FLUID AND ELECTROLYTES

Homeostasis

Maintenance of constant internal equilibrium in a biologic system that involves positive & negative feedback mechanisms. State of equilibrium in the internal environment, maintained by adaptive responses that promote healthy survival Balance of body fluids and electrolytes play an important role

3. Transport cellular waste products to lungs & kidneys for elimination 4. Normal cellular chemical functioning 5. Lubricates, insulates, and cushions tissues 6. Hydrolysis of food in GIT (Addition of water for food breakdown) 7. Universal Solvent for electrolytes and non electrolytes
Electrolytes

Water Content of the Body

Infants 70 to 80% of body weight Adult 60% of body weight Elderly 65 y/o up 40 to 50% of body weight Muscle, skin and blood have the highest amount of water Fat cells and skeleton has low water content Varies with age, gender, & body mass or body fat. 1kg of body weight = 1L of body water

Factors that influence amt of Body Fluid

1. Age younger (greater muscle mass; low in fat tissues) older (muscle mass decreases; body water declines when aging) 2. Gender men (greater muscle mass and lower fat tissues) women (lesser muscle mass and more fat tissues) 3. Body Mass thin (lean tissue is rich in water) obese (fat cells contain less water) Remember: Greater muscle mass = H20 content Lesser muscle mass = H20 content Adipose tissues have H20 content b/c fat cells contain less water.

Active chemicals in body fluids that carries positive (cations) & negative (anions) electrical charges Expressed in milliequivalents per liter (mEq/L), a measure of electrochemical activity of 1mg of Hydrogen (H+). Cations and anions are equal in mEq/L in a solution Electrolyte concentrations differ in compartments Sources a. Dietary intake (food and oral liquids) b. IVF and TPN solutions c. Medications

Functions of Electrolytes

1. 2. 3. 4. 1. 2. 3. 4. 5.

Maintains fluid balance Maintains fluid volume & osmolality Regulates acid base balance Transmits neuromuscular reactions Sodium Potassium Calcium Magnesium Hydrogen Ion (H+) released by acids

Major Cations

Major Anions

1. Chloride 2. Bicarbonate base or alkali that have low H+ concentration 3. Phosphate 4. Sulfate 5. Proteinate

Functions of Body Water

1. Maintains normal blood volume 2. Transports oxygen and nutrients to and from the cells & other substances such as hormones & enzymes

Major Electrolytes Major Cations Sodium (Na) Potassium (K+) Calcium (Ca++) Magnesium (Mg++) Total Cations Major Anions Chloride (Cl-) Bicarbonate (HCO3 ) Proteinate Organic Acids Phosphate (HPO4 ) Sulfate (SO4 ) Total Anions

ICF

ECF (mEq/L) 142 5 5 2 154 103 26 17 5 2 1 154

b. Maintains blood volume

3 Compartments of Extracellular Fluids 1. Interstitial Space (Interstitium)

40 150 10 200

40 10 150 200

Contains fluids that surround the cells in body tissues 2/3 of ECF 11 12L in an Adult Lymph is an interstitial fluid Function: Intracellular Communication (i.e. transports wastes from cell thru lymph directly to plasma)

2. Intravascular Space

ECF has low concentration of K+ and can only tolerate small changes in K+ concentrations. Release of large amounts of intracellular K+ caused by cell and tissue trauma is dangerous Sodium concentration affects overall concentration of ECF. It regulates the volume of body fluids. o Sodium gain or retention = fluid retention or volume of body fluid o Sodium Loss = fluid loss, vol. of body fluids o Sodium Potassium Pump maintains high extracellular concentration of Na+ and Intracellular concentration of K+

Fluids within the blood vessels that contains PLASMA, the circulating blood volume Average blood volume in an Adult is 6L o 3L of Plasma o 3L Blood Cells RBCS, WBCS, Platelets Measured with Blood Tests Higher Protein Content Major Functions o Transport oxygen and nutrients and other substances such as electrolytes, enzymes, & hormones o Transport wastes to and from the cells

Body Fluids Distribution: Two Fluid Compartments or Spaces 1. Intracellular Compartment (ICF)

Ex. Plasma carries oxygen from lungs and glucose from GIT to the capillary wall of vascular system. Oxygen and glucose move across capillary wall into interstitial & across cell membrane into cells; opposite route is for waste products CO2 is transported from cells to the lungs & metabolic wastes to kidneys for elimination.
3. Transcellular Space

Contains fluids within the cells 2/3 of total body fluids of an adult & located primarily in skeletal muscle mass 42% of total body weight Potassium is the most prevalent cation Phosphates & Sulfates are the most prevalent anions Major Functions: a. Normal cellular chemical functioning b. Cellular metabolism

Smallest division of ECF but an important fluid compartment. Approximately 1L in Adult Includes fluids in CSF, pericardial, pleural spaces (lungs), peritoneal (GIT), synovial spaces (joints, bursae, tendons), intracolular, digestive secretions, sweat

2. Extracellular Compartment (ECF) Contains fluids outside the cells 1/3 of total body fluids in Adult Sodium is the most prevalent cation Chloride is the most prevalent anion

Fluid Compartments are separated by:

1. Semi Permeable Membrane (ICF ECF)

Major Functions a. Transport system to & from the cell

Permeable to water but impermeable to sodium and potassium (needs active transport ATP & NaK+ Pump)

2. Capillary Wall (Interstitial Plasma) Permeable to water but impermeable to protein Permeable allows water and solutes
Semi permeable (Selective Permeability)

Magnitude of this force depends on the amt of dissolved substances (dissolved solutes) No. of dissolved substances determines the osmolality of solution, which influences fluid movement between 2 compartments.

3 Terms Associated with Osmosis: 1. Osmotic pressure

allows water but not all solutes

Solutes

Substances dissolved in a solution Body solutes are electrolytes, oxygen, carbon dioxide, glucose, proteins, amino acids Types of Solutes a. Colloids large substances that doesnt readily dissolve to solutions Protein is the major colloid in vascular system b. Crystalloids salts that dissolve readily Solvent Liquid substance that dissolves the solute Water is the universal solvent for electrolytes & non electrolytes Ex. Sugar (solute) added to Coffee (solvent)
Regulation of Fluid Compartments
(Mechanisms Controlling Fluid & Electrolyte Movement)

Amount of hydrostatic pressure to stop flow of water by osmosis Primarily determined by solute concentration in a solution Water moves from LESS CONCENTRATED TO A MORE CONCENTRATED AREA

2. Oncotic Pressure (Colloid Osmotic P.) Osmotic pressure exerted by Plasma Proteins (i.e. Albumin) Osmotic pressure exerted by Colloids Protein is the major colloid in vascular system 3. Osmotic Diuresis Urine output caused by excretion of substances in urine Glucose, mannitol, or contrast agents
Osmoles

Standard unit of osmotic pressure amt of dissolved substances in a solution

Osmolality

Body fluids normally shift between the two major compartments to maintain equilibrium between spaces for homeostasis Energy is required or theres expenditure for movement to occur ATP Sodium Potassium Pump energy

No. of osmoles per kg of solution Concentration of solute per kg of blood & urine Expressed as milliosmoles per kilogram (mOsm/kg) of solution

Active Transport

Osmolarity

Passive Transport

no energy expenditure or energy not required for movement to occur Osmosis, Diffusion, and Filtration

No. of osmoles per liter of solution Concentration of solution per liter expressed as milliosmoles per liter of solution (mOsm/L)

P A S S I V E T R A N S P O R T Osmosis (ECF ICF) Fluid moves between compartments across a

semi-permeable membrane from LOW TO HIGH SOLUTE CONCENTRATION AREAS until the solutions on both sides of the membrane are equal in solute concentrations

NaK+ Pump located in cell membrane which moves Na+ from cell into ECF (low to high) intracellular concentration of K+ in cell is maintained by pumping K+ into the cell Na+K+ Pump maintains higher concentration of extracellular Na and intracellular K+ Cell membrane pump that exchange Na and K+ ions.

Tonicity

Fluid tension within ECF or ICF that describes relationship between solutes and water Ability of all solutes to cause an osmotic driving force that promotes water movement between compartments. Determines normal cell hydration & cell size. Sodium, glucose, mannitol dont readily cross cell membrane (effective osmoles affecting water movement)
ICF)

Diffusion (ECF

Movement of solutes from HIGHER TO LOWER SOLUTE CONCENTRATION AREAS Occurs through random movement of molecules and ions Occurs in solids, liquids, gases Membrane that separates 2 compartments must be permeable for diffusion to occur. Examples of Diffusion o Exchange of O2 & CO2 between pulmonary capillaries and alveoli o Sodium move from ECF where sodium concentration is to the ICF where its concentration is low.

Facilitated Diffusion

Allows substances to cross cell membrane with assistance of specific carrier molecules (PROTEINS) to accelerate diffusion but no energy is expended
T R A N S P O R T

AC T I V E

Energy must be expended for the movement to occur against a concentration gradient ATP is the energy source Physiologic pump (Na+K+ Pump) moves fluid from LOWER TO HIGHER CONCENTRATED AREAS Sodium concentration in ECF is , it tends to enter cell by diffusion (high to low) offset by

Filtration

Movement of water & solutes by Hydrostatic Pressure from HIGH TO LOW PRESSURE AREAS Hydrostatic pressure in capillaries filters fluids out of IVC (plasma) into interstitial. Allows kidneys to filter 180L of plasma/day. Ex. Hemodialysis

retention of excess water

Fluid Shifts 1) Plasma to Interstitial Fluid = E D E M A

Hydrostatic Pressure Plasma Oncotic Pressure Interstitial Oncotic Pressure

2) Interstitial Fluid to Plasma Normal movements of fluids thru capillary wall into tissues depend on: Plasma Interstitial 1. Hydrostatic Pressure

Edema

Plasma Osmotic or Oncotic Pressure Therapeutic Action: Wear compression stockings or hose

Pressure exerted by the fluids on the walls of blood vessels at arterial & venous ends resulting from cardiac contraction (pumping action) Major force that pushes fluids out of blood vessels (plasma) into tissue space (interstitial) from HIGH PRESSURE TO LOW PRESSURE AREAS Pressure exerted by plasma proteins Pulls interstitial fluid into blood vessels (plasma)

2. Osmotic Pressure

Accumulation of fluid in interstitial spaces Localized result of traumatic injury from accident or surgery, local inflammatory processes or burns Generalized (Anasarca) excessive accumulation of fluid in interstitial space throughout the body as a result of cardiac, renal or liver failure

Fluid Spacing

Remember: ARTERIAL END of capillary: HP > OP = fluids and solutes move out of the capillary VENOUS END of capillary, OP > HP = fluids and some solutes move into the capillary Balance of Hydrostatic & Osmotic Pressure regulates movement of water between Interstitial and Intravascular Direction of fluid movement depends on the differences of Hydrostatic Pressure and Osmotic Pressure Water deficit (ECF) is associated w/ symptoms that result from cell shrinkage as water is pulled into vascular system Water excess (ECF) develops from gain or Average Daily Intake and Output in a Normal Adult Intake (mL) Output (mL) Oral Liquids 1300 Urine (Kidneys) 1500 Water in 1000 Stool or Feces 200 Food Water 300 Insensible Lungs 300 Produced Skin 600 by Metabolism Total 2600 Total 2600

1. First spacing normal distribution of fluid in ICF and ECF 2. Second spacing abnormal accumulation of interstitial fluid 3. Third spacing (Third Space Fluid Shift) Fluid is not lost but unavailable for use by either ICF or ECF Loss of ECF into a space that doesnt contribute to equilibrium between ECF and ICF Clinical Manifestations Initial Sign: Decreased UO despite adequate fluid intake Decreased BP & CVP Increased Heart Rate Edema Increased Body Weight Imbalanced I & O Fluid shifts out Intravascular Space (Plasma) Kidneys receives less blood Kidneys compensate by urine output Occurs in the ff Clients Ascites, Burns, Massive Bleeding, Peritonitis, Bowel Obstruction

Systemic Routes of Gains & Losses of F & E

Organs involved in Homeostasis

Gains Dietary Intake of food & fluids or enteral feeding Parenteral Fluids (through IV PN, TPN) Water produced by oxidation of food Losses Kidney : Urine Output Skin Loss: Sensible & Insensible losses Lungs: Insensible loss GI Tract Others Kidneys Major organ responsible in excreting fluids thru urination. Average daily urine volume is 1 2L in Adult General rule: Output is 1ml of urine per kilogram of body weight per hour (1ml/kg/h) in all age groups. Skin (Sensible Perspiration) Visible water & electrolyte loss thru sweating (Excessive or profuse sweating diaphoresis) Vary from 0 1000ml or more per hour, depending on factors such as environmental temperature. Chief solutes in sweat: Na, Cl, K Skin (Insensible Perspiration) Non visible water loss from skin by evaporation approximately 600ml daily. No electrolytes are lost Increases insensible water loss: a. Fever thru lungs &skin b. Loss of natural barrier like major burns Lungs (Insensible Loss) Eliminate water vapour approx 300 ml/day Loss increases in a dry climate and increased RR and depth such as: o hyperventilation o hyperpnea o continuous coughing Gastrointestinal Tract (GI Losses) 100 200 mL daily Because fluid is reabsorbed in the small intestine, vomiting, diarrhea & fistulas cause large losses.

1. 2. 3. 4. 5. 6.

Kidneys Lungs Heart Pituitary Gland (Anterior & Posterior Pituitary) Adrenal Gland Parathyroid Glands

Regulation of Water Balance

1. 2. 3. 4. 5. 6.

Renal Regulation Cardiac Regulation Hypothalamic Regulation Pituitary Regulation Adrenal Cortical Regulation Gastrointestinal Regulation

Effects of Stress in Fluid & Electrolyte Balance Kidneys Function & Renal Regulation

Primary organs for the regulation of fluid and

electrolyte balance. Filters 180L of plasma daily Excretes 1 2 L of urine daily. Kidney or renal tubules are the site of action of Aldosterone and ADH

Major functions of kidneys for fluid balance 1. Regulates ECF volume & osmolality by selective retention or excretion body fluids. 2. Regulates electrolyte levels in ECF by selective electrolyte retention and secretion 3. Regulates pH of ECF by retention of H+

4. Excretes metabolic wastes & toxic substances.

Heart & Blood Vessels Function

THIRST occurs Person increases Oral Intake of Fluids

c. Pituitary Regulation (ADH Mechanism) Under the control of Hypothalamus,

Pumping action of heart (cardiac contraction) circulates blood thru kidneys to allow urine formation and renal perfusion.

Lung Function Removes 300mL of water daily by exhalation Increases Insensible water losses

Hypothalamic Regulation a. Osmoreceptors

Hyperpnea (abnormally deep respiration) Hyperventilation Continuous coughing Mechanical ventilation with excessive moisture decreases fluid loss. Maintains acid-base balance

Located in hypothalamus senses the ff: a. Plasma Volume (fluid deficit) b. Plasma Osmolality c. Changes in sodium concentration Stimulates thirst and ADH release Result in increased free water, decreased plasma osmolarity & plasma volume. Increased Osmotic pressure Dehydration of neurons

posterior pituitary releases ADH, a water conserving hormone (retains water) Functions of ADH o Maintains osmotic pressure by controlling retention or excretion of water by the kidneys o Regulates Blood volume Absence or presence of ADH determines if urine is concentrated (UO) or diluted (UO) Other factors that stimulates ADH release Stress Surgery Nicotine

ANTIDIURETIC HORMONE REGULATION MECHANISMS

Plasma Osmolarity or Plasma Volume (Fluid Deficit)
Blood volume or BP Volume receptor Atria and great veins

Osmoreceptors in hypothalamus

Hypothalamus Posterior pituitary gland

ADH

Kidney / Renal tubules

Release impulses to Posterior Pitutary Gland Increase ADH release Kidney tubules (Alters kidneys permeability to water) H20 reabsorption Urine Output (Na reabsorption & K+ excretion)
b. Thirst Mechanisms
Stress, Surgery, Heat, Narcotics , Anesthetics, Heat, Nicotine, Antineoplastic agents

H2O reabsorption and UO

free water plasma volume or blood volume

plasma osmolarity

Anesthetics Morphine
Adrenal Cortical Regulation

Thirst influences oral intake of fluids Oral intake is controlled by the thirst center located in hypothalamus Plasa Osmolality Plasma Volume (fluid deficit) Hypothalamic neurons are stimulated by Intracellular dehydration

Adrenal cortex releases hormones to regulate both water and electrolytes o Glucocorticoids o Mineralcorticoids

a. Aldosterone

mineralocorticoid secreted by ZONA GLUMERULOSA OF ADRENAL CORTEX Retains sodium and excretes potassium

Hyperaldosteronism () = sodium and water retention and potassium loss Hypoaldosteronism () = sodium and water loss and potassium retention adrenocortical hormone If secreted in large amounts or administered as corticosteroid therapy results to sodium and fluid retention

PTH influences the ff: o Bone resorption o Calcium absorption from intestine o Calcium reabsorption from renal tubules. GIT accounts most of the water intake Eliminated by GI tract in feces Small nerve receptors located in Left Atrium & Carotid Aortic Arches that detect changes in pressure within blood vessels & transmit this info in CNS

b. Cortisol

Gastrointestinal Regulation

Baroreceptors

Factors affecting Aldosterone Secretion Renin Angiotension Aldosterone System

a. Renin b. Aldosterone released as: serum sodium decreases serum potassium increases ACTH increases
Decreased Renal Perfusion ( Plasma Volume), Juxtaglumerular cell in Kidneys Releases enzyme RENIN Angiotensin I formed by liver is converted to Angiotension II by ACE (Angiotensin Converting Enyzmes) Vasoconstriction of arterial smooth muscle * increased atrial pressure* Activates SNS

Stimulates Anterior Pituitary Gland ACTH release ZONA GLUMERULOSA OF ADRENAL CORTEX ALDOSTERONE release Kidney Tubules Na+ reabsorption H20 reabsorbed by Sodium K+ excretion Plasma Volume (Blood Volume) Parathyroid Function Embedded in thyroid gland Regulates calcium & phosphate balance by

Functions: a. Responds to circulating blood volume changes b. Regulates PNS & SNS neural activity c. Regulates Endocrine activities d. Responds to Atrial Pressure Decrease SNS stimulation Constricts renal arterioles Aldosterone release GFR & Na+ and Water reabsorption

parathyroid gland hormone (PTH)

Cardiac Regulation: Atrial Natruiretic Factor

28-amino-acid peptide released by CARDIAC ATRIA of the heart due to: a. SNS Stimulation b. Increased Atrial Pressure (Vasoconstricition) c. Angiotensin II stimulation d. Endothelin (vasoconstrictor of vascular smooth muscle released from damaged endothelial cells in kidneys) Causes vasodilation and increased urinary excretion of sodium and water Action is opposite to Angiotensin Aldosterone system it decreases BP &volume

Increases release due to: a. condition that results volume expansion (exercise, pregnancy) b. hypoxia c. Increase cardiac filling pressures (Na intake, heart failure, chronic renal failure, atrial tachycardia, vasoconstrictor agents - Epinephrine)

Increased Level Acute heart failure Hyperthyroidism Subarachnoid hemmorhage Small cell lung cancer Decreased Level Chronic heart failure Meds: urea (ureaphil) and prazosin (minipres Gerontologic Considerations 1. Reduced homeostatic mechanisms cardiac, renal, and respiratory function 2. Decreased respiratory function causes impaired pH (acid base imbalance) 3. Decreased Renal function Elevated serum creatinine Dehydration 4. Decreased body fluids 5. Multiple meds affects renal & cardiac function 6. Presence of concomitant conditions (preexisting chronic illnesses)