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Movement of Fluids
Fluid compartments are separated by membranes that are freely permeable to water. Movement of fluids due to: Diffusion Osmotic pressure Active transport Hydrostatic pressure Reabsorption
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DIFFUSION
Solutes shift from an area of greater concentration to an area of higher concentration Passive process
OSMOSIS
Movement of fluid across membrane from a lower solute concentration to a higher solute concentration
Passive process
ACTIVE TRANSPORT
Solutes move from an area of lower concentration to an area of higher concentration
Process requires energy
Hydrostatic Pressure
Capillary filtration
Movement of fluid through capillaries results from blood pushing against walls of the capillary. It forces fluids and solutes through the capillary wall
REABSORPTION
Prevents too much fluid from leaving capillaries no matter how much hydrostatic static pressure is inside them
Non-electrolytes - Uncharged
Proteins (i.e. albumin), urea, glucose, O2, CO2
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Body fluids are: Electrically neutral Osmotically maintained Specific number of particles per volume of fluid
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TONICITY:
Isotonic A solution that has the same solute concentration as another solution to which its being compared i.e. sodium in blood vs. 0.9% NSS
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TONICITY:
Hypertonic - A solution that has a higher solute concentration than another solution to which its being compared Dextrose 5% in NSS
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TONICITY:
Hypotonic - A solution that has a lower solute concentration than another solution to which its being compared
0.45%NSS
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Balance
Fluid and electrolyte homeostasis is maintained in the body Neutral balance: input = output Positive balance: input > output Negative balance: input < output
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Skin (perspiration)
Lungs (respiration) GI Tract (feces)
(Smeltzer et al, 2008)
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Balancing Systems
Renal System (kidneys)
RF = difficulty maintaining fluid balance Na+ & K+ are either filtered or reabsorbed via the renal system
Balancing Systems
Antidiuretic Hormone (ADH)
Water-retaining hormone Hypothalamus senses low blood volume & increased serum osmolality; triggers its release from the pituitary gland Prompts kidneys to retain H2O Increases concentration of urine
Balancing Systems
Renin-Angiotensin-Aldoseterone System (RAAS)
Release of renin triggered by low pressures Angiotensin II potent vasoconstrictor and triggers the release of aldosterone from the adrenal cortex Aldosterone = fluid retention and secretion of K+; triggers the thirst center
Balancing Systems
Atrial Natriuretic Peptide (ANP)
Released when atrial pressures increase Opposes the RAAS (shuts it off) Key Functions of ANP:
Suppresses serum renin levels Decreases aldosterone release Increases glomerular filtration rate (excretion of Na+ and H2O) Decreases ADH release Decreases vascular resistance by causing vasodilation
Balancing Systems
Thirst Mechanism
Simplest mechanism in maintaining fluid balance Increases after even small fluid loss Increase in salty foods dries mucous membranes, which stimulates the thirst center in the hypothalamus
Hypovolemia
A decreased blood volume that may be caused by internal or external bleeding, fluid losses, or inadequate fluid intake. (Tabers Online Dictionary, 2007)
A.K.A. Fluid Volume Deficit (FVD) or Extracellular Fluid Volume Deficit (ECFVD)
Hypovolemia
FVD occurs when the loss of ECF exceeds the intake of fluid. (Smeltzer et al, 2008)
Hypovolemia
Signs & Symptoms Weight Loss Decreased Skin Turgor Oliguria Concentrate Urine Postural Hypotension Weak, rapid pulse Flattened Neck Veins Signs & Symptoms Increased Temp Cool, clammy skin Thirst Anorexia Nausea Muscle Weakness Muscle Cramps
Hypovolemia
Treatment:
Infusion of Isotonic IV solutions for hypotensive patients Infusion of Hypotonic IV solutions for normotensive patients Hypovolemia d/t blood loss blood transfusion
Hypervolemia
ECF H2O gain is balanced with retention of sodium Usually secondary to retention of sodium
Concentration of sodium to H2O is balanced serum sodium levels usually WNL A.K.A. Extracellular Fluid Volume Excess (ECFVE)
Hypervolemia
Hormonal Imbalances - ADH Can occur secondary to heart failure, renal failure, or cirrhosis of liver Fluid overload related to administration of excessive IV fluids Dietary: Excessive sodium intake
Hypervolemia
Signs & Symptoms
JVD Edema Crackles Tachycardia Elevated B/P Weight Gain Increased Urine Output SOB/Wheezing
Hypervolemia
Treatment:
Treat the underlying cause!!!
Renal Failure dialysis Heart Failure diuretics, etc. Dietary low-salt diet and/or fluid restriction Discontinuation of IV infusions
Kidney Dysfunction
Permanent fluid shift from intravascular space to interstitial space Nonfunctional fluid shift & physiologically useless
ELECTROLYTES
ELECTROLYTES
Compounds, that when placed in a solution, conduct an electric current and emit dissociated particles of electrolytes (ions) that carry either a positive charge (cation) or negative charge (anion)
(Kee & Paulanka, 2000, p. 42)
ELECTROLYTES
Na+ & Cl- ECF K+ ICF Mg+ = ICF
ELECTROLYTES
Terms:
Potassium
Potassium
Potassium is gained by intake and lost by excretion. If either is altered, hyperkalemia or hypokalemia may result! Regulated by aldosterone and insulin
Potassium
Potassium levels directly affect cell, nerve, & muscle function:
Maintains the electrical neutrality and osmolality of cells Aids in neuromuscular transmission of nerve impulses Assists skeletal and cardiac muscle
Potassium
Hypokalemia
Levels < 3.5 Mildly Low Levels usually asymptomatic
If level < 3.2, usually accompanied by symptoms
Hypokalemia
Causes of Hypokalemia: Increased Urine Output Malnutrition Vomiting and/or Diarrhea Hypomagnesemia DKA
Hypokalemia
May be a result of acid-base imbalances = alkalosis In alkalosis, potassium moves into the cell to maintain balance, which may lead to hypokalemia
Treatment
Oral or IV Potassium Chloride Replacement D/C or adjust medications that may cause hypokalemia Reverse alkalosis, if cause Monitor closely for arrhythmias Monitor Respiratory Status Monitor LOC Monitor GI symptoms
Hyperkalemia
Levels > 5.1 Mildly elevated levels usually asymptomatic
Hyperkalemia
Causes of Hyperkalemia: Renal Failure Meds (ACEIs, ARBs, K+ sparing diuretics, NSAIDs) Addisons Disease Aldosterone Insufficiencies Dig Overdose Beta-Blocker Therapy
Hyperkalemia
May be a result of acid-base imbalances = acidosis In acidosis, excess hydrogen ions move into cells and push potassium into ECF, which may lead to hyperkalemia as potassium moves out of the cell to maintain balance.
Treatment
Medications:
Cation-exchange resins (bind with K+ and excreted via feces) IVP insulin and glucose (K+ binds to insulin) IV Ca++ (protect the heart from the effects of hyperkalemia) Sodium bicarbonate (to reverse acidosis) Diuretics (non-K+ sparing) Beta2 Adrenergic agonists (epinephrine, albuterol)
D/C meds that may cause hyperkalemia Restrict foods with K+ Dialysis for renal failure Monitor closely for arrhythmias Monitor Blood Pressure Monitor GI symptoms
Sodium
Sodium
Accounts for 90% of ECF cations Almost all Na+ is found in ECF; 10% in ICF Na+ attracts fluid and helps preserve ECF volume and fluid distribution Na+ helps transmit impulses in nerve and muscle fibers and combines w/ Clabd HCO3 to regular acid-base balance
Sodium
Excreted mainly via the kindeys (GU)
Also via the GI tract and perspiration
Increased Na+ levels trigger thirst and the ADH Sodium-Potassium pump helps maintain normal Na+ levels
Pump also creates an electrical charge for both cardiac and neuromuscular function
Sodium
Hyponatremia
Hyponatremia
Signs & Symptoms:
Nausea/Vomiting Headache Malaise Confusion Diminished Reflexes Confusion Convulsions Stupor or Coma
Hyponatremia
Causes of Hyponatremia: Vasopressin/ADH SIADH Adrenal Insufficiency Diuretics Hypervolemia Liver Failure Heart Failure
Treatment
Administration of oral or IV Na+ (3%) Supplements Encourage foods high in Na+ Fluid restriction Monitor Neuro Status Monitor for Arrhythmias Normovolemic hyponatremia
Vaprisol (conivaptan) IV infusion Samsca (tolvaptan) - PO
Hypernatremia
Causes
Dehydration/Hypovolemia Diabetes Insipidus Ingestion of Hypertonic Solutions IV Infusion of Hypertonic Solutions Cushings Syndrome Hyperaldosteronism Loss of pure water
(excessive sweating or respiratory infections)
Treatment
Administration of IV Fluids
(Isotonic Salt-Free)
Encourage foods low in Na+ Push P.O. Fluids Monitor Neuro Status Monitor for Arrhythmias
Magnesium
Magnesium
2nd most abundant ICF cation (K+ #1) 60% Mg+ found in bones, < 1% ECF Mg+ performs the following functions:
Promotes enzyme reactions in carbohydrate metabolism Helps produce ADP (adenosine triphosphate) Helps with protein synthesis Influences vasodilation (normal CV function) Helps Na+ and K+ ions cross cell membranes
Magnesium
Mg+ performs the following functions:
Regulates muscle contractions Affects irritability and contractility of
Magnesium
Hypomagnesemia
Results in cardiac dysrhythmias and irritates the nervous system (tetany)
Hypomagnesemia
Causes of Hypomagnesia: Malnutrition Chronic Diarrhea Malabsorption ETOH Abuse Diuretics AMI Pancreatitis
Hypomagnesemia
Does not produce specific EKG changes May contribute to arrhythmias caused by digoxin toxicity, ischemia, or potassium imbalances
Hypomagnesemia
Replacement of Mg PO or IV PO = Mg Oxide 400mg tabs
Hypomagnesia
Monitor
Monitor EKG for Arrhythmias Monitor for muscle cramps
Hypermagnesemia
Severe hypermagnesemia is associated with AV blocks and intraventricular conduction disturbances
Calcium
Calcium
99% Ca++ in bones; 1% in serum & soft tissue (measured in blood serum levels) Is found in both ECF and ICF Can be measured in 2 ways:
Total serum calcium (total Ca++in blood) Ionized calcium level (various forms of Ca++ in ECF)
41% ECF Ca++ is bound to protein; 9% bound to citrate or other organic ions
Calcium
Ca++ functions in the following ways:
Responsible for formation of bones and teeth Helps maintain cell structure & function Plays a role in cell membrane permeability and
impulse transmission Affects contraction of cardiac muscle, smooth muscle, and skeletal muscle Participates in blood-clotting process
Calcium
Calcium helps potassium & sodium move into and out cells in the sodiumpotassium pump mechanism
Hypocalcemia
Causes:
Vitamin D Deficiency
Vitamin D promotes Ca++ absorption in intestines, resorption from bones, and kidney resorption all of which raise Ca++ levels
Hypocalcemia
Causes:
Deficiency of parathyroid hormone (PTH)
Calcitonin, secreted by PTH, helps regulate Ca++ Decreases absorption of Ca++ and enhances its excretion by the kidneys
Hypocalcemia
Hypocalcemia May Cause
Laryngospasm Cardiac Arrhythmias EKG s prolonged QT interval
Hypocalcemia
Management
PO or IV calcium replacement (depends on severity of symptoms or deficiency)
Vitamin D supplement
Encourage foods high in calcium
Hypercalcemia
Causes of Hypercalcemia:
Excessive calcium release Increased intestinal calcium absorption
Hypercalcemia
Hypercalcemia May Cause Cardiac Arrhythmias EKG s shortened QT interval
Hypercalcemia
Severe Hypercalcemia (> 15mg/dl) is a
Medical Emergency
May result in Coma or Cardiac Arrest
Hypercalcemia
Signs & Symptoms
Fatigue Depression Confusion Anorexia N/V Constipation Pancreatitis Increased Urination
Hypercalcemia
Treatment
Hydration Increased Salt Intake Diuretics Dialysis (renal failure) Glucocorticoids
Renal Function
Renal Function
The main function of the renal system is to excrete biowaste, regulate water and electrolyte levels, and release of hormones that affect RBC production, bone metabolism, and hypertension.
Renal Function
Minimal urine output = 30 ml/hr Output affected by fluid intake, hormones, & medications Renal impairment causes imbalances of both fluids and electrolytes
If BUN (up to 35 mg/dl) but the creatinine is WNL = DEHYDRATION Usually as a result of Diarrhea, vomiting, and/or inadequate fluid intake
BUN WNL after hydration. If not, may indicate pre-renal or renal failure
Creatinine
Reference Range: 0.8 1.3 mg/dl A by-product of muscle catabolism
Creatinine
Reference Range: 0.7 1.5 mg/dl If creatinine (> 2.5 mg/dl) this could be indicative of renal impairment IF both BUN and creatinine are elevated, then renal disorder is present
BUN/Creatinine Ratio
Reference Range: 10 - 20 Low Suspect acute tubular necrosis, malnutrition, low protein intake, pregnancy, liver disease, hemodialysis High Reduced renal perfusion (dehydration, heart failure), glomerular disease, tissue or muscle destruction, high protein intake, azotemia (elevated urea levels)
References
Kee, J. L. (2005). Laboratory and diagnostic tests with nursing implications (7th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Kee, J. L. & Paulanka, B. J. (2000). Handbook of fluid, electrolyte, and acid-base imbalances. Scarborough, Canada: Delmar Publishers. Priff, N. (ed.). (2006). Nurses quick check: Fluids and electrolytes. Ambler, PA: Lippincott, Wilkins, and Williams.
Smeltzer, S. C. et al. (2008). Brunner and suddarths textbook of medical-surgical nursing (11th ed.). Philadelphia, PA: Lippincott Williams and Wilkins. Tabers On-Line Medical Dictionary