a.

Right atrium – receives unoxygenated blood

HEART
- Hollow muscular organ about the size of a
closed fist which weighs approximately 300 grams
- Located at the center of the thorax, where it
occupies the space between the lungs (mediastinum)
- Lies obliquely where the base is at the upper
right and the apex is at the lower left.
from superior and inferior vena cava and
coronary sinus
b. Left atrium – receives oxygenated blood
from the lungs via the four pulmonary veins
VALVES OF THE HEART:
- Permits unidirectional flow of blood in the
heart and allows forward flow and prevents
backward flow of blood.

1. ATRIOVENTRICULAR VALVES (AV VALVES)

- separates the atria from the ventricles and
prevents backflow of blood from the
ventricles

a. Mitral (Bicuspid) valve

b. Tricuspid valve
LAYERS OF THE HEART
1. Endocardium – inner layer consists of
endothelial tissues that lines the inside of the heart
and valves
2. Myocardium – middle layer that forms most of
the heart wall. It is composed of striated involuntary
muscle fibers that cause the heart to contract
3. Epicardium – outer layer made up of
squamous epithelial cells overlying connective
tissues
2. SEMILUNAR VALVES (SL VALVES)
PERICARDIUM - prevents backflow of blood from
- Fibrous sac that surrounds the heart and the pulmonary arteries and aorta back into the
roots of the great vessels ventricles
- Consists of two layers:
a. Pulmonic valve
 Parietal Pericardium b. Aortic valve
 Visceral Pericardium

VASCULAR SYSTEM
CHAMBERS OF THE HEART: Aorta Systemic Arteries Arterioles
ATRIA – the upper collecting chambers separated Veins Venules Capillaries
by the inter-atrial septum; receives blood
returning to the heart and pumps blood into the
ventricles
Coronary Arteries
- Oxygenates and nourishes the heart especially
the myocardium;
- arises at the beginning of the aorta just above
the aortic valve
2 MAJOR CORONARY ARTERIES:
o RIGHT CORONARY- Supplies blood to most
areas of the right side of the heart
o LEFT CORONARY ARTERIES
a. Left Anterior Descending Artery
- Supplies blood to the septum
and anterior part of the heart
b. Left Circumflex Artery -
Supplies blood to the Left
Ventricle
Coronary Vein
- collects unoxygenated blood from the
myocardium and drains it into the Coronary Sinus.
GREAT VESSELS OF THE HEART:
1. Superior and Inferior Vena Cava
2. Pulmonary Arteries - carry oxygen-
poor blood out of the heart to the
lungs
3. Pulmonary Veins - return oxygenated
blood to the heart
4. Aorta - main artery that carries blood
away from your heart to the rest of your
body
CONDUCTION SYSTEM OF THE HEART
- controlled by the heart itself
SA node AV node Bundle of His
Purkinje Fibers Bundle Branches
PROPERTIES OF CARDIAC CONDUCTION:
1. Automaticity
2. Excitability
3. Conductivity
4. Contractility
5. Refractoriness
Repolarization – occurs when the cardiac cells
return to its baseline or resting state
Depolarization – rapid reversal of membrane
potential or electrical activation of the cell caused
by the influx of sodium into the cell while
potassium exits the cell
CARDIAC CYCLE - refers to one complete cycle of
the heart’s contraction and relaxation
Systole – portion of the cardiac cycle when the
ventricles depolarize and contract to pump blood
into the pulmonary and systemic circulation
 Atrial Systole
 Ventricular Systole
Diastole – portion of the cardiac cycle when the
ventricles repolarize and refill with blood
• Ventricular Diastole
Cardiac Output – amount of blood (in liters)
ejected by each ventricle in every minute
CO = Heart Rate x Stroke Volume
⮚ Heart Rate = number of complete
cardiac cycles per minute (Ave. =
75 beats/min)
⮚ Stroke Volume – volume of
blood ejected in each ventricle per
heartbeat (Ave – 70 mL/beat)
Starling’s Law of Heart – the further the heart is
stretched, the stronger it springs back to normal
FACTORS THAT INFLUENCE THE STROKE VOLUME:
• Preload
• Afterload
• Contractility
 FLUID VOLUME DIT URBANCE (hy po/hy per volemia deficit
excess) • Accurate assessment (I&O, wt, v/s, CVP,
LOC and breath sounds and skin color) to
HYPOVOLEMIA/ FLUID VOLUME DEFICIT determine need to slow therapy to prevent
- ECF loss > fluid intake overload
- Water and electrolytes are lost in the SAME  I&O is monitored q8h
PROPORTION (fluid volume decreases but water and  Daily weight (loss of .5kg = loss of
electrolyte ratio is STILL THE SAME) .5L)
- Different from DEHYDRATION (loss of water  Assess for orthostatic
alone, causing increased serum sodium) hypotension (decreased systolic
- Occurs rapidly when coupled with fluid intake
pressure by
CAUSES/RISK FACTORS: 15mmHg from lying to sitting
- FLUID LOSS position)
 Check for skin turgor
• Diabetes insipidus (forehead, sternum and inner
• Adrenal insufficiency thigh)
• Osmotic diuresis  Assess the oral cavity and
• Hemorrhage tongue (small and with multiple
• Third-space fluid shifting longitudinal furrow)
 Assess LOC
- low fluid intake
• Comatose  FLUID CHALLENGE TEST – for
S/Sx: patients with U.O., to
determine presence of Acute
• Decreased BP/Orthostatic Hypotension Tubular Necrosis (ATN) caused by
• Acute weight loss prolonged FVD
• Decreased skin turgor
• Oliguria/Concentrated urine ✔ Amount of fluids are given at
• Rapid but weak pulse specific rates/intervals while
• Decreased CVP patients hemodynamic response is
• Cool and clammy skin monitored (V/S/, LOC, CVP, U.O.,
• Thirst and anorexia Breath sounds)
✔ For patients with ATN, still
ASSESSMENT AND Dx FINDINGS: U.O., and for patients with
normal
• Hct
renal function, U.O.
• Urine specific gravity
• Hyper (adrenal insufficiency) and Hypo  Shock – 25% loss of
(GI and renal losses) kalemia intravascular fluid
• Hyper (DI) and Hypo (Osmotic
 FVD prevention measures by
Diuresis) natremia
identifying and controlling risk
MANAGEMENT:
 OFI depending on patient’s
• Oral fluid replacement for mild losses likes and dislikes and type of
fluid patient has lost
• IV route is required for acute and
 Oral rehydration solution can
severe cases
be given
- Fluid of choice for hypotensive patients:
ISOTONIC SOLUTION (PNSS/PLRS); As soon
as BP normalizes, HYPOTONIC SOLUTIONS
HYPERVOLEMIA/FLUID VOLUME EXCESS

- Isotonic expansion of ECF caused by

abnormal retention of water and sodium in
same proportions; Always caused by
increased sodium in the body
 Causes: EDEMA
- Fluid overload (excessive intake/ - cause by hydrostatic pressure/ ECF
administration of Na-containing fluid) volume
- function of the homeostatic mechanisms - can be localized/generalized(anasarca)
(renal, heart and liver failure) - usually affects dependent areas
(Periorbital region, Ankle, Sacrum and
S/Sx:
Scrotum)
• Edema - Pitting edema – pit forms after finger-press
• Distended neck vein - Pulmonary Edema – fluid in alveoli
• Crackles and shortness of breath and pulmonary interstitium
• H.R. - Ascites – fluids that accumulate in the
• BP peritoneal cavity caused by nephritic
• Pulse pressure syndrome, cirrhosis and some
• CVP malignant tumors
• Wt. *S/sx: shortness of breath/pressure
• U.O. sensation, abdominal bloating

ASSESSMENT AND Dx FINDINGS:

• BUN
• Hct
• Serum Sodium/Osmolality

MANAGEMENT:
• Management is directed at the cause MANAGEMENT:
• Symptomatic treatment
• DIURETICS
• Administer DIURETICS as prescribed
• Extremity elevation
- decreases reabsorption of sodium
• Elastic compression stockings
- Thiazide diuretics – given for
• Paracentesis (for ascites)
mild cases
• Dialysis
- Loop – for severe cases
(S/E: decreased potassium
and magnesium levels)
• Hemodialysis/Peritoneal Dialysis
- removal of water, sodium and
nitrogenous wastes
- to control potassium levels
and acid-base balance
• Nutritional Therapy
- Dietary restriction of sodium/Low
sodium diet of 250mg/day (normal
average intake: 6-15 g of salt)
- Advise the patient to read food
and beverage labels
- Provide patient the option of
consuming salt substitutes
(usually contains potassium)
- Consume distilled water (local
water supply may contain
high volumes of sodium)
FLUID AND ELECTROLYTE
FLUID
- 60% of adult’s body wt. consists of fluid
(water and electrolytes)
FACTORS AFFECTING AMOUNT OF BODY FLUID:
• Body fat (thin > obese)
• Gender (male > female)
• Age (young > adult)
Highest volume of water
– a) skin, b) muscle, c) blood
2 Body fluid compartments:
Intracellular – 2/3 of body fluid
Extracellular – 1/3 of body fluid
• Intravascular
- 6L
- FLUID: blood (3L plasma, 3L
formed elements)
• Interstitial
- 12L
- FLUID: fluid surrounding cells
• Transcellular
- 1L
- FLUID: fluids in body cavities (e.g.
CSF, Pericardial, Intraocular,
Pleural, Sweat/Tears, Digestive
Secretions)
- ICF and ECF normally shifts between
each other to maintain EQUILIBRIUM
- DISEQUILIBRIUM happens if there’s:
 a LOSS OF FLUID from the body
 THIRD SPACE FLUID SHIFT
- fluid shifts into a space
that doesn’t contribute to
equilibrium
- Fluid shift from
INTRAVASCULAR into
INTERSTITIAL (edema) and
into TRANSCELLULAR space
Manifestations:
• H.R.
• Wt.
• BP
• CVP
• I=O
ELECTROLYTES
- active chemicals either positively
(CATIONS) or negatively (ANIONS) charged
- measured in mEq/L
- most accessible medium of measuring
electrolyte concentration: plasma
MAJOR ELECTROLYTES IN THE BODY:
N.V. (Serum)
a) Sodium: 135 – 145
mEq/L Potassium: 3.5 – 5
mEq/L
b) Calcium: 4.5 – 5.5 mEq/L
c) Magnesium: 1.5 – 2.5 mEq/L
Phosphorus: 2.5 – 4.5 mg/dl
d) Chlorine: 96 – 106 mEq/L
FLUID SHIFTING
• Hydrostatic pressure – pressure
exerted by fluid on blood vessel
wall
• Osmotic pressure – pressure
exerted by plasma cells
REGULATION OF BODY FLUID
COMPARTMENT
OSMOSIS – FLUID moves from LOWER to
HIGHER solute concentration
Related terms:
 Osmolality – Solute concentration
 Tonicity – ability of solute to cause
osmosis (Hypertonic/↑tonicity
osmoles: Na, Mannitol and Glucose)
 Osmotic pressure – concentration of
solute that is needed to stop osmosis
 Oncotic pressure – osmotic pressure
exerted by proteins
 Osmotic diuresis - ↑U.O. caused by
excretion of hypertonic osmoles
 (+) Penrose drain = 50mL
DIFFUSION – SOLUTE moves from area of HIGHER  (+) IFC = 1.2L
CONCENTRATION to LOWER CONCENTRATION  (+) NGT, oral feeding = 800 mL
 BT = 250cc/bag x 2
 (+) IVF = @1000cc(start of shift)
and @100cc (end of shift)
 (+) Colostomy = 300mL
 Suctioned oral secretions = 50 mL
FILTRATION – Intravascular to Interstitial Shift
Hydrostatic Pressure to ↑Hydrostatic Pressure
LAB TEST FOR FLUID STATUS:
- 180L of plasma is being filtered by the
kidney every 24 hours a) Serum OSMOLALITY (mOsm/kg) and
OSMOLARITY (mOsm/L)
ACTIVE TRANSPORT - energy must be expended to
- plasma sodium concentration
allow movement against a concentration gradient
- Normal value: 275-300

b) Urine OSMOLALITY (mOsm/kg) and

OSMOLARITY (mOsm/L)
- Most reliable indicator of
urine concentration
- Normal value: 250-900

c) Urine Specific Gravity

- Measures kidney’s ability to
ROUTES of GAINS and LOSSES: conserve and excrete water
- Normal value: 1.010 – 1.025
• Input: Oral (eating and drinking), - Inversely proportional to U.O.
Parenteral and Enteral administration of
fluids d) Blood Urea Nitrogen (BUN)
• Output - End product of of the metabolism
Kidneys of protein by the liver
- 1mL/kg/hr or 1 1/2 L of urine every day - Made up of urea
- Normal value: 10 – 20 mg/dL
Skin - INCREASES with: Increased
- Sensible perspiration (0-1L/hour) protein intake, GI
- Insensible perspiration (600mL/day) bleeding, dehydration and
through evaporation decreased renal function
- DECREASES with: liver
Lungs
disease, decreased protein
- Insensible (400mL/day) water vapor loss
intake/starvation, fluid
- increased loss in DRY climate/ R.R.
overload
GIT - Inversely proportional to
- 100-200 mL/day renal function
e) Serum Creatinine • Other Mechanisms:
- End product of muscle metabolism
 Baroreceptors
- Better indicator of renal function because
 RAAS
it is not affected by protein
 Osmoreceptors
intake/metabolic state
 ADH + Thirst
- Normal value: 0.7-1.4 mg/dL
 Release of ANP/ANF by atrial
cardiac cells
f) Hematocrit
- Percentage of RBC vs. WHOLE BLOOD
- Normal value: Males: 42-52% Females: 35-
47%
- HIGH in: dehydration/polycythemia
- LOW in: overhydration/anemia

HOMEOSTATIC MECHANISMS:

• Kidney – regulates ECF, electrolytes

(selective retention and excretion) and
pH (retaining H ions)
- excretion of metabolic wastes
and toxins
- responds to ADH and aldosterone
- thus, renal failure causes
multiple fluid and electrolyte
imbalances
• Heart and Blood Vessels- blood being
pumped by the heart circulates through
the blood vessels and being filtered in the
kidney for excretion
• Lung - regulation of pH
- medium of insensible fluid loss
• Pituitary – stores ADH secreted by
the hypothalamus
• Adrenal Glands – secretion of
ALDOSTERONE at the ADRENAL CORTEX
which promotes sodium and water
retention, and potassium excretion
• CORTISOL produced in ADRENAL MEDULLA
when secreted/administered in large
quantities can also cause sodium and
water retention
• Parathyroid Glands – Calcium
and phosphate balance
• Increases serum calcium by bone
resorption and absorption in the intestine