Fluids

And
Electrolytes 1

Mary J. Aigner, RN, MSN, FNPC

Humans: How much water?

 Babies
– 70-80% water
– 20-30% solids
 Adults (>)
– 50-60% water
– 40-50% solids
– 70 kg man: avg 40L
 Elderly
– 45-55% water
– 45-55% solids
How divided? (70 kg man: 40L/42L)

Kozier/Lewis
How do F & E’s move in the body?

 Diffusion Plasma
Extracellular fluid

 Osmosis
Intracellular
Fluid
 Filtration

 Active Transport Interstitial Fluid

Cell Membrane
Diffusion
Diffusion tidbits

 Does not require any energy (to occur)

 Does not depend on pressure
 Occurs between body fluid and cells when solids
permeate the cell … excess solids in the cells =
diffusion of fluid into cell to equalize amount of solid
and fluid in cell

 Infusion of an isotonic IV solution (neutral) will have

no effect on the volume of fluid within the cells
 From what you’ve read…
what is the definition
Osmosis of ‘osmosis’???
 Osmosis tidbits

 Water moves from area of lesser concentration to area of

higher conc. = equal number of particles (solutes) per
quantity of water
 Pressure exerted by water to equalize both sides is called
osmotic pressure or osmolality
 Osmolality is influenced by sodium (a cation, Na +)
 Only water moves
 Does not require energy (to occur)
 Depends on both hydrostatic (BP) and osmotic pressure
Example of Osmosis: Thirst

 Thirst mechanism
– Water lost (eg. sweating,
diuretic abuse)
 Results in < ECF fluid
– Message sent to
hypothalamus
 Creates thirst
– Person drinks fluid
 Once enough fluid replaced,
message stops to hypothalamus
and thirst is gone
 *either area could
be high or low
Filtration pressure

(capillary) high pressure area*

(interstitial fluid) low pressure area*

 Interstitial Fluid:
80% of ECF that surrounds cells
20%: Plasma or intravascular fluid

Filtration tidbits and transcellular fluid (in GI,

cerebrospinal, intraocular)

 Fluid moves through cell membrane because of

liquid pressure differences on both sides of the
cell membrane
– Eg. hydrostatic pressure (BP)
 Process is active in capillaries – sometimes
called capillary pressure
– Result of heart pumping blood in the capillaries
 As blood enters (pumped) capillaries, pressure >,
fluid/electrolytes/waste move out of capillaries into interstitial
spaces
Plasma Pressure –
opposes capillary pressure

 Opposing pressure – plasma pressure – moves

f/e/w back into capillaries
– Contains proteins (albumin, globulin, fibrinogen)
– This pressure is generally greater than hydrostatic
pressure and prevents leakage of fluid back into
interstitial spaces
 Ifproteins somehow leak into interstitial fluid, lymph system
returns them (quickly) to the plasma
 Plasma is only ECF influenced by changes in body’s fluid
balance
Also – leaking of fluid from intravascular spaces into
interstitial spaces is called hypovolemia, can lead to shock
or tissue edema.
When does edema occur?
(when normal filtration fails)

 If pressure from the heart

changes
– Eg. right sided heart failure

 Capillary pressure will exceed the

hydrostatic pressure in the
interstitial fluid
– Causes fluid to travel from capillaries
into interstitial spaces
Active transport

 Takes energy (ATP used for Na/K transport)

– Therefore, different from diffusion and osmosis
A substance combines with a carrier on
outside surface of cell membrane
– Together, they move across the membrane
– Once inside, they separate and substance
released in cell
– Specific carrier for each substance (enzymes)
ATP = adenosine triphosphate (produced in mitochondria)
Active transport tidbits
 Problems with oxygen intake affects production of ATP (O2
needed to make ATP)
– Eg. chest injury = < O2 intake = < ATP production = failure of Na
and K pumps to work efficiently = cellular swelling = eventual lysis
(cells burst) = cellular death

 Active transport is the medium in which substances are

absorbed into cells to carry out metabolic activities

 The actual energy for active transport comes from breaking off
a phosphate group from an ATP molecule.

 Remember: Na and K are transported into the ICF by active

transport … but in opposite directions.
Practice Questions:
1. What are 4 transport
methods associated with
capillary permeability?
Osmosis, diffusion, filtration,
And active transport
6. True or False: When
plasma pressure is less
than hydrostatic pressure,
fluid leaks into the
interstitial spaces.
True
1. In right sided heart failure,
edema may occur as a
result of:
Capillary pressure exceeds the
hydrostatic pressure in the
interstitial fluid…causes fluid to
move from capillaries into
interstitial spaces.
7. True or False: When K is
transported across the cell
membrane by active
transport, water follows.
False
Some Facts re Fluid Balance

 Total body sodium content:

– Determines fluid or volume status
– Majority in extracellular fluid (85-90%)
– Thus – principal osmotic ion in extracellular space
– Actively pumped between compartments by ion
pumps
– Water passively follows (Na+) ions to equilibrate
between all compartments
– Regulated by renal and GI systems

Saunders, 2000
 SIADH causes
water retention

Regulation of Water Balance in Body

 Hypothalamic – osmoreceptors
– Stimulate thirst and ADH release
 Pituitary Regulation
– an increase in plasma osmolality or decreased circulating
volume stimulates ADH release
(ADH synthesized in hypothalamus, stored in posterior
pituitary, acts in renal distal and collecting tubules
causing water reabsorption – decreased urine
output)
Diabetes Insipidus causes dilute urine in
copius amounts because of <ADH
release or action
More regulation

ECF is maintained by a combination of hormones

– ADH affects H2O absorp. only

 Adrenal Cortical Regulation – two hormones

– Glucocorticoids (eg. cortisol) have anti-inflam. effect
and increase serium glucose levels
 Cortisol excreted normally but > with stress
– Mineralocorticoids (eg. aldosterone) enhance Na
retention and K excretion. When Na is reabsorped,
H2O follows 2° osmotic changes
 And more …

 Renal: primary organ for regulating F&E balance

– Total plasma volume filtered multiple times daily
– Kidney reabsorbs 99% of filtrate normally
– Produces approx. 1.5L urine daily
– Maintains balance between fluid and lytes
Impaired renal function ---
edema, K and P retention, acidosis, and other
electrolyte imbalances
Elderly may have decreased ability to concentrate urine
Almost done …with regulation

 Cardiac
– ANF (atrial natriuretic factor) – hormone released in
response to >volume/atrial pressure
 Vasodilation and increased urine excretion of Na and H2O
which decreases blood volume
 GI
– Water I&O usually 2000-3000 cc/day

 Insensible H2O loss

– Invisible vaporization from lungs and skin (not sweat)
– Sweating is sensible perspiration or loss
 Practice Questions on Fluid Balance
Regulation

1. What ion primarily affects 1. Why is #2 on left true or

fluid balance? false (why does this
happen)?
To maintain equilibrium
Na+
between fluid
compartments.

7. True or False: water is 6. True or False: the lungs

actively transported across
the cell membrane.
False, it passively follows
the Na+ ion.
and heart are the primary
organs that regular fluid
balance in the body.
False, kidneys primarily
regulate F&E.
Fluid Deficit (FVD) and
Fluid Overload (FVE)

Body
retains
Water
ECF excess H2O
Lytes and Na in a
similar ratio
as normal ECF
 Weight Loss:
Risks/Causes of 2% = mild FVD
5% = moderate
FVD (>Na) 8% = severe

Risk Factors (Kozier)

 Loss H2O, lytes from:

– NG suction
– N/V – Abnormal drainage
– Diarrhea
– Excessive sweating
– Anorexia
– Polyuria – Can’t access fluids
– Fever – Dysphagia
– Confusion, depression

Kozier
What are the symptoms of FVD?
(volume depletion)

 Mild
– Thirst, fatigue
 Moderate
– Anorexia, N, cramps, crying w/o tears, no
axillary sweating, near-syncope
 Severe
– Lethargy, confusion
 Moribund
– Cool extremities

Saunders, 2000
Signs of FVD

 Mild:
– Dry mucosa, concentrated urine
 Moderate:
– Resting >HR, < urine output, < weight, flat neck veins
– Orthostatic hypotension
 Severe:
– Sunken eyes, hypotention, hypothermia
 Moribund:
– Vasoconstriction (*what effect will this have for you?)
– Shock, coma
Saunders, 2000
FVDeficit – Nursing Diagnoses

 Deficient fluid volume r/t

excessive ECF losses or
decreased fluid intake
 Decreased cardiac output r/t
(same)

 Potential Complication:
hypovolemic shock
FVD Interventions

 Monitor weight, VS (w/temp), I&O,

 Assess skin turgor, breath sounds,
 Frequent mouth care, Prevent skin
breakdown,
 Monitor Labs, Give oral/IV fluids as ordered
 and Provide safety measures
 Weight Gain:
2% = mild, 5% = mod, 8% = severe

Risks/Causes/Symptoms FVE/>Na

Risk Factors:
 Excess IV w/Na
 Excess PO Na
– Diet
– Meds (eg. Alka Seltzer, Fleet’s enema –
hypertonic)
 Impaired regulation
– Eg. CHF, renal failure, cirrhosis of liver
Kozier
What about FVE? (volume overload)

Symptoms
 Fatigue
 Extremity swelling (edema)
 Increased girth
 Exertional dyspnea
 Paroxysmal nocturnal dyspnea
 Resting dyspnea
 Early satiety
Saunders, 2000
 Signs of FVE

Signs
 Tachypnea
 Tachycardia; S4 sound
 Crackles
 Dependent edema
 Jugular vein distention
 Tender hepatomegaly
 Ascites
 Pleural effusion
 Subungual edema
 *Weight*
 FVExcess – Nursing Diagnoses

 Excess fluid volume related to increased Na and

H2O retention
 Ineffective airway clearance r/t (same)
 Risk for impaired skin integrity r/t edema
 Disturbed body image r/t edema/body appearance

 Potential Complications: pulmonary edema,

ascites
FVE - Interventions

 Monitor weight, VS (w/temp),

I&O, lab results
 Assess for edema, breath
sounds
 Place in Fowler’s position
 Administer diuretics as
ordered
 Restrict fluids/Na as ordered
 Prevent skin breakdown
Tonight’s assignment

Be prepared to
discuss both
fluids and
electrolytes.