BODY FLUIDS

Total Body Water

● 50% to 60% of total body weight.
● total body weight and total body water (TBW) is relatively constant for an individual
● primarily a reflection of body fat
● Lean tissues such as muscle and solid organs have higher water content than fat and bone
● young, lean males have a higher proportion of body weight as water than elderly or obese
individuals.
● adult male, TBW accounts for 60% of total body weight
● adult female, it is 50%; The lower percentage of TBW in females correlates with a higher

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percentage of adipose tissue and lower percentage of muscle mass in most

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● The highest percentage of TBW is found in newborns, with approximately 80% of their total body
weight being water.
○ decreases to approximately 65% by 1 year of age and thereafter remains fairly constant

Fluid Compartments

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● three functional fluid compartments:
○ Plasma

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○ extravascular interstitial fluid (extracellular); and
○ intracellular fluid
● extracellular fluids (ECF), plasma, and interstitial fluid together compose about one-third of the TBW
● intracellular compartment composes the remaining two thirds
● extracellular water composes 20% of the total body weight and is divided between plasma (5% of
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body weight) and interstitial fluid (15% of body weight)
● Intracellular water makes up approximately 40% of an individual’s total body weight, with the largest
proportion in the skeletal muscle mass

Composition of Fluid Compartments

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● ECF compartment is balanced between sodium, the principal cation, and chloride and bicarbonate,
the principal anions.
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● intracellular fluid compartment is composed primarily of the cations potassium and magnesium, the
anions phosphate and sulfate, and proteins
● concentration gradient between compartments is maintained by adenosine triphosphate–driven
sodium-potassium pumps
● composition of the plasma and interstitial fluid differs only slightly in ionic composition.
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● slightly higher protein content (organic anions) in plasma results in a higher plasma cation
composition relative to the interstitial fluid,
● Proteins add to the osmolality of the plasma and contribute to the balance of forces that determine
fluid balance across the capillary endothelium
● water is freely diffusible and is distributed evenly throughout all fluid compartments of the body so
that a given volume of water increases the volume of any one compartment relatively little.
● Sodium, however, is confined to the ECF compartment, and because of its osmotic and electrical
properties, it remains associated with water
● Sodium-containing fluids are distributed throughout the ECF and add to the volume of both the
intravascular and interstitial spaces.
● administration of sodium-containing fluids expands the intravascular volume, it also expands the
interstitial space by approximately three times as much as the plasma
BODY FLUID CHANGES
Normal Exchange of Fluid and Electrolytes
● A healthy person consumes an average of 2000 mL of water per day, approximately 75% from oral
intake and the rest extracted from solid foods
● Daily water losses include 800 to 1200 mL in urine, 250 mL in stool, and 600 mL in insensible
losses.
● Insensible losses of water occur through both the skin (75%) and lungs (25%) and can be increased
by such factors as fever, hypermetabolism, and hyperventilation
● Sensible water losses such as sweating or pathologic loss of gastrointestinal (GI) fluids vary widely,
but these include the loss of electrolytes as well as water

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● To clear the products of metabolism, the kidneys must excrete a minimum of 500 to 800 mL of urine

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per day, regardless of the amount of oral intake.

Classification of Body Fluid Changes

● Disorders in fluid balance may be classified into three general categories: disturbances in
○ (a) volume

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■ Isotonic gain or loss of salt solution results in extracellular volume changes, with little
impact on intracellular fluid volume.
○ (b) concentration, and
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■ If free water is added or lost from the ECF, water will pass between the ECF and
intracellular fluid until solute concentration or osmolarity is equalized between the
compartments.
○ (c) composition
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■ Unlike with sodium, the concentration of most other ions in the ECF can be altered
without significant change in the total number of osmotically active particles,
producing only a compositional change
● each of these may occur simultaneously, each is a separate entity with unique mechanisms
demanding individual correction.
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Disturbances in Fluid Balance

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● Extracellular volume deficit can be either acute or chronic

● The most common cause of volume deficit is a loss of GI fluids from vomiting, diarrhea, as well as
sequestration secondary to soft tissue injuries, burns

Volume Control
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● Volume changes are sensed by both osmoreceptors and baroreceptors.

● Osmoreceptors are specialized sensors that detect even small changes in fluid osmolality and drive
changes in thirst and diuresis through the kidneys.
○ Ex. plasma osmolality is increased, thirst is stimulated and water consumption increases,
although the exact cell mechanism is not known
● Baroreceptors also modulate volume in response to changes in pressure and circulating volume
through specialized pressure sensors located in the aortic arch and carotid sinuses.
○ responses are both neural, through sympathetic and parasympathetic pathways, and
hormonal, through substances including renin-angiotensin, aldosterone, atrial natriuretic
peptide, and renal prostaglandins.

Concentration Changes
 ● Changes in serum sodium concentration are inversely proportional to TBW. Therefore,
abnormalities in TBW are reflected by abnormalities in serum sodium levels

● Hyponatremia
○ A low serum sodium level occurs when there is an excess of extracellular water relative to
sodium
○ Extracellular volume can be high, normal, or low
○ In most cases of hyponatremia, sodium concentration is decreased as a consequence of
either sodium depletion or dilution
○ Dilutional hyponatremia frequently results from excess extracellular waterand therefore is
associated with a high extracellular volume status.

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○ Excessive oral water intake or iatrogenic intravenous (IV) excess free water administration

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can cause hyponatremia
○ a number of drugs can cause water retention and subsequent hyponatremia, such as
antipsychotics and tricyclic antidepressants as well as angiotensin-converting enzyme
inhibitors.
○ Depletional causes of hyponatremia are associated with either a decreased intake or

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increased loss of sodium-containing fluids.
○ A normal ECF volume deficit is common. Causes include decreased sodium intake, such as

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consumption of a low-sodium diet or use of enteral feeds, which are typically low in sodium;
GI losses from vomiting, prolonged nasogastric suctioning, or diarrhea; and renal losses due
to diuretic use or primary renal disease.
○ Hyponatremia also can be seen with an excess of solute relative to free water, such as with
untreated hyperglycemia or mannitol administration
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○ Lastly, extreme elevations in plasma lipids and proteins can cause pseudohyponatremia
because there is no true decrease in extracellular sodium relative to water
● Hypernatremia
○ Hypernatremia results from either a loss of free water or a gain of sodium in excess of water
○ can be associated with an increased, normal, or decreased extracellular volume
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○ Hypervolemic (high volume) hypernatremia usually is caused either by iatrogenic

administration of sodium-containing fluids, including excess sodium bicarbonate, or
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mineralocorticoid as seen in hyperaldosteronism, Cushing’s syndrome, and congenital

adrenal hyperplasia.
○ Normovolemic (normal volume) hypernatremia can result from renal causes, including
diabetes insipidus, diuretic use, and renal disease, or from non renal water loss from the GI
tract or skin, although the same conditions can result in hypovolemic hypernatremia.
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○ Symptomatic hypernatremia usually occurs only in patients with impaired thirst or restricted
access to fluid because thirst will result in increased water intake
○ Central nervous system symptoms can range from restlessness and irritability to seizures,
coma, and death
○ The classic signs of hypovolemic hypernatremia (tachycardia, orthostasis, and hypotension)
may be present, as well as the unique findings of dry, sticky mucous membranes.

Composition Changes
● Potassium Abnormalities
○ The average dietary intake of potassium is approximately 50 to 100 mEq/d, which in the
absence of hypokalemia is excreted primarily in the urine
○ This small amount is critical to cardiac and neuromuscular function; thus, even minor
changes can have major effects on cardiac activity.
● Hyperkalemia
○ serum potassium concentration above the normal range of 3.5 to 5.0 mEq/L.
○ caused by excessive potassium intake, increased release of potassium from cells, or
impaired potassium excretion by the kidneys
○ Increased intake can be either from oral or IV supplementation, or from red cell lysis after
transfusion
○ [LOOK AT MNEMONICS ON PPT]
○ Number of medications can contribute to hyperkalemia, particularly in the presence of renal
insufficiency, including potassium-sparing diuretics, angiotensin-converting enzyme
inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs)
○ Symptoms of hyperkalemia are primarily GI, neuromuscular, and cardiovascular

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■ GI symptoms include nausea, vomiting, intestinal colic, and diarrhea

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■ Neuromuscular symptoms range from weakness to ascending paralysis to respiratory
failure.
● Hypokalemia
○ may be caused by inadequate potassium intake; excessive renal potassium excretion;
potassium loss in pathologic GI secretions, such as with diarrhea, fistulas, vomiting, or high

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nasogastric output; or intracellular shifts from metabolic alkalosis or insulin therapy
○ Additionally, drugs such as amphotericin, aminoglycosides, cisplatin, and ifosfamide that

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induce magnesium depletion cause renal potassium wastage
○ The symptoms of hypokalemia, like those of hyperkalemia, are primarily related to failure of
normal contractility of GI smooth muscle, skeletal muscle, and cardiac muscle.
○ Findings may include ileus, constipation, weakness, fatigue, diminished tendon reflexes,
paralysis, and cardiac arrest.
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○ In the setting of ECF depletion, symptoms may be masked initially and then worsened by
further dilution during volume repletion
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