Fluid and Electrolyte Balance sArYono WHY IS IT IMPORTANT FOR NURSES TO KNOW ABOUT FLUID & ELECTROLYTE BALANCE

? INTRODUCTION Water is found everywhere on earth including human body In an adult 60% of the weight is water Two third of the bodys water is found in the cell

and 60% of male total body mass Intracellular fluid (ICF) inside cells About 2/3 of body fluid Extracellular fluid (ECF) outside cells Interstiti al fluid between cell is 80% of ECF Plasma in blood is 20% of ECF Also includes lymph, cerebros pinal fluid, synovial fluid, aqueous humor, vitreous body, endolym ph, perilymp h, pleural, pericardi al, and peritone al fluids Fluids

Body weight of adult male 55-60%, female 5055%, newborn 75-80% Very little in adipose tissues Loss of 20% fatal Elderly decreases to 4550% of body weight R/T decrease d muscle mass, smaller fat stores, and decrease in body fluids

Functions of Water in the Body Transporting nutrients to cells and wastes from cells Transporting hormones, enzymes, blood platelets, and red and white blood cells Facilitating cellular metabolism and proper cellular chemical functioning Acting as a solvent for electrolytes and nonelectrolytes Helping maintain normal body temperature Facilitating digestion and promoting elimination Acting as a tissue lubricant

Fluid Shifts in Infants predisposed to serious, rapid fluid volume deficit limited ability to concentr ate urine proporti onately greater ratio of surface area to volume higher metaboli c rate

Body Fluid Compartments In lean adults, body fluids constitute 55% of female

Variations in Fluid Content Healthy person total body water is 50% to 60% of body weight An infant has considerably more body fluid and ECF than an adult More prone to fluid volume deficits Sex and amount of fat cells affect body water Women and obese people have less body water Total Body Water It is measured by isotope water dilution technique (Deuterium) Males Females Infants TBW 60% 50% 80%

A rise in ambient temp. leads to hyperventilation, excessive sweating and insensible loss For a rise in body temp. of 1C, there is an extra loss of 200ml/day

Compartments Intracellular (ICF) Fluid within the cells themselves 2/3 of body fluid Located primarily in skeletal muscle mass Provide nutrients for metabolism: High in K, Po4, protein Moderate levels of Mg, So4 Assists in cellular metabolism Compartments Extracellular (ECF) 1/3 of body fluid

4. Operation & Trauma: due to increased aldosterone & ADH secretions in neuro- endocrine response. Fluid collect in 3 space. Dehydration. Overhydration can lead to pulmonary edema, wound dehiscence & hyponatremia. Body Fluid Compartments Body Fluid Compartments 2/3 (65%) of TBW is intracellular (ICF) 1/3 extracellular water 25 % interstitial fluid (ISF) 5- 8 % in plasma (IVF intravascular fluid) 1- 2 % in transcellular fluids CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)
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Comprised of 3 major components Intravascular Plasma Interstitial Fluid in and around tissues Transcellular Over or across the cells Compartments Extracellular Nutrients for cell functioning Na Ca Cl Glucose Fatty acids

Factors influence TBW 1. Age: Infants need more fluids because of large surface area. high growth rate,

2. Body weight: in obese (fatty) persons decrease 10-20% while in muscular (lean) ones increase 10-20%.

3. Temperature:

Amino Acids Compartments Intravascular Component Plasma fluid portion of blood Made of: water plasma proteins small amount of other substances Compartments Interstitial component Made up of fluid between cells Surrounds cells Transport medium for nutrients, gases, waste products and other substances between blood and body cells Back-up fluid reservoir Compartments Transcellular component 1% of ECF Located in joints, connective tissue, bones, body cavities, CSF, and other tissues Potential to increase significantly in abnormal conditions Fluid compartments are separated by membranes that are freely permeable to water. Movement of fluids due to: hydrostatic pressure osmotic pressure\

Capillary filtration (hydrostatic) pressure Capillary colloid osmotic pressure Interstitial hydrostatic pressure Tissue colloid osmotic pressure Balance Fluid and electrolyte homeostasis is maintained in the body Neutral balance: input = output Positive balance: input > output Negative balance: input < output Electrolyte Composition of Body Fluid Compartments Cairan ekstrasel dan intrasel Composition of GI Fluids (mEq/L) Fluid Balance 2 barriers separate ICF, interstitial fluid and plasma Plasma membrane separates ICF from surrounding interstitial fluid Blood vessel wall divide interstitial fluid from plasma Body is in fluid balance when required amounts of water and solutes are present and correctly proportioned among compartments An inorganic substance that dissociates into ions in solution is called an electrolyte Water is by far the largest single component of the body making up 45-75% of total body mass Process of filtration, reabsorption, diffusion, and osmosis all continual exchange of

water and solutes among compartments Sources of Body Water Gain and Loss Fluid balance related to electrolyte balance Intake of water and electrolytes rarely proportional Kidneys excrete excess water through dilute urine or excess electrolytes through concentrated urine Body can gain water by Ingestion of liquids and moist foods (2300mL/day) Metabolic synthesis of water during cellular respiration and dehydration synthesis (200mL/day) Body loses water through Kidneys (1500mL/day) Evaporation from skin (600mL/day) Exhalation from lungs (300mL/day) Feces (100mL/day) Daily Water Gain and Loss Regulation of body water gain Mainly by volume of water intake Dehydration when water loss is greater than gain Decrease in volume, increase in osmolarity of body fluids Stimulates thirst center in hypothalamus Regulation of water and solute loss

Elimination of excess body water mostly through urine Extent of urinary salt loss is the main factor that determines body fluid volume Main factor that determines body fluid osmolarity is extent of urinary water loss 3 hormones regulate renal Na+ and Cl- reabsorption (or not) Angiotensin II and aldosterone promote urinary Na+ and Clreabsorption of (and water by osmosis) when dehydrated Atrial natriuretic peptide (ANP) promotes natriuresis, excretion of Na+ and Cl- followed by water excretion to decrease blood volume 27_table_01 Hormonal Regulation of Na+ and ClMajor hormone regulating water loss is antidiuretic hormone (ADH) Also known as vasopressin Produced by hypothalamus, released from posterior pituitary Promotes insertion of aquaporin2 into principal cells of collecting duct Permeability to water increases Produces concentrated urine Movement of water between compartments Normally, cells neither shrink or swell because intracellular and interstitial fluids have the same osmolarity

Increasing osmolarity of interstitial fluid draws water out of cells and cells shrink Decreasing osmolarity of interstitial fluid causes cells to swell Changes in osmolarity most often result from changes in Na+ concentration Water intoxication drinking water faster than the kidneys can excrete it Can lead to convulsions, coma or death Series of Events in Water Intoxication Electrolytes in body fluids Ions form when electrolytes dissolve and dissociate 4 general functions Control osmosis of water between body fluid compartments Help maintain the acid-base balance Carry electrical current Serve as cofactors Concentrations in body fluids Concentration of ions typically expressed in milliequivalents per liter (mEq/liter) Na+ or Cl- number of mEq/liter = mmol/liter Ca2+ or HPO42- number of mEq/liter = 2 x mmol/liter Chief difference between 2 ECF compartments (plasma and interstitial fluid) is plasma

contains many more protein anions Largely responsible for blood colloid osmotic pressure ICF differs considerably from ECF ECF most abundant cation is Na+, anion is ClSodium Impulse transmission, muscle contraction, fluid and electrolyte balance Chloride Regulating osmotic pressure, forming HCl in gastric acid Controlled indirectly by ADH and processes that affect renal reabsorption of sodium ICF most abundant cation is K+, anion are proteins and phosphates (HPO42-) Potassium Resting membrane potential , action potentials of nerves and muscles Maintain intracellular volume Regulation of pH Controlled by aldosterone Na+ /K+ pumps play major role in keeping K+ high inside cells and Na+ high outside cell Solutes dissolved particles Electrolytes charged particles Cations positively charged ions Na+, K+ , Ca++, H+ Anions negatively charged ions Cl-, HCO3- , PO43-

Non-electrolytes - Uncharged Proteins, urea, glucose, O2, CO2 Body fluids are: Electrically neutral Osmotically maintained Specific number of particles per volume of fluid Homeostasis maintained by: Ion transport Water movement Kidney function Osmolality Concentration of body fluids affects movement of fluid by osmosis Reflects hydration status Measured by serum and urine Solutes measured - mainly urea, glucose, and sodium Measured as solute concentration/Kg Osmolality Serum Osm/L = (serum Na x 2) + BUN/3 + Glucose/18 Normal serum value - 280-300 mOsm/Kg Serum <240 or >320 is critically abnormal Normal urine Osm 250 900 mOsm / kg Factors that affect Osmolality Serum Increasing Osm Free water loss

Diabetes Insipidus Na overload Hyperglycemia Uremia Factors that affect Osmolality Serum Decreasing Osm SIADH: The syndrome of inappropriate antidiuretic hormone hypersecretion Renal failure Diuretic use Adrenal insufficiency Factors that affect Osmolality Urine Increasing Osm Fluid volume deficit SIADH: The syndrome of inappropriate antidiuretic hormone hypersecretion Heart Failure Acidosis Factors that affect Osmolality Urine Decreasing Osm Diabetes Insipidus Fluid volume excess Urine specific gravity Factors affecting urine Osm affect urine specific gravity identically Electrolyte and protein anion concentrations

COMMON ELECTROLYTES Sodium (Na++) Functions Regulates volume of body fluids Maintains water balance Regulates ECF Influences ICF Generation and transmission of nerve impulses Sodium-Potassium pump Sodium Na+ Most abundant ion in ECF 90% of extracellular cations Plays pivotal role in fluid and electrolyte balance because it account for almost half of the osmolarity of ECF Level in blood controlled by Aldosternone increases renal reabsorption ADH if sodium too low, ADH release stops Atrial natriuretic peptide increases renal excretion Review of Sodium Ion Its an electrolyte! Important: Maintenance of ECF vol. Effects osmotic pressure Essential for conduction of nerve impulses Muscle contractions

Normal sodium level: 135-145 mmol/L Impulse Conduction Hyponatremia Regulation of Sodium Renal tubule reabsorption affected by hormones: Aldosterone Renin/angiotensin Atrial Natriuretic Peptide (ANP) Chloride ClMost prevalent anions in ECF Moves relatively easily between ECF and ICF because most plasma membranes contain Cl- leakage channels and transporters Can help balance levels of anions in different fluids Chloride shift in RBCs Regulated by ADH governs extent of water loss in urine Processes that increase or decrease renal reabsorption of Na+ also affect reabsorption of ClCHLORIDE (Cl ) Chief extracellular anion Functions Works with sodium to maintain osmotic pressure of blood Regulates acid-base balance Buffering action during O2/CO2 exchange Production of Hydrochloric acid in digestion
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Potassium K+ Most abundant cations in ICF Key role in establishing resting membrane potential in neurons and muscle fibers Also helps maintain normal ICF fluid volume Helps regulate pH of body fluids when exchanged for H+ Controlled by aldosterone stimulates principal cells in renal collecting ducts to secrete excess K+ POTASSIUM (K+) Major cation in ICF Reciprocal to sodium Functions Regulates cellular enzyme activity and water content Transmission of nerve and muscle impulses Metabolism of proteins and carbohydrates Regulation of acid-base balance by cellular exchange with H+ Potassium and Hydrogen Ions Regulation of Potassium Through kidney Aldosterone Insulin Bicarbonate HCO3Second most prevalent extracellular anion Concentration increases in blood passing through systemic

capillaries picking up carbon dioxide Carbon dioxide combines with water to form carbonic acid which dissociates Drops in pulmonary capillaries when carbon dioxide exhaled Chloride shift helps maintain correct balance of anions in ECF and ICF Kidneys are main regulators of blood HCO3Can form and release HCO3when low or excrete excess BICARBONATE (HCO3-) Major chemical base buffer Found in ECF and ICF Function Essential for acid base balance. Works with carbonic acid to make up the bodys acid base buffer system Calcium Ca2+ Most abundant mineral in body 98% of calcium in adults in skeleton and teeth In body fluids mainly an extracellular cation Contributes to hardness of teeth and bones Plays important roles in blood clotting, neurotransmitter release, muscle tone, and excitability of nervous and muscle tissue Regulated by parathyroid hormone

Stimulates osteoclasts to release calcium from bone resorption Also enhances reabsorption from glomerular filtrate Increases production of calcitriol to increase absorption for GI tract Calcitonin lowers blood calcium levels CALCIUM (Ca++) Most abundant electrolyte in body 99% found in bones and teeth Functions Nerve impulse transmission and blood clotting Catalyst for muscle contraction Thickness and strength of of cell membranes Phosphate About 85% in adults present as calcium phosphate salts in bone and teeth Remaining 15% ionized H2PO4-, HPO42-, and PO43- are important intracellular anions HPO42- important buffer of H+ in body fluids and urine Same hormones governing calcium homeostasis also regulate HPO42- in blood Parathyroid hormone stimulates resorption of bone by osteoclasts releasing calcium and phosphate but inhibits reabsorption of phosphate ions in kidneys

Calcitriol promotes absorption of phosphates and calcium from GI tract PHOSPHATE (PO4-)

Metabolism of carbohydrates and proteins Vital enzyme actions Protein and DNA synthesis Maintaining intracellular levels of Potassium Maintain electrical activity in nervous tissue and muscle tissue membranes OTHER ELECTROLYTES Sulfate Anion ICF Excreted in the kidney Lactic acid Anion Facilitates diffusion to and from capillaries 27_table_02 DISTRIBUTION OF BODY FLUIDS Body fluids are distributed in two distinct compartments: 1.Extracellular fluids[ECF] Which includes interstitial fliud & intravascular fluid 2.Intracellular fluids[ICF] COMPOSITION OF BODY FLUIDS The fluids circulating throughout the body in extracellular and intracellular fluid spaces contain 1.Electrolytes 2.Minerals 3.Cells FLUID AND ELECTROLYTE MOVEMENT

Major anion in body cells Buffer in ICF and ECF Functions Maintains bodys acid-base balance Cell division and transmission of heredity Chemical reactions use of Vit B, CHO metabolism, nerve and muscle action Magnesium In adults, about 54% of total body magnesium is part of bone as magnesium salts Remaining 46% as Mg2+ in ICF (45%) or ECF (1%) Second most common intracellular cation Cofactor for certain enzymes and sodium-potassium pump Essential for normal neuromuscular activity, synaptic transmission, and myocardial function Secretion of parathyroid hormone depends on Mg2+ Regulated in blood plasma by varying rate excreted in urine MAGNESIUM (Mg++) Second most important cation in ICF Functions

Osmosis Fluid passes from areas of low solute concentration to areas of high solute concentration Diffusion tendency of solutes to move freely from areas of high concentration to low concentration (down hill) Active Transport requires energy to move through a cell membrane from area of lesser concentration to one of greater concentration Filtration passage of fluid through a permeable membrane. Movement is from high to low pressure Transport of Water and Fluids Osmolality: concentration of a solution determined by the number of dissolved particles per kilogram of water. Osmolality controls water movement and distribution in body fluid compartments Diffusion: the random movement of particles in all directions through a solution Active transport: movement of solutes across membranes; requires expenditure of energy Filtration: transfer of water and solutes through a membrane from a region of high pressure to a region of low pressure Osmosis: movement of water across a membrane from a less concentrated solution to a more concentrated solution Factors Influence of Diffusion Temperature ---linear comparable

Particle consentration --inversely Molecule size --- inversely Molecule weight ---inversely Wide of Surface area --proportionate Far away ---inversely Factors influence of Osmotic Solute consentration in the solution Temperature Electrical potential Osmotic differ from solution Movements Fluid Imbalances Involves either volume or distribution of water or electrolytes Hypovolemia deficiency in amount of water and electrolytes in ECF with near normal water/electrolyte proportions Dehydration decreased volume of water and electrolyte change Third-space fluid shift distributional shift of body fluids into potential body spaces Fluid Volume Excess Hypervolemia excessive retention of water and sodium in ECF Overhydration above normal amounts of water in extracellular spaces Edema excessive ECF accumulates in tissue spaces

Interstitial-to-plasma shift movement of fluid from space surrounding cells to blood Fluid Volume Excess 2 Clinical manifestations edema, distended neck veins, crackles, tachycardia, increased blood pressure, increased weight Fluid Excess--Edema Excessive amount of fluid in EC compartment Edema: excessive amount of fluid in EC compartment Swelling Localized or general Highly visible or invisible Causes of Edema High Capillary Hydrostatic Pressure Cause of pulmonary edema Loss of Plasma Proteins Particularly albumin Obstruction of Lymphatic Circulation Localized Increased Capillary Permeability Localized High Capillary Hydrostatic Pressure Prevents return of fluid from interstitial compartment Which end of the capillary? OR forces excessive amounts of fluid out of caps into tissue Pulmonary edema

Excessive pressure forces fluid into alveoli Effect on respiratory function? Specific causes: High blood volume (hypervolemia) Loss of Plasma Proteins Particularly albumin Results in lower plasma osmotic pressure Fewer plasma proteins allow more fluid to leave cap Less fluid returned to venous end of cap Causes of protein loss? Obstruction of Lymphatic Circulation Localized Excessive fluid and protein not returned to general circulation Develops: Turmo or infection damage lymph node Lymph node removal Increased Capillary Permeability Localized Results from inflammatory response and infecton Histamines released increase permeability increase fluid movement to interstitial area Causes of Edema Effects of Edema Swelling (duh!) Pitting

Increased body weight Functional impairment Pain Impairment of arteriole circulation Other complications (as always!) Fluid Deficit--Dehydration Insufficient body fluid resulting either from inadequate intake or excessive loss or a combo Affect extracellular compartment 1st Vomit and lose fluid from digestive tract How is fluid replaced? Water loss accompanied by loss of electrolytes and protein (sweat) Electrolyte loss influence water balance significantly Isotonic Hypotonic Hypertonic Causes of Dehydration Vomiting, diarrhea Excessive sweating Diabetic ketoacidosis Insufficient water intake Effects of Dehydration Dry mucus membranes Low blood pressure High hematocrit How is fluid loss compensated?

Osmolarity of a solution Isotonic same concentration of particles as plasma Hypertonic greater concentration of particles than plasma Hypotonic lesser concentration of particles than plasma Filtration Colloid osmotic pressure Hydrostatic pressure Source of Fluids for the Body Ingested liquids Food Metabolism Fluid Losses Kidneys urine Intestinal tract feces Skin perspiration Insensible water loss REGULATION OF BODY FLUIDS Fluid intake Fluid output Hormonal influence Lymphatic influences Neurologic influences Renal influences Introduction to Fluid and Electrolyte Balance Intake must = Exhaust Water, lytes ECF or ICF

O2 and CO2 Many systems involved Kidneys most important BP Plays a role Hydrostatic and osmotic gradients Kidneys maintain H2O balance by regulating urine concentration Daily H2O intake balanced by H2O excretion (ins and outs) Kidneys react to changes in osmolarity, volume, and blood pressure Urine Concentration Established by LOH, CD and vasa recta reabsorption of varying amounts of H2O and Na+ Key player: ADH (= Vasopressin) LOH; loop of Henle CD: colecting duct Urine concentration, contd Often expressed in osmolarity mM/L or osmolality mM/kg Blood: 300 mOsm

Control of Fluid Balance Hypothalamus Thirst mechanism Osmoreceptors ADH Hormone Controls amount of fluid leaving in urine Promotes reabsorption in kidney tubules Aldosterone Hormone Determines reabsorption of sodium and water in kidney tubules MECHANISMS OF HOMEOSTASIS Kidneys Cardiovascular system Lungs Adrenal Glands Thyroid Gland Parathyroid Gland Gastrointestinal tract

Adrenal glands help body conserve sodium, save chloride and water, and excrete potassium. Thyroid gland increases blood flow in body and increases renal circulation. Effect of ADH Controls Urine concentration via regulation of water reabsorption from the filtrate in the collecting duct Osmoreceptors in hypothalamus ADH caused by: Na+ and/or osmolality in the ECF H2O deprivation renal blood flow Effect of ADH, contd LOH: Countercurrent Multiplier leads to Hyperosmotic IF in medulla Hyposmotic fluid leaving LOH Regulation of BP: RAAS Pathways RAAS = renin-angiotensinaldosterone system JG cells release renin in response to BP Renin converts Angiotensinogen to Angiotensin I ANG I converted to ANG II by ACE RAAS Pathways, contd ANG II causes BP via ADH Secretion

Filtrate in Bowmans Capsule: 300 mOsm Bottom of LOH: 1200 mOsm Urine: 50-1200 mOsm Regulated by ADH (vasopressin) Osmoreceptors in hypothalamus BP and blood volume, too HOMEOSTASIS PROCESS OF MAINTAINING A STABLE STATE UNDER VARIABLE CONDITIONS

Nervous system Primary Organs of Homeostasis Kidneys normally filter 170 L plasma, excrete 1.5 L urine. Cardiovascular system pumps and carries nutrients and water in body. Lungs regulate oxygen and carbon dioxide levels of blood. Primary Organs of Homeostasis, continued

Thirst Vasoconstriction Sympathetic stimulation of heart HR and CO ACE inhibitors will BP Adrenal Cortex Mineralocorticoids Regulate the electrolyte concentrations of extracellular fluids Aldosterone most important mineralocorticoid Maintains Na+ balance by reducing excretion of sodium from the body Stimulates reabsorption of Na+ by the kidneys Mineralocorticoids Aldosterone secretion is stimulated by: Rising blood levels of K+ Low blood Na+ Decreasing blood volume or pressure Aldosterone Mechanism The Four Mechanisms of Aldosterone Secretion Renin-angiotensin mechanism kidneys release renin, which is converted into angiotensin II that in turn stimulates aldosterone release Plasma concentration of sodium and potassium directly influences the zona glomerulosa cells

ACTH causes small increases of aldosterone during stress Atrial natriuretic peptide (ANP) inhibits activity of the zona glomerulosa The Four Mechanisms of Aldosterone Secretion Adrenal Medulla Made up of chromaffin cells that secrete epinephrine and norepinephrine Secretion of these hormones causes: Blood glucose levels to rise Blood vessels to constrict The heart to beat faster Blood to be diverted to the brain, heart, and skeletal muscle Adrenal Medulla Epinephrine is the more potent stimulator of the heart and metabolic activities Norepinephrine is more influential on peripheral vasoconstriction and blood pressure Stress and the Adrenal Gland Regulation of Fluid Volume, cont. Antidiuretic hormone (ADH) Produced by the hypothalamus Stored in the pituitary gland Restores blood volume by increasing or decreasing excretion of water Increased osmolality or decreased blood volume stimulates the release of ADH

Then the kidneys reabsorb water Also may be released by stress, pain, surgery, and some meds Regulation of Fluid Volume, cont. Renin-angiotensin-aldosterone system Renin secreted in kidney Amount of renin produced depends on blood flow and amount of Na in the blood Produces angiotensin II (vasoconstrictor) Angiotensin causes peripheral vasoconstriction Angiotensin II stimulates the production of aldosterone Regulation of Fluid Volume, cont. Aldosterone Secreted by the adrenal gland response to angiotensin II The adrenal gland may also be stimulated by the amount of Na and K + in the blood Causes the kidneys to retain Na and H2O Leads to increases in fluid volume and Na levels Decreases the reabsorption of K+ Maintains B/P and fluid balance Regulation of Fluid Volume, cont Atrial natriuretic peptide or factor (ANP) (ANF) Cardiac hormone Released in response to increased pressure in the atria (increased blood volume)

Opposes the renin-angiotensinaldosterone system Stimulates excretion of Na and H2O Suppresses renin level Decreases the release of aldosterone Decreases ADH release Reduces vascular resistance by causing vasodilation REGULATION OF FLUID VOLUME