2. Objectives
At the end of this lecture the students will acquainted to;
Body fluid distribution, regulation of fluids in body compartments
Discuss the types of fluid i.e. Hypotonic , hypertonic & isotonic
Explain the fluid volume deficit , S/S , diagnosis & intervention .
Discuss fluid volume excess , S/S, diagnosis & intervention
Discuss about the following disorders;
Hyponatremia & Hypernatremia and its management
Hypokalemia & Hyperkalemia and its management
Hypocalcemia & Hypercalcemia and its management
Hypomagnesemia & Hypermagnesemia and its management.
Hypophosphatemia & hyperphosphatemia .
2
3. 3
All chemical reactions occur in liquid medium
It is crucial in regulating chemical and bioelectrical
distributions within the cells.
Transports substances such as hormones and nutrients
O2 transport from lungs to body cells.
CO2 transport in the opposite direction.
Dilutes toxic substances and waste products and transports them
to the kidneys and liver.
Distributes heat around the body
Why We Need to Drink Water
4. 4
Where does all this water go…..
Water constitutes an average 50 – 70 % of the total body
weight;
Young males – 60% of total body weight
Older males – 52%
Young females – 50% of total body weight
Older females – 47%
Variation of + 15% in both groups is normal
Obese have 25 to 30% less body water than lean people.
Infants 75 – 80%
• Gradual physiological loss of body water
• 65% at one year of age
6. 6
Functional components of the body
fluid
The water of the body is divided in to 2 functional components (TBW – 60% into 3
Intracellular fluid – 40%of
the body Weight
Extracellular fluid – 20% of
the body weight
Extra vascular & interstitial
fluid 15%of BW
Intra vascular 5%
of BW
Rapidly equilibrating/functional
component 13 – 14% of BW
Slowly equilibrating /non-functional
Component 1 – 2 % BW
1. Connective tissue water
2. Transcellular fluid e.g. CSF, Joint fluid
7. 7
Total Body weight
(Female)
Total Body weight
(Male)
45%
Solids
55%
Fluids
40%
Solids
60%
Fluids
2/3 Intracellular
Fluid (ICF)
1/3 Extracellular
Fluid (ECF)
80% Interstitial
20% Plasma
8. 8
Water is the universal solvent
Solutes
Electrolytes - inorganic salts, all acids and bases, and some
proteins.
Non – electrolytes – most non electrolytes are organic
molecules- glucose, lipids, creatinine and urea
Electrolytes have greater osmotic power than non electrolytes
Water moves according to osmotic gradients
Composition of body fluids
9. 9
1/3 of body fluid
Comprised of 3 major components
Intravascular:
Plasma
Interstitial:
Fluid in and around tissues spaces
Transcellular:
Passing from one cell to another, through adjacent cell membranes.
(total body water contained within epithelial lined spaces, is about
2.5% of the total body water) fluid within epithelium-lined spaces.
It includes cerebrospinal fluid (CSF), gastrointestinal fluids, urine
in the bladder, aqueous humor, and joint fluid
Extracellular (ECF)
11. Cont…
Intravascular Component
Plasma
Fluid portion of blood
Made of:
Water
Plasma Proteins
Small amount of other substances
11
12. Interstitial component
Made up of fluid between cells
Surrounds cells
Transport medium for nutrients, gases, waste products
and other substances between blood and body cells
Back-up fluid reservoir
12
Cont…
13. Cont…
Transcellular component
Located in joints, connective tissue, bones, body cavities, CSF,
and other tissues.
Potential to increase significantly in abnormal conditions.
13
14. 14
Body control systems regulate ingestion and excretion:
Constant total body water
Constant total body osmolarity
Homeostatic mechanisms respond to changes in ECF
Osmolarity is identical in all body fluid compartments
(steady state condition)
Body water will redistribute itself as necessary to
accomplish this
Principles of body water distribution
16. 16
Homeostasis means the constancy of the internal environment
by the coordinated activities of all the systems of the body.
The working systems include;
1. Respiratory system
2. Excretory system
3. Digestive system
4. Circulatory system
5. Nervous and endocrine systems
The amount of water we drink is regulated by homeostasis;
1. Output = intake
2. Thirst & satiety
3. Hormonal regulation
Cont…
18. 18
Causes of Hyper and Hypo
volemia
Hypervolemia Hypovolemia
Excessive infusion of intravenous fluids Vomiting, diarrhea , fistulae
Retention of water in abnormal conditions
such as cardiac, renal and hepatic failure
When the patient is febrile; fluid loss
increases by 12% with every centigrade
rise in temperature
Absorption of water as during
transurethral resection of prostate using
distilled water
Sequestration of fluid in third
space/interstitial space
Hemorrhage
21. 21
Serum electrolytes
Treat the cause
Regulation of water and salt
Diuretics or dialysis: to remove excess of water in case of
hypervolemia
Management
22. 22
Signs and symptoms of
hyponatremia
o Nausea and vomiting.
o Headache.
o Confusion.
o Loss of energy and fatigue.
o Restlessness and irritability.
o Muscle weakness, spasms or cramps.
o Seizures.
o Coma.
Signs and symptoms of
hypernatremia
o Early symptoms may include a Strong
Feeling of
•Thirst,
•Weakness,
•Nausea,
•Loss of appetite.
o Severe symptoms include confusion,
muscle twitching, and bleeding in or
around the brain.
23. 23
Etiology and management of
hypernatremia
Hypernatremia Etiology Treatment
Hypervolemic Administration of
hypertonic sodium –
containing solution .
Minerolocorticoid excess
Diuretics
Isovolemic Insensible skin and
respiratory loss diabetes
insipidus
Water replacement
Hypovolemic Renal losses.
Gastrointestinal losses,
respiratory losses, profuse
sweating, adrenal
deficiencies
Isotonic Na Cl, then
hypotonic saline
24. 24
Imbalance of potassium
Imbalances of chloride
Imbalances of magnesium
Imbalance of composition
25. 25
Major cation in intracellular compartments
Regulates metabolic activities , necessary for glycogen deposits
in liver and skeletal muscle, transmission and conduction of
nerve impulses, normal cardiac conduction and skeletal and
smooth muscle contraction.
Regulated by dietary intake and renal excretion
Normal level – 3.5 – 5.5 meq /l
Body conserves potassium poorly
Increased urine output decreases serum K
Imbalances in levels of potassium
27. Osmoreceptors
A receptor in the central nervous system (probably the
hypothalamus) that responds to changes in the osmotic pressure
of the blood.
Baroreceptor
A receptor sensitive to changes in pressure, a sensory nerve
ending especially in the walls of large arteries (such as the
carotid sinus) that is sensitive to changes in blood pressure.
27
28. Chemoreceptor
Chemoreceptor detect the levels of carbon dioxide in the blood
by monitoring the concentrations of hydrogen ions in the
blood.
Central chemoreceptors, located on the ventral surface of medulla
oblongata, detect changes in pH of cerebrospinal fluid.
Peripheral chemoreceptors act mostly to detect variation of the
oxygen in the arterial blood, in addition to detecting arterial
carbon dioxide and Ph.
28
29. Regulation of Body Fluid Volume
Hypervolemia excess fluid
volume
Hypovolemia Deficient fluid
volume
Inhibit Stimulation
ADH release
Inhibited
Aldosterone
release Inhibited
Thirst
Inhibited
Contribute to
Increased urination of dilute
urine
Normal fluid volume restored
Aldosterone release
Stimulated
ADH release
Stimulated
Thirst
Stimulated
Contribute to
Decreased urination of
concentrated urine
29
30. Regulation of Fluids in
Compartments
Osmosis
Movement of water through a selectively permeable membrane from an
area of low solute concentration to a higher concentration until equilibrium
occurs.
Movement occurs until near equal concentration found
Passive process
30
33. Osmosis versus Diffusion
Osmosis
Low to high
Water potential
Diffusion
High to low
Movement of particles
Both can occur at the same time
33
34. Isotonic Solution
Isotonic: The concentration of solutes in the solution is equal to the
concentration of solutes inside the cell.
Result: Water moves equally in both directions and the cell remains same
size! (Dynamic Equilibrium)
34
35. Hypotonic Solution
Hypotonic: The solution has a lower concentration of solutes and a
higher concentration of water than inside the cell. (Low solute;
High water)
Result: Water moves from the solution to inside the cell): Cell Swells and bursts
open (cytolysis)!
35
36. Hypertonic Solution
Hypertonic: The solution has a higher concentration of solutes and a lower
concentration of water than inside the cell. (High solute; Low water)
Result: Water moves from inside the cell into the solution: Cell
shrinks (Plasmolysis)!
Shrinks
36
37. Regulation of Fluids
Active Transport
Allows molecules to move against concentration and osmotic
pressure to areas of higher concentration
Active process – energy is expended
37
38. Active Transport
Na / K pump
Exchange of Na ions for K ions
3 Na ions move out of cell
2 potassium ions move into the cell
More water pulled into cell when sodium enters
Water passively follows the sodium
ECF / ICF balance is maintained
38
39. Fluid Volume Shifts
Fluid normally shifts between intracellular and extracellular
compartments to maintain equilibrium between spaces.
Fluid not lost from body but not available for use in either
compartment – considered third-space fluid shift (“third-
spacing”) are called (transcellular fluid).
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40. Causes of Third-Spacing
Burns
Peritonitis
Bowel obstruction
Massive bleeding into joint or cavity
Liver or renal failure
Lowered plasma proteins
Increased capillary permeability
Lymphatic blockage
40
41. Fluid volume deficit
Hypovolemia
Abnormally low volume of body fluid in intravascular and/or
interstitial compartments.
Causes
o Vomiting
o Diarrhea
o Fever
o Excess sweating
o Burns
o Diabetes insipidus
o Uncontrolled diabetes mellitus
41
42. Fluid volume deficit
What happens
Output > Intake -> Water extracted from ECF
ECF hypertonic (water moves out of cell - cell dehydration) +
osmotic pressure increased (stimulates thirst receptor in
hypothalamus)
ICF hypotonic with decreased osmotic pressure = posterior
pituitary secretes more ADH
Decreased ECF volume = adrenal glands secrete Aldosterone
which helps in regulation/ retention of water and sodium.
42
43. Signs and Symptoms
Acute weight loss
Decreased skin turgor
Oliguria
Concentrated urine
Weak, rapid pulse
Capillary filling time elongated
Decreased BP
Increased pulse
Sensations of thirst, weakness, dizziness, muscle cramps
43
44. Significant Points
Dehydration – one of most common disturbances in
infants and children
Additional S/S
Sunken eyeballs
Depressed fontanels
Significant wt loss
44
45. Labs
Increased hct Normal 35% – 45%
25% means that there are 25 milliliters of red blood cells in
100 milliliters of blood.
Increased BUN
High serum osmolality
Increased urine osmolality
Increased specific gravity
Decreased urine volume, dark color
45
46. Interventions
Major goal prevent or correct abnormal fluid volume status
before ARF occurs
Encourage fluids
IV fluids
Isotonic solutions (0.9% NS or L/R) until BP back to normal,
then hypotonic (0.45% NS)
Monitor I & O, urine specific gravity, daily weights.
46
47. Cont…
Monitor skin turgor
Monitor vital sign and mental status
Evaluation
Normal skin turgor, increased UOP with normal specific
gravity, normal VS, clear sensory stimuli , good oral intake
of fluids, labs WNL.
47
48. Fluid Volume Excess (FVE)
Hypervolemia
Isotonic expansion of ECF caused by abnormal retention of
water and sodium
Fluid moves out of ECF into cells and cells swell
48
49. Causes
Cardiovascular – Heart failure
Urinary – Renal failure
Hepatic – Liver failure, cirrhosis
Other – Cancer, thrombus, PVD, drug therapy (i.e.,
corticosteroids), high sodium intake, protein malnutrition.
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53. Interventions
Sodium restriction (foods/water high in sodium)
Fluid restriction, if necessary
Closely monitor IVF
If dyspnea or orthopnea provide Semi-Fowler’s sitting
Strict I & O, lung sounds, daily weight, degree of edema, re-
position 2 x hourly
Promote rest and diuresis.
53
55. Sources of Water
Oral liquids: 1300ml/day
Water in foods: 1000ml/day
Meats and vegetables: 60-90% water
Water from oxidation: 300ml/day
10ml/cal of food metabolized
Parenteral fluids
Enteral feedings
55
56. “ Normal” Water Loss
Skin:
Perspiration: 0-1000 ml/day
Lungs: 300-400 ml/day
Increases with increased respiratory rate or depth or dry
climate
GI Tract: 100-200 ml/day
Kidneys: 1-2 L/day
Insensible loss: 600 ml/day (evaporation)
1ml/kg of body wt/hr in all ages
56
57. Other Causes of Water Loss
Fever
Burns
Diarrhea
Vomiting
N-G Suction
Fistulas
Wound drainage
57
58. IV Fluid Replacement
IV Fluid to manage fluid volume imbalances
Isotonic fluids (approximate normal serum plasma)
Rapid ECF expansion needed
DW5%, NS, L/R
Hypotonic fluids
Treatment of cellular dehydration
.45% NS, NS, 2.5% dextrose
58
59. Cont…
Hypertonic
Treatment of water intoxication
D5 ½ NS, DW 10%, 3% NS
Shifts fluids from ICF & ECF to intravascular
component – expands blood volume
Now can be removed by kidneys
59
60. References
Helen Giannakopoulos, LEE Carrasco. Jason Alabakoff, peter D. Quinn.
Fluid and electrolyte management and blood product usage.
Fluid, Electrolyte, and Acid-base Balance Heitz, Horne-Mosby, 4th edition
IV Therapy made incredibly Easy!
McCann, Lippincott, 3rd edition
Fluid & Electrolytes Chernecky, Macklin, Murphy- ende, Saunders 2002
Fluids, Electrolytes & Acid-Base Balance Hogan, Wane, Prentice Hall
nursing
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