxication can be fatal, but this outcome is quite rare. Dehydration

Definition
Dehydration is the loss of water and salts essential for normal body function.

Description
Dehydration occurs when the body loses more fluid than it takes in. This condition can result from illness; a hot, dry climate; prolonged exposure to sun or high temperatures; not drinking enough water; and overuse of diuretics or other medications that increase urination. Dehydration can upset the delicate fluid-salt balance needed to maintain healthy cells and tissues. Water accounts for about 60% of a man's body weight. It represents about 50% of a woman's weight. Young and middle-aged adults who drink when they're thirsty do not generally have to do anything more to maintain their body's fluid balance. Children need more water because they expend more energy, but most children who drink when they are thirsty get as much water as their systems require. Age and dehydration Adults over the age of 60 who drink only when they are thirsty probably get only about 90% of the fluid they need. Developing a habit of drinking only in response to the body's thirst signals raises an older person's risk of becoming dehydrated. Seniors who have relocated to areas where the weather is warmer or dryer than the climate they are accustomed to are even likelier to become dehydrated unless they make it a practice to drink even when they are not thirsty. Dehydration in children usually results from losing large amounts of fluid and not drinking enough water to replace the loss. This condition generally occurs in children who have stomach flu characterized by vomiting and diarrhea, or who can not or will not take enough fluids to compensate for excessive losses associated with fever and sweating of acute illness. An infant

can become dehydrated only hours after becoming ill. Dehydration is a major cause of infant illness and death throughout the world. Types of dehydration Mild dehydration is the loss of no more than 5% of the body's fluid. Loss of 5-10% is considered moderate dehydration. Severe dehydration (loss of 10-15% of body fluids) is a life-threatening condition that requires immediate medical care. Complications of dehydration When the body's fluid supply is severely depleted, hypovolemic shock is likely to occur. This condition, which is also called physical collapse, is characterized by pale, cool, clammy skin; rapid heartbeat; and shallow breathing. Blood pressure sometimes drops so low it can not be measured, and skin at the knees and elbows may become blotchy. Anxiety, restlessness, and thirst increase. After the patient's temperature reaches 107 F (41.7 C) damage to the brain and other vital organs occurs quickly.

Causes and symptoms

Strenuous activity, excessive sweating, high fever, and prolonged vomiting or diarrhea are common causes of dehydration. So are staying in the sun too long, not drinking enough fluids, and visiting or moving to a warm region where it doesn't often rain. Alcohol, caffeine, and diuretics or other medications that increase the amount of fluid excreted can cause dehydration. Reduced fluid intake can be a result of:
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appetite loss associated with acute illness excessive urination (polyuria) nausea bacterial or viral infection or inflammation of the pharynx (pharyngitis) inflammation of the mouth caused by illness, infection, irritation, or vitamin deficiency (stomatitis)

Other conditions that can lead to dehydration include:

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disease of the adrenal glands, which regulate the body's water and salt balance and the function of many organ systems diabetes mellitus eating disorders kidney disease chronic lung disease.

An infant who does not wet a diaper in an eight-hour period is dehydrated. The soft spot on the baby's head (fontanel) may be depressed. Symptoms of dehydration at any age include cracked lips, dry or sticky mouth, lethargy, and sunken eyes. A person who is dehydrated cries without

shedding tears and does not urinate very often. The skin is less elastic than it should be and is slow to return to its normal position after being pinched. Dehydration can cause confusion, constipation, discomfort, drowsiness, fever, and thirst. The skin turns pale and cold, the mucous membranes lining the mouth and nose lose their natural moisture. The pulse sometimes races and breathing becomes rapid. Significant fluid loss can cause serious neurological problems.

Diagnosis
The patient's symptoms and medical history usually suggest dehydration. Physical examination may reveal shock, rapid heart rate, and/or low blood pressure. Laboratory tests, including blood tests (to check electrolyte levels) and urine tests (e.g., urine specific gravity and creatinine), are used to evaluate the severity of the problem. Other laboratory tests may be ordered to determine the underlying condition (such as diabetes or an adrenal gland disorder) causing the dehydration.

Treatment
Increased fluid intake and replacement of lost electrolytes are usually sufficient to restore fluid balances in patients who are mildly or moderately dehydrated. For individuals who are mildly dehydrated, just drinking plain water may be all the treatment that is needed. Adults who need to replace lost electrolytes may drink sports beverages (e.g., Gatorade or Recharge) or consume a little additional salt. Parents should follow label instructions when giving children Pedialyte or other commercial products recommended to relieve dehydration. Children who are dehydrated should receive only clear fluids for the first 24 hours. A child who is vomiting should sip one or two teaspoons of liquid every 10 minutes. A child who is less than a year old and who is not vomiting should be given one tablespoon of liquid every 20 minutes. A child who is more than one year old and who is not vomiting should take two tablespoons of liquid every 30 minutes. A baby who is being breast-fed should be given clear liquids for two consecutive feedings before breastfeeding is resumed. A bottle-fed baby should be given formula diluted to half its strength for the first 24 hours after developing symptoms of dehydration. In order to accurately calculate fluid loss, it's important to chart weight changes every day and keep a record of how many times a patient vomits or has diarrhea. Parents should note how many times a baby's diaper must be changed. Children and adults can gradually return to their normal diet after they have stopped vomiting and no longer have diarrhea. Bland foods should be reintroduced first, with other foods added as the digestive system is able to tolerate them. Milk, ice cream, cheese, and butter should not be eaten until 72 hours after symptoms have disappeared. Medical care Severe dehydration can require hospitalization and intravenous fluid replacement. If an individual's blood pressure drops enough to cause or threaten the development of shock, medical treatment is usually required. A doctor should be notified whenever an infant or child exhibits signs of dehydration or a parent is concerned that a stomach virus or other acute illness may lead to dehydration.

a doctor should also be notified if:

y y y y y y

a child less than three months old develops a fever higher than 100 F (37.8 C) a child more than three months old develops a fever higher than 102 F (38.9 C) symptoms of dehydration worsen an individual urinates very sparingly or does not urinate at all during a six-hour period dizziness, listlessness, or excessive thirst occur a person who is dieting and using diuretics loses more than 3 lb (1.3 kg) in a day or more than 5 lb (2.3 kg) a week

When treating dehydration, the underlying cause must also be addressed. For example, if dehydration is caused by vomiting or diarrhea, medications may be prescribed to resolve these symptoms. Patients who are dehydrated due to diabetes, kidney disease, or adrenal gland disorders must receive treatment for these conditions as well as for the resulting dehydration.

Alternative treatment
Gelatin water can be substituted for electrolyte-replacement solutions. It is made by diluting a 3oz package in a quart of water or by adding one-quarter teaspoon of salt and a tablespoon of sugar to a pint of water.

Prognosis
Mild dehydration rarely results in complications. If the cause is eliminated and lost fluid is replaced, mild dehydration can usually be cured in 24-48 hours. Vomiting and diarrhea that continue for several days without adequate fluid replacement can be fatal. The risk of life-threatening complications is greater for young children and the elderly. However, dehydration that is rapidly recognized and treated has a good outcome.

Prevention
Patients who are vomiting or who have diarrhea can prevent dehydration by drinking enough fluid for their urine to remain the color of pale straw. Ensuring that patients always drink adequate fluids during an illness will help prevent dehydration. Infants and young children with diarrhea and vomiting can be given electrolyte solutions such as Pedialyte to help prevent dehydration. People who are not ill can maintain proper fluid balance by drinking several glasses of water before going outside on a hot day. It is also a good idea to avoid coffee and tea, which increase body temperature and water loss. Patients should know whether any medication they are taking can cause dehydration and should get prompt medical care to correct any underlying condition that increases the risk of dehydration. Other methods of preventing dehydration and ensuring adequate fluid intake include:
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eating more soup at mealtime drinking plenty of water and juice at mealtime and between meals keeping a glass of water nearby when working or relaxing

ELECTROLYTE BALANCE

Electrolyte balance refers to the combined levels of the different electrolytes found in the blood. An electrolyte is a substance with free ions that conduct electrical signals. The appropriate balance of these substances in the body is critical to regulating everything from oxygen delivery to fluid balance within the cells. An imbalance in electrolytes can be caused by reduced elimination of water or excessive intake of electrolytes. This is most often tied to dehydration or excessive hydration. The effects are noticed when the level of sodium, potassium, or calcium in the body is too high or too low. In a healthy person, it is not difficult to maintain the proper electrolyte balance, through regular hydration and elimination. Seniors, children and people with complex medical illnesses are at greatest risk for poor electrolyte balance as a long-term health concern.

Electrolyte disturbance
Electrolytes play a vital role in maintaining homeostasis within the body. They help to regulate myocardial and neurological function, fluid balance, oxygen delivery, acid-base balance and much more. Electrolyte imbalances can develop by the following mechanisms: excessive ingestion or diminished elimination of an electrolyte or diminished ingestion or excessive elimination of an electrolyte. The most common cause of electrolyte disturbances is renal failure. The most serious electrolyte disturbances involve abnormalities in the levels of sodium, potassium, and/or calcium. Other electrolyte imbalances are less common, and often occur in conjunction with major electrolyte changes. Chronic laxative abuse or severe diarrhea or vomiting can lead to electrolyte disturbances along with dehydration. People suffering from bulimia or anorexia are at especially high risk for an electrolyte imbalance.

Table of common electrolyte disturbances

Electrolyte Sodium Potassium Calcium Magnesium Chloride Ionic formula Na+ K+ Ca2+ Mg2+ ClElevation disorder hypernatremia hyperkalemia hypercalcemia hypermagnesemia hyperchloremia Depletion disorder hyponatremia hypokalemia hypocalcemia hypomagnesemia hypochloremia

Phosphate Bicarbonate

PO43HCO3-

hyperphosphatemia

hypophosphatemia

hyperbicarbonatemia hypobicarbonatemia

Electrolyte Abnormalities and ECG Changes

The most notable feature of hyperkalemia is the "tent shaped" or "peaked" T wave. Delayed ventricular depolarization leads to a widened QRS complex and the P wave becomes wider and flatter. When hyperkalemia becomes severe, the ECG resembles a sine wave as the P wave disappears from view. In contrast, hypokalemia is associated with flattenting of the T wave and the appearance of a U wave. When untreated, hypokalemia may lead severe arrhythmias. The fast ventricular depolarization and repolarization associated with hypercalcemia lead to a characteristic shortening of the QT interval. Hypocalcemia has the opposite effect, lengthening the QT interval.