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Fluid and Electrolyte Review

Body Fluid Compartments


2/3 (65%) of TBW is intracellular (ICF)
1/3 extracellular water
25 % interstitial fluid (ISF)
8 % in plasma (IVF intravascular fluid)
2 % in transcellular fluids CSF, intraocular
fluids, serous membranes, and in GI,
respiratory and urinary tracts

Fluid compartments are separated by


membranes that are freely permeable to
water.
Movement of fluids due to hydrostatic
pressure and osmotic pressure

Balance
Fluid and electrolyte homeostasis is
maintained in the body
Neutral balance: input = output
Positive balance: input > output
Negative balance: input < output

Solutes dissolved particles


Electrolytes charged particles
Cations positively charged
Na+, K+ , Ca++, H+

Anions
Cl-, HCO3- , PO43-

Non-electrolytes - Uncharged
Proteins, urea, glucose, O2, CO2

Body fluids are:


Electrically neutral
Osmotically maintained
Specific number of particles per
volume of fluid

Homeostasis maintained by:


Ion transport
Water movement
Kidney function

MW (Molecular Weight) = sum of the weights of


atoms in a molecule
mEq (milliequivalents) = MW (in mg)/ valence
mOsm (milliosmoles) = number of particles in a
solution

Tonicity
Isotonic
Hypertonic
Hypotonic

Cell in a
hypertonic
solution

Cell in a
hypotonic
solution

Movement of body fluids


Where sodium goes, water follows.
Diffusion movement of particles down a
concentration gradient.
Osmosis diffusion of water across a
selectively permeable membrane
Active transport movement of particles up
a concentration gradient ; requires energy

ICF to ECF osmolality changes in ICF not


rapid

IVF ISF IVF happens constantly due to


changes in fluid pressures and osmotic forces
at the arterial and venous ends of capillaries

Regulation of body water


ADH antidiuretic hormone + thirst
Decreased amount of water in body
Increased amount of Na+ in the body
Increased blood osmolality
Decreased circulating blood volume

Stimulate osmoreceptors in hypothalamus


ADH released from posterior pituitary
Increased thirst

Result:
increased water consumption
increased water conservation
Increased water in body, increased
volume and decreased Na+ concentration

Decreased amount of water in body


Increased amount of Na+ in the body
Increased blood osmolality
Decreased circulating blood volume
Can also be due to dysfunction or trauma

Edema is the accumulation of fluid within the


interstitial spaces
increased hydrostatic pressure
lowered plasma osmotic pressure
increased capillary membrane permeability
lymphatic channel obstruction

Hydrostatic pressure increases due to:


Venous obstruction:
thrombophlebitis (inflammation of veins)
hepatic obstruction
tight clothing on extremities
prolonged standing
Salt or water retention
congestive heart failure
renal failure

Decrease plasma osmotic pressure:


plasma albumin (liver disease or
protein malnutrition)
plasma proteins lost in :
glomerular diseases of kidney
hemorrhage, burns, open wounds
and cirrhosis of liver

Increased capillary permeability:


Inflammation
immune responses

Lymphatic channels blocked:


surgical removal
lymphedema

Fluid accumulation:
increases distance for diffusion
may impair blood flow
= slower healing
increased risk of healing
pressure sores over bony
prominences

Edema of specific organs can be life


threatening (larynx, brain, lung)

Water is trapped, unavailable for metabolic


processes. Can result in dehydration
and shock. (severe burns)

Electrolyte balance
Na + (Sodium)
90 % of total ECF cations
136 -145 mEq / L
Pairs with Cl- , HCO3- to neutralize charge
Low in ICF
Most important ion in regulating water balance

Regulation of Sodium
Renal tubule reabsorption affected by
hormones:
Aldosterone
Renin/angiotensin
Atrial Natriuretic Peptide (ANP)

Potassium

Major intracellular cation


ICF conc. = 150- 160 mEq/ L
Resting membrane potential
Regulates fluid, ion balance inside cell
pH balance

Regulation of Potassium
Through kidney
Aldosterone
Insulin

Isotonic alterations in water


balance
Occur when TBW changes are
accompanied by = changes in electrolytes
Loses plasma or ECF
Isotonic fluid loss
ECF volume, weight loss, dry skin and
mucous membranes, urine output, and
hypovolemia ( rapid heart rate, flattened
neck veins, and normal or B.P. shock)

Isotonic fluid excess


Excess IV fluids
Hypersecretion of aldosterone
Effect of drugs cortisone
Get hypervolemia weight gain, decreased
hematocrit, diluted plasma proteins, distended
neck veins, B.P.
Can lead to edema ( capillary hydrostatic
pressure) pulmonary edema and heart failure

Electrolyte imbalances
Sodium
Hypernatremia
Plasma Na+ > 145 mEq / L
Due to Na + or water
Water moves from ICF ECF
Cells dehydrate

Due to:
Hypertonic IV soln.
Oversecretion of aldosterone
Loss of pure water
Long term sweating with chronic fever
Respiratory infection water vapor loss
Diabetes polyuria
Insufficient intake of water

Clinical manifestations
Thirst
Lethargy
Neurological dysfunction due to
dehydration of brain cells

Treatment
Lower serum Na+
Isotonic salt-free IV fluid

Hyponatremia
Overall decrease in Na+ in ECF
Two types: depletional and dilutional
Depletional
Na+ loss:
diuretics, chronic vomiting
Chronic diarrhea
Decreased aldosterone
Decreased Na+ intake

Dilutional
Renal dysfunction with intake of hypotonic
fluids
Excessive sweating increased thirst
intake of excessive amounts of pure water
Syndrome of Inappropriate ADH (SIADH) or
oliguric renal failure, severe congestive heart
failure, cirrhosis all lead to:
Impaired renal excretion of water

Hyperglycemia attracts water

Clinical manifestations
Neurological symptoms
Lethargy, confusion, apprehension, depressed
reflexes, seizures and coma

Hypokalemia
Serum K+ < 3.5 mEq /L
Beware if diabetic
Insulin gets K+ into cell
Ketoacidosis H+ replaces K+, which is lost in
urine

Causes of hypokalemia
Decreased intake of K+
Increased K+ loss
Chronic diuretics
Acid/base imbalance

Clinical manifestations
Neuromuscular disorders
Weakness, flaccid paralysis, respiratory
arrest, constipation

Dysrhythmias
Postural hypotension
Cardiac arrest
Treatment Increase K+ intake, but slowly

Hyperkalemia

Serum K+ > 5.5 mEq / L


Check for renal disease
Massive cellular trauma
Insulin deficiency
Addisons disease
Decreased blood pH

Clinical manifestations

Early hyperactive muscles


Late - Muscle weakness, flaccid paralysis
Change in ECG pattern
Dysrhythmias
Bradycardia , heart block, cardiac arrest

Treatment
Insulin + glucose
Bicarbonate
Ca++ counters effect on heart

Calcium Imbalances
Most in ECF
Regulated by:
Parathyroid hormone
Blood Ca++ by stimulating osteoclasts
GI absorption and renal retention
Calcitonin from the thyroid gland
Promotes bone formation
renal excretion

Hypercalcemia
Results from:
Hyperparathyroidism
Hypothyroid states
Renal disease
Excessive intake of vitamin D
Malignant tumors hypercalcemia of
malignancy
Tumor products promote bone breakdown
Tumor growth in bone causing Ca++ release

Hypercalcemia
Usually also see hypophosphatemia
Effects:
Many nonspecific fatigue, weakness, lethargy
Increases formation of kidney stones
Muscle cramps
Bradycardia, cardiac arrest
Pain
GI activity also common
Nausea
Abdominal cramps
Diarrhea / constipation

Metastatic calcification

Hypocalcemia
Hyperactive neuromuscular reflexes and
tetany differentiate it from hypercalcemia
Convulsions in severe cases
Caused by:
Lack of vitamin D
Suppression of parathyroid function
Hypersecretion of calcitonin
Malabsorption states
Abnormal intestinal acidity
Widespread infection or peritoneal inflammation