CHAPTER I

PREMINILARY

1.1 Background
Healthy balance of acid-base in the body is maintained by intake,
distribution and waterways and electrolytes, as well as regulation of these
components by the kidneys and lungs. The fluid and electrolyte balance involves
the composition and movement of body fluids. Body fluids are solutions consisting
of water (solvents) and certain substances (solutes). Electrolytes are chemicals that
produce electrically charged particles called ions when they are in solution. Liquids
and electrolytes enter the body through food, drink, and intravenous fluids (IV) and
distribution throughout the body. Liquid and electrolyte balance means the normal
distribution of total body water and electrolytes into all parts of the body. The fluid
and electrolyte balance are interdependent with one another. If one is disturbed it
will affect the other.
Many factors can cause fluids and electrolytes, one of which is a disease. A
healthy, well-mobilized, well-oriented adult can usually maintain a normal fluid
and electrolyte and acid balance due to the mechanism of his body. However,
infants, infants, adults with severe illness, clients with impaired orientation or
immobilized clients, and the elderly are often unable to respond independently and
over time their adaptive abilities no longer maintain fluid and electrolyte balance,
and acid-base acids without assistance, therefore, nursing care for a wide range of
clients involves assessing and correcting imbalances or attempting to maintain
fluid, electrolyte and acid-base imbalances.
Living cells in the body are covered with interstitial fluid containing the
concentrations of nutrients, gases and electrolytes needed to maintain normal cell
function. Survival requires a constant internal environment (homeostasis). The
regulatory mechanism is important for controlling the balance of the body's alkaline
balance, composition and acid-base balance during normal metabolic fluctuations
or during abnormalization such as illness or trauma.

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 Keeping the volume of body fluids remains relatively constant and the
composition remains stable is important for homeostasis. The regulatory system
maintains the constant body fluids, fluid balance and alkaline base electrolytes, and
the exchange of extracellular and intracellular fluid compartments.
Human life is very dependent on what is around him including in meeting
the basic needs of eating and drinking approximately 60% of adult body weight
generally consists of fluids (water and electrolytes). Factors that affect the amount
of body fluids are age, sex, and fat content in the body.
In general, younger people have a higher percentage of body fluids
compared with older people, and men proportionately have more body fluids than
women. A fattier person has less fluid compared with a thinner person, because fat
cells contain less water.

1.2 Problem Restrictions

Nursing actions that are invasive tend to have risks in the implementation,
so the formulations of the problem in this paper are:
1. What is fluid in the body?
2. How many different types of electrolytes ?
3. What is the acid base balance?
4. What is the problem of electrolyte needs?
5. What are the factors that affect the electrolyte?
1.3 General Purpose
1. To know the fluid in the body
2. To know the balance of fluids in the body
3. To know how to move body fluids

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 CHAPTER II
CONTENTS
2.1 Electrolyte regulation
Body fluids are solutions consisting of water (solvents) and certain substances
(solutes). Electrolytes are chemicals that produce electrically charged particles
called ions when they are in solution.
Body Fluid Distribution
Distributed in two different compartments:

Extracellular fluid
Consisting of interstitial fluid (CIS) and Intravaascular Liquids. Interstitial fluid
fills the space between most of the body's cells and makes up most of the body
fluids. About 15% of body weight is interstitial body fluid.

Intravascular fluid consists of plasma, part of lymphatic fluid containing colorless

water, and blood contains leukocyte, erythrocyte, and platelet suspension. Plasma
composes 5% body weight.

Intracellular fluid
Is the fluid in the cell membrane containing dissolved substances or solutes which
are important for fluid and electrolyte balance and for metabolism. Intracellular
fluid forms 40% body weight. The intracellular fluid compartment has many of the
same solutes as the liquid in the extracellular room. But the proportion of subtansi
substance is different. For example, the proportion of potassium is greater in the
intracellular fluid than in the extracellular fluid.

Schematically The Type and Amount of Body Fluids can be described as follows:
The distribution of body fluids is relatively dependent on the size of the body itself.
Adult 60%
Children 60 - 77%
Infant 77%
Embryo 97%
Elderly 40 - 50%

In the elderly, the total percentage of body fluids is reduced due to the loss of body
tissue.

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2.2 Type of electrolyte

a. Intracellular fluid (CIS)

The outer cell membrane plays an important role in regulating intracellular volume
and composition. ATP-dependent membrane-bound pumps will exchange Na with
K in a 3: 2 ratio. Because cell membranes are relatively un permeable to Na ions
and K ions, potassium will therefore be concentrated in cells while sodium ions will
be concentrated in extra cells. Potassium is the main cation of ICF and its main
anion is phosphate. As a result, potassium becomes a dominant factor that
determines intracellular osmotic pressure, whereas sodium is the most important
factor determining extracellular osmotic pressure.
The impermeability of cell membranes to proteins causes a high concentration of
intracellular proteins. Because protein is a non-ionizing solute (anion), the unequal
exchange ratio of 3 Na+ and 2 K+ by the cell membrane pump is essential for the
prevention of relativ intracellular hyperosmolality. Disturbances in Na-K-ATPase
pump activity as occurring in the ischemic state will cause cell swelling.

b.Circular Extracellular (CES)

The basic function of the extracellular fluid is to provide nutrients for the cell and
transfer its metabolism results. The balance between normal extracellular volume,
especially the circulating component (intravascular volume) is very important.
Therefore, quantitatively sodium is the most important extracellular cation and is a
major factor in determining osmotic pressure and volume while the main anions are
chloride (Cl-), bicarbonate (HCO3-). Changes in extracellular fluid volume are
related to changes in the total amount of sodium in the body. This depends on the
sodium entering, renal sodium excretion and the loss of extra renal sodium

c. Interstitial fluid (ISF)

Normally a small amount of interstitial fluid in the form of a free liquid. Most
interstitial water is chemically related to extracellular proteoglycan forming gel. In
general, interstitial fluid pressure is negative (approximately -5 mmHg). If there is

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 an increase in iterstitial fluid volume then interstitial pressure will also increase and
sometimes become positive. When this happens, the free liquid in the gel will
increase rapidly and will clinically cause edema. Only a small portion of the protein
plasma can pass through the capillary crack, therefore the protein content in the
interstitial fluid is relatively low (2 g / Dl). Proteins entering the interstitial space
will be returned to the vascular system via the lymphatic system

d. Intravascular fluid (IVF)

Intravascular fluid is formed as plasma maintained in intravascular space by the
vascular endothelium. Most of the electrolyte can be freely in and out through
plasma and interstitial which causes the compositions of both electrolytes are not
much different. However, strong endothelial cell bonds prevent protein from
intravascular space. As a result, plasma proteins (especially albumin) are the only
osmotic active substances in exchange of fluid between plasma and interstitial fluid.
Increased extracellular volume normally also reflects intravascular and interstitial
volume. When interstitial pressure changes to positive it will be followed by an
increase in extracellular fluid which will result in an expansion only in the
interstitial fluid compartment. In this state the interstitial compartment will act as a
reservoir of the intravascular compartment. This can be seen clinically as tissue
edema.
2.3 Electrolyte requirements
Electrolyte is an element or compound, which if melted or dissolved in
water will break into ions and be able to carry an electrical charge. Electrolytes that
have a positive charge are called cations. Whereas the electrolyte having a negative
charge is called an anion. The concentration of each electrolyte in the intracellular
and extracellular fluids is different but the total number of anions and cations in
each liquid compartment must be the same.
2.4 Acid Base balance
Acids are defined as substances that can give H + ions to other substances
(called proton donors), whereas a base is a substance that can receive H + ions from
other substances (referred to as the proton acceptor). A new acid may release a

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proton if there is a base that can accept the released proton. Therefore, the acid-base
reaction is a reaction of the release and reception of protons.

The acid-base balance is a condition in which the concentration of hydrogen

ions produced is equivalent to the concentration of hydrogen ions released by the
cell. In life processes the acid balance at the molecular level is generally associated
with weak acids and weak bases, as well as at very low levels of H + or OH-ion
concentrations.

The acid base balance is the balance of hydrogen ions. Although the
production will continue to produce hydrogen ions in very large quantities, it turns
out the concentration of hydrogen ions is maintained at low levels of 40 + 5 nM or
pH 7.4. Basic acid balance arrangements are maintained through the coordination
of 3 systems:

1. System buffer

Neutralize the excess hydrogen ions, are temporary and do not eliminate. The main
function of the buffer system is to prevent pH changes caused by the effects of fixed
acids and organic acids on extracellular fluids. As a buffer, this system has
limitations:

• Can not prevent pH changes in extracellular fluid caused by increased CO2.

• This system only works when the respiratory system and central respiratory
system controller work normally

• The ability to operate a buffer system depends on the availability of bicarbonate

ions.

There are 4 buffer systems:

1. Bufer bicarbonate; is a buffer system in extracellular fluids primarily for

changes caused by non-bicarbonate
2. Bufer protein; is a buffer system in extracellular and intracellular fluids
3. Bufer hemoglobin; is a buffer system in the erythrocytes for changes in
carbonic acid
4. Bufer phosphate; is a buffer system in urinary and intracellular fluid
systems.
Chemical systems can only overcome temporary acid-base imbalances. If the
buffchemistry does not adequately correct the imbalance, then the pH control will
be followed by the lungs responding rapidly to changes in H-ion concentration in
the stimulating blood of the chemoreceptors and respiratory center, then

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maintaining the level until the kidneys remove the imbalance. The kidneys are able
to regulate H-ion imbalances slowly by secreting H ions and adding new
bicarbonate into the blood because they have phosphate buffer and ammonia.

The process of elimination is done by the lungs and kidneys. Pulmonary and renal
mechanisms in support of buffer system performance is to regulate the secretion,
excretion, and absorption of hydrogen and bicarbonate ions and form additional
buffers (phosphate, ammonia). For the long term, excess acid or base is removed
through the kidneys and lungs while for the short term, the body is protected from
changes in pH with the buffer system. The buffer mechanism aims to maintain
blood pH between 7.35-7.45.

2. Lung System

The role of the respiration system in acid-base balance is to keep Pco2 always
constant despite changes in CO2 levels due to metabolic processes of the body. The
acid-base balance of respiration depends on the production and CO2 excretion. The
amount of CO2 present in the blood depends on the rate of metabolism while the
process of CO2 excretion depends on the lung function.

Abnormalities of ventilation and perfusion will basically result in unfavorable ratio

of perfusion ventilation so that there will be an imbalance, this eventually leads to
hypoxia and CO2 retention resulting in acid-base balance disturbance.

3. Kidney System

To maintain the acid-base balance, the kidneys must excrete non-volatile acid
anions and replace HCO3-. The kidneys regulate acid base balance by secretion and
reabsorption of hydrogen ions and bicarbonate ions. In the mechanism of regulation
by the kidney it plays a 3 carbonic acid buffer system, phosphate buffer and
ammonia formation. The hydrogen, CO2, and NH3 ions are excreted into the
tubular lumen with the help of energy generated by the sodium pump mechanism
in the basolateral tubules. In the process, carbonic and sodium acids are released
back to the circulation to re-function. The proximal tubule is the main site of
reabsorption of bicarbonate and acid release.

The hydrogen ion is highly reactive and readily joins the negatively charged ions at
very low concentrations. At very low levels, hydrogen ions have a great effect on
biological systems. Hydrogen ions interact with various biological molecules that
can affect protein structure, enzyme function and membrane extension. The
hydrogen ion is essential to the normal functioning of the body eg as a
mitochondrial proton pump in the oxidative phosphorylation process that generates
ATP.

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2.5 Problem of electrolyte needs
Problems with fluid needs:
1. Respiratory acidosis,
Is a condition caused by respiratory system failure in removing carbon dioxide from
body fluids.
2. Metabolic acidosis
It is a state of loss of base or acid buildup occurs.

3. Respiratory alkalosis
It is a state of loss of CO2, from the lungs that can cause arterial paCO 2 less than
35 mmHg, a pH greater than 7.45.

4. Metabolic alkalosis
It is a state of loss of hydrogen ions or addition of alkaline fluids in body fluids in
the presence of plasma bicarbonate increase of more than 26 mmHg and an arterial
pH of more than 7.45.

Electrolyte needs problems:

1) Hyponatremia
It is a state of deficient sodium in blood plasma characterized by plasma sodium
levels of less than 135 mmHg, nausea, vomiting and diarrhea.
2) Hypernatremia
A condition where high levels of sodium in plasma are characterized by dry mucosa,
oliguria / anuria, poor skin turgor and swollen skin surface, redness of the skin, dry
tongue, etc.
3) Hypokalemia
M is a state of deficiency of potassium in the blood. Hypokalemia can occur very
quickly. Often occurs in patients with prolonged diarrhea.
4) Hyperkalemia

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 It is a condition where potassium levels in the blood are high. This condition often
occurs in burn patients, kidney disease, metabolic acidosis. Hyperkalemia is
characterized by nausea, digestive system hyperactivity, etc.
5) Hypocalcaemia
It is a deficiency of calcium in blood plasma. Hypocalcaemia is characterized by
muscle and stomach cramps, seizures, confusion, etc.
6) Hypercalcaemia
It is a state of excess calcium in the blood. This occurs in patients who have elevated
thyroid glands and overeating vitamin D. Hypercalcaemia is characterized by bone
pain, muscle relaxation, kidney stones, etc., and plasma calcium concentrations
greater than 4.3 mmHg.
7) Hypomagnesia
It is a deficiency of magnesium levels in the blood. Hypomagnesia is characterized
by irritability, tremors, cramps of the feet and hands, etc., as well as a magnesium
level in the blood of less than 1.3 mmHg.
8) Hipermagnesia
It is an excess of magnesium in the blood. It is characterized by coma, respiratory
distress, and magnesium levels of more than 2.5 mmHg.
9) Acid Base Balance
Body activity requires acid base balance, acid base balance can be measured by pH
(acidity degree). Under normal circumstances, the pH value of body fluids is 7.35 -
7.45. balance can be maintained through a metabolic process with a buffer system
in all body fluids and through respiration with the regulatory system (arrangement
in the kidney). Three kinds of liquid body buffer solution system are bicarbonate
solution, phosphate buffer solution, and protein buffer solution.

2.6 Factors that affect electrolyte reqirements

1. Age
Individual fluid intake varies by age. In this case, age affects body proportions,
body surface area, metabolic needs, and weight. Infants and children in the growing
period have a greater proportion of body fluids than adults. Therefore, the amount

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of fluid needed and the amount of fluid lost is also greater than that of adults. The
magnitude of fluid requirements in infants and children is also influenced by high
metabolic rates and their unruly kidney conditions compared to adult kidneys. Loss
of fluid can occur due to the release of large fluid from the skin and breathing. In
elderly individuals, fluid and electrolyte imbalances are often caused by heart
problems or renal impairment.

2. Activity
One's life activity is very influential to the needs of fluids and electrolytes. Activity
causes increased metabolic processes in the body. This results in increased fluid
output through sweat. Thus, the amount of fluid required also increases. In addition,
insensible water loss also increases respiratory rate and sweat gland activation.

3. Climate
Normally, individuals living in a climate that is not too hot will not experience
extreme fluid expulsion through the skin and breathing. In this situation, the
outgoing liquid is generally insensible (IWL). The magnitude of IWL in each
individual varies, influenced by environmental temperature, metabolic rate, and
age. Individuals living in high-temperature environments or in areas with low
humidity will experience more frequent loss of fluid and electrolytes. Similarly in
people who work hard in high-temperature environments, they can lose five liters
of fluid a day through sweat. Generally, people who used to be in a hot environment
will lose as much fluid as 700 ml per hour while in a hot place, while unusual people
are in a hot environment can lose fluid up to two liters per hour.

4. Diet
A person's diet also affects fluid and electrolyte intake. If the intake of food is
unbalanced, the body attempts to split the protein by first breaking up the stored fat
and glycogen. This condition causes a decrease in albumin levels.

5.Stress

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Stress conditions affect the fluid and electrolyte needs of the body. During stress,
the body experiences increased cellular metabolism, increased blood glucose
concentration, and muscle glycolysis. This mechanism leads to water retention and
sodium. In addition, stress also leads to increased production of anti-deuritic
hormones that can reduce urine production.

6. Illness
Trauma to the tissues can cause fluid and electrolyte losses from damaged cells or
tissues (eg, tear, or burns). Patients suffering from diarrhea may also experience
increased fluid requirements due to fluid loss through the gastro intestinal tract.
Heart and kidney disorders can also cause fluid and electrolyte imbalances. As the
blood flow to the kidneys decreases as the ability of the pompajantung decreases,
the body will accumulate fluid and sodium resulting in fluid retention and fluid
overload (hipervelomia). More closely, these conditions can cause pulmonary
edema. Normally, the urine will be removed in sufficient quantities to balance the
fluids and electrolytes and the levels of acids and bases in the body. If fluid intake
is large, the kidneys will filter more fluids and hold ADH so that urine production
will increase. Conversely, in a state of lack of fluids, the kidneys will decrease the
production of urine by sharing a way. These include increased tubular reapsorption,
sodium retention and renin release. If the kidney is damaged, the ability of the
kidney to do the regulation will decrease. Therefore, when renal impairment occurs
(eg, renal failure) individuals may experience oliguria (urine production less than
40ml / 24 h) so anuria (urine production less than 200 ml / 24 h).

7. Medical Measures
Some medical measures have secondary effects on fluid and electrolyte
requirements of the body. The action of gastric suction can cause decreased levels
of calcium and potassium.

8. Treatment

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The use of some drugs such as Diuretics or laxatives can cause excessive increase
in fluid loss in the body. As a result, there is a defist of body fluids. In addition, the
use of diuretic causes loss of sodium so that potassium levels will increase. The use
of corticosterreroids can also cause sodium and water retention in the body.

9. Surgery
Clients undergoing high-risk surgery experience fluid imbalances. Some clients
may lose a lot of blood during perode surgery, while some other clients just
experience fluid overload due to intravenous fluid intake during surgery or ADH
hormone secretion during stressful periods due to anesthetic drugs.

CHAPTER III
CONCLUSIONS

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REFERENCES

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