INTRODUCTION Body is formed by solids and fluids. The fluid part is more than 2/3 of the whole body.

Water forms most of the fluid part of the body. In human beings, the total body water varies from 45 to 75% of body weight. In a normal young adult male body contains 60-65% of water and 35-40% of solids. In a normal adult female, the water is 50-55% and solids are 45-50%. In females, the water is less because of more amount of subcutaneous adipose tissue. In thin persons, water content is more than in obese persons. In old age, water content is decreased due to increase in adipose tissue. The total quantity of body water in an average human being Weighing about 70 kg is about 40 litres. COMPARTMENTS OF BODY FLUIDS Total water in the body is about 40 litres. It is distributed into two major fluid compartments namely : 1. Intracellular fluid (ICF) forming 55% of the total body water (22litres). 2. Extracellular fluid (ECF) forming 45% of the total body water( 18 litres). Extracellular fluid is divided into 5 subunits:1) Interstitial fluid and lymph 2) Plasma 3) Fluid in bones

4) Fluid in dense connective tissue like cartilage 5) Transcellular fluid that includes: a. Cerebrospinal fluid b. Intraocular fluid c. Digestive juices d. Serous fluid- intra pleural fluid - Pericardial fluid - peritoneal fluid e. Synovial fluid in joints and f. Fluid in urinary tract The volume of Interstitial fluid is about 12 liters. The volume of plasma is about 2.75 liters. The volume of other subunit of extracellular is about 3.25 liters. Water moves between different compartments. COMPOSITION OF BODY FLUIDS Body fluids contains water and solids. Solids are organic and inorganic.

Organic substancesOrganic substances are glucose, amino acids, proteins, enzymes, fatty acids, lipids and hormones. Inorganic substancesInorganic substances present in body fluids are sodium, potassium, calcium, magnesium, chloride, bicarbonate, phosphate and sulfate. Extracellular fluid contains large quantity of sodium, chlorides, bicarbonate, glucose, fatty acids and oxygen. PH of extracellular fluid is 7.4 Intracellular fluid contains large quantities of potassium, magnesium, phosphates, sulfates, proteins. PH of intracellular fluid is 7.0 ELECTROLYTE Electrolyte is defined as any substance containing free ions that make the substance electrically conductive. Example- sodium, chloride, magnesium, phosphate, sulfate etc. REGULATION OF ELECTROLYTES AND FLUIDS There are four rules of regulation of fluids and electrolyte:1) All homeostatic mechanisms for fluid composition respond to changes in the ECF. - Receptors monitor the composition of plasma and CSF and triggers neural and endocrine mechanisms in response to change. - Individual cells cannot be monitored and thus ICF has no direct impact. 2) No receptors directly monitor fluid or electrolyte balance
3

- only plasma volume and osmotic concentration are monitored which give an direct measure of fluid or electrolyte levels. 3) water follows salt - cells cannot move water by active transport. - water will always move by osmosis and this movement Cannot be stopped. 4) The body`s content of water or electrolyte rises and loss to and from the environment. - Too much intake = high content in the body. - Too much loss= low content in the body. PRIMARY REGULATORY HORMONE a. Antidiuretic Hormone(ADH)Osmoregulators in the hypothalamus monitor the ECF and release ADH in response to high osmotic concentration( low water, high solute.) Increase in osmotic concentration causes increase in ADH levels. Primary effects of ADH:a) It stimulate water conservation at kidneys. b) It stimulate thirst. b.AldosteroneIt is released by the adrenal cortex to regulate sodiumabsorption and potassium loss in the DCT and collecting system in the kidney. Retention of sodium will result in water conservation. Aldosterone is released in response to : a) high potassium or low sodium in the ECF( e.g. renal circulation) b) activation of renin- angiotensinogen system due to a drop in blood pressure or blood volume. c) Decline in kidney filtrate osmotic concentration at the DCT. Natriuretic peptides- It is released in response to stretching of heart wall. It function to reduce thirst and block release of ADH and aldosterone resulting in diuresis.

The above diagram shows how the regulation of sodium ion levels in the extracellular fluid take place in the case of drop in the blood pressure. Here, there is decrease in the blood pressure leading to increased renin secretion from kidney and secretion of angiotensinogen which is converted into angiotensinogen1 and later into angiotensinogen2 which in turn stimulate aldosterone secretion from adrenal cortex. Aldosterone stimulates sodium ions and promotes water reabsorption in the kidney. An increase in the blood pressure in the right atrium of the heart causes increased secretion of atrial natriuretic hormone which increases the sodium ion secretion and water loss in the form of urine. Below the diagram is showing how the electrolyte regulation takes place in the body with increased blood pressure and how the hormones maintain it to the normal.

CONCENTRATION OF BODY FLUIDS The concentration of body fluids is measured by three ways1) OSMOLALITY:- it determines the distribution of water among different compartments of extracellular and intracellular compartments.
6

It is expressed as number of particles per kg of solvent. In other words it is the concentration of osmotically active substances in the solution. ) 2) OSMOLARITY:It is expressed as the number of osmoles / litre of solution. When osmolality of ECF increases, water moves from ICF to ECF. When osmolality of ECF decreases water moves from ECF to ICF. Water movement continues until osmolality of these two fluid compartment becomes equal. 3) TONICITY:It refers to relative concentration of solute particle inside a cell with respect to concentration outside the cell. when RBC are placed inA) ISOTONIC RBC placed in isotonic solution neither gain nor lose water because of osmotic equilibrium between inside and outside cell membrane. eg; 0.9% Nacl solution and 5% glucose. B) HYPERTONIC - In RBC ,water moves out of cells resulting in shrinkage of cells(crenation) eg-2%Nacl. C)HYPOTONIC- In RBC, water moves into the cells resulting in swelling and rupture of cells. eg- 0.3%Nacl.

REGULATION OF BODY FLUIDS: The body fluids mainly regulate by the following processes: 1) Diffusion 2) osmosis 3) Filtration 4) Active transport 1) DIFFUSION- It is also known as passive transport i.e. no external source of energy is required by which molecules moves from areas of high concentration to areas of low concentration. it is the movement of substances along the concentration or electrical gradient or both is known as diffusion.eg- swimming in direction of water flow in river. It is also known as downhill movement. It doesnt require energy. It is of two types- simple diffussion - facilitated diffussion Simple diffusion occurs through the lipid bilayer and the rate of diffusion is directly proportional to the lipid solubility. No carrier protein binding. Facilitated diffusion requires interacting carrier protein with the molecules.

2) OSMOSIS- -It is the passive flow of the solvent.Process of movement of water caused by a concentration difference of water

3)

FILTRATION- It is the movement of water and solutes from an area of high hydrostatic pressure to an area of low hydrostatic pressure.

ACTIVE TRANSPORT- When a cell membrane moves molecules or ions uphills against a concentration gradient, the process is known as active transport. eg- sodium potassium pump. It is the movement of substances against chemical or electrical or both gradient is known as active transport. Eg swimming in opposite direction to water flow. It is also known as uphill transport and requires energy in the form of adenosine tri phosphate. It occurs with help of carrier protein as in case of facilitated diffusion. Each carrier protein carry only one substance known as uniport pump. If more than one substance is known as antiports/ symport.
4)

Mechanism of active transport- when the substance to be transported across cell membrane it combines with carrier protein of cell membrane leading to formation of protein complex. This complex move towards the inner surface of cell membrane. The substance is then released from
10

carrier protein and the carrier protein moves back to outer surface of cell membrane. Substances transported by active transport are in two formIonic form- sodium, choride, calcium, potassium. Eg; sodium potassium pump for distribution of sodium and potassium across cell membrane. It transport sodium from inside cell to outside and potassium from outside intio the cells. Non ionic form- glucose, amino acids, urea.

Diagram showing active and passive transport. ACID BASE BALANCE

11

ACID- is a substance that liberates hydrogen ions. (Donor) BASE- is a substance that accepts hydrogen ions. (Acceptor) In healthy person PH of ECF=7.4 and varies from 7.38and 7.42 Maintenance of acid base status is important As even a slight change in Ph causes serious threats to physiological function. REGULATION OF ACID BASE BALANCE There are three different mechanism : a) Acid base buffer system which binds hydrogen ions. b) Respiratory mechanism which eliminates carbon dioxide. c) Renal mechanism which excretes hydrogen ions and conserves the bicarbonate ions. Acid base buffer is fastest one and it can readjust ph within seconds. Respiratory mechanism adjust the ph in minutes. Renal mechanism is slower and it takes few hours to few days to bring ph back to normal. It is the most powerful mechanism than others. DETERMINATION OF ACID BASE STATUS It is difficult to measure by direct method. Indirect method can be calculated by Henderson hasselbalch equation. To determine ph of fluid the concentration of bicarbonate ions and carbon dioxide dissolved in fluid are measured. PH= PK+ LOG HCO3_ / CO2 ACID BASE BUFFER SYSTEM It is of three types:a) Bicarbonate buffer system b) Phosphate buffer system c) Protein buffer system

12

Above diagram showing the types of acid base buffer system that occur in the ICF and ECF. The bicarbonate buffer system is not very powerful because the pk of bicarbonate is 6.1 while the ph of ECF is 7.4 as there is large difference between them. While the phosphate buffer system is comparatively more powerful as the pk value is 6.8 and the ph of ICF is 7.1 as there is less difference.
13

ACID BASE DISTURBANCES The acid base disturbances are-Respiratory Acidosis -Respiratory Alkalosis -Metabolic Acidosis -Metabolic

Alkalosis

The clinical manifestation, lab findings and the management is given in the table.

14

15

SIGNIFICANCE OF BODY FLUIDS

In Homeostasis:Body cells survive in the fluid medium or milieu interieur. Term Milieu interieur given in 19th century by french physiologist Claude bernard. Growth and functions of cells depend upon the availability of minerals like glucose, amino acids, lipids, oxygen in proper quantities in internal environment. The maintenance of internal environment is called as HOMEOSTASIS. The term homeostasis is given by the Harvard profecessor Walter b menon. Homeostasis is of two types positive feedback mechanism and the negative mechanism.
1. 16

) IN TRANSPORT MECHANISM: Water forms an important medium through which various enzymes, hormones, minerals, vitamins are carried from one part to another part of body. 3) IN METABOLIC REACTIONS: Water inside the cells forms the medium for metabolic reaction necessary for growth and functional activities of the cells. 4) IN TEMPERATURE REGULATION Fluid plays a vital role in maintanence of normal body temperature

MEASUREMENT OF VOLUME OF BODY FLUIDS

17

It is measured by Indicator dilution method or dilution method. Principle:- A known quantity of substance or dye is administered into body fluid compartment. After administration it is mixed thoroughly and sample of fluid is drawn to determine the concentration of marker substance. substances whose concentration can be determined by calorimeter or radio active substances are used as marker substances. Formula to measure volume of fluid V= M/C Where V is volume of fluid compartnent M is mass or quantity of marker substances. C is the concentration of marker substance in sample fluid. Correction factor some amount of marker substance is lost through urine during distribution. Volume= Amt of substance injected- Amt of substance excreted/ concentrationn of sustance in sample of fluid. USES OF INDICATOR DILUTION METHOD It is used to measure ECF volume, plasma volume and total body water. Marker substances used to measure total body water are Deuterium oxide - Tritium oxide Substances used to measure Extracellular fluid Radio active sodium, chloride, bromide, sulfate thiosulfate. - Non metabolizable saccharides like inulin, mannitol, sucrose. Substances used to measure plasma volume - radio active 131i - Evan`s blue (T- 1824) MEASUREMENT OF INTRACELLULAR FLUID VOLUME

18

The volume intracellular fluid cannot be measured directly. It is calculated as ICF volume= total body water- ECF volume MEASUREMENT OF INTERSTITIAL FLUID VOLUME It is calculated as: Interstitial fluid volume= ECF volume- plasma volume APPLIED PHYSIOLOGY FLUID VOLUME DEFICIT ( HYPOVOLEMIA) Mild:- 2% of body weight loss Moderate:- 5% of body weight loss Severe:- 8% of body weight loss Pathophysiology results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake Clinical manifestation:-Acute weight loss -Decrease skin turgor -Oliguria -Concentrated urine - Postural hypotension - Weak, rapid, heart rate - Flattened neck veins - Increased temperature - Decreased central venous pressure

19

Management - Fluid replacement therapy & continued fluid maintenance.

Fluid Volume Excess (Hypervolemia) - An increase in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2 to: -Increased HP [pregnancy, CHF] -Decreased OP [malnutrition, end-stage liver disease, nephrotic syndrome] An excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute It occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment fluid overload from increased production of adrenal corticoid hormones (Cushings syndrome)
20

Clinical manifestations edema, distended neck veins, crackles, tachycardia, increased blood pressure, increased weight

Management --Restrict fluids to lower fluid volume -Diuretics or hypertonic saline -Continuous assessments to prevent skin breakdown Record daily weight of the patient. Electrolyte Balance:

21

-Electrolyte balance is important because : -total electrolyte concentrations directly affect water balance - concentrations of individual electrolytes can affect cell functions -The two most important electrolytes are sodium and potassium: 1) Sodium Balance (normal blood values: 130-145 mEq/L *) -Na+ is the dominant cation in the ECF -90% of the ECF osmotic concentration is due to sodium salts: NaCl and NaHCO3 -The total amount of Na+ in the ECF is due to a balance between Na+ uptake in the digestive system and Na+ excretion in urine and perspiration The overall sodium concentration in body fluids rarely changes because water always moves to compensate: e.g. high sodium levels in the blood will cause retention of water to maintain the same Na+ concentration, but this results in a high blood volume (this is why salt is bad for hypertensive patients) -Minor gains and losses of Na+ in the ECF are compensated by water in the ICF and later adjusted by hormonal activities: -ECF volume too low renin-angiotensin system is activated to conserve water and Na+ -ECF volume too high
22

 natriuretic peptides released: block ADH and aldosterone resulting in water and Na+ loss

Normal range 135 to 145 mEq/L Hyponatremia Sodium level less than 135 mEq/L It may be caused by vomiting, diarrhea, sweating, diuretics, etc Clinical manifestations Poor skin turgor Dry mucosa Decreased saliva production Orthostatic hypotension Nausea/abdominal cramping Altered mental status

MANAGEMENT:- Sodium replacement - water restriction - Ringer lactate solution, isotonic solution(0.9%)- in cases who cannot eat or drink. Hypernatremia Sodium level is greater than 145 mEq/L - Can be caused by a gain of sodium in excess of water or by a loss of water in excess of sodium Pathophysiology

23

 Fluid deprivation in patients who cannot perceive, respond to, or communicate their thirst. Mostly affects very old, very young, and cognitively impaired patients Clinical manifestations Thirst Dry, swollen tongue Sticky mucous membranes Flushed skin Postural hypotension

MANAGEMENT Diuretics given in sodium excess Administration of hypotonic sodium solution(0.3 to 0.45%)

24

Potassium It is a major Intracellular electrolyte about 98% of the bodys potassium is inside the cells. It Influences both skeletal and cardiac muscle activity. Normal serum potassium concentration 3.5 to 5.5 mEq/L. -K+ is the dominant cation in the ICF (98% of the total body K+ is inside cells) -The concentration of K+ in the ECF depends on absorption in the GI vs. excretion in urine
25

-The exchange pump at the kidney tubules secrete K+ (or H+) in order to reabsorb Na+ -The rate of tubular secretion of K+ in the kidney is controlled by three factors: 1. Changes in the K+ concentration of the ECF K+ in ECF = K+ secretion 2. Changes in blood pH at low pH, H+ is used for Na+ reabsorption instead of K+ at the exchange pump pH in ECF = K+ secretion 3. Aldosterone levels aldosterone = Na+ reabsorption and K+ secretion Hypokalemia Causes: Diarrhea, diuretics, poor K intake, stress, steroid administration. Manifestation:1)Skeletal muscle weakness 2)Constipation 3)Irregular, weak pulse 4)Orthostatic hypotension 5)Numbness (paresthesia)

26

6)ECG changes ( ST elevation)

Nursing interventions: -Encourage high K foods -Monitor ECG results -Dilute KCl can cause -cardiac arrest occurs if given IV Administering IV Potassium -It Should be administered only after adequate urine flow has been established. Decrease in urine volume to less than 20 mL/h for 2 hours is an indication to stop the potassium infusion IV K should not be given faster than 20 mEq/h Hyperkalemia Serum Potassium greater than 5.5 mEq/L It is more dangerous than hypokalemia because cardiac arrest is frequently associated with high serum K+ levels.
27

Causes: - Decreased renal potassium excretion as seen with renal failure and oliguria - High potassium intake - Renal insufficiency - Shift of potassium out of the cell as seen in acidosis Clinical manifestations: -Skeletal muscle weakness/paralysis -ECG changes -such as peaked T waves, -widened QRS complexes -Heart block

Medical/Nursing Management: Monitor ECG changes telemetry Administer Calcium solutions to neutralize the potassium Monitor muscle tone Give Kayexelate Give Insulin Calcium

-More than 99% of the bodys calcium is located in the skeletal system The normal serum calcium level is 8.5 to 10mg/dL and needed for transmission of nerve impulses. Intracellular calcium is needed for
28

contraction of muscles. Extracellular needed for blood clotting. It is needed for tooth and bone formation and needed for maintaining a normal heart rhythm. Hypocalcemia The Serum Calcium level less than 8.5 mEq/L Causes - Vitamin D/Calcium deficiency - Hyperparathyroidism - Pancreatitis

Renal failure

Clinical Manifestations - Tetany and cramps in muscles of extremities Definition A nervous affection characterized by intermitent tonic spasms that are usually paroxysmal and involve the extremities .

29

 Trousseaus sign carpal spasms

Chvosteks sign cheek twitching

Medical/Nursing management
30

- IV or orally Calcium Carbonate or Calcium Gluconate - Encourage increased dietary intake of Calcium - Monitor neurological status Hypercalcemia>10mg/dl)

Causes: Hyperparathyroidism Prolonged immobilization Thiazide diuretics Large doses of Vitamin A and D Clinical manifestations: Muscle weakness, nausea and vomiting Lethargy and confusion Constipation Cardiac Arrest (in hypercalcemic crisis, level 17mg/dL or higher)

Medical/Nursing Management - Eliminate Calcium from diet - Corticosteroids drugs decreases the intestinal absorbtion of calcium. - Increase fluids (IV or Orally) - Calcitonin - used to lower serum calcium level - useful for pts with heart disease or renal failure - reduces bone resorption - increases deposit of calcium and phosphorus in the bones - increases urinary excretion of calcium and phosphorus

31

Magnesium It Helps maintain normal muscle and nerve activity. It Exerts effects on the cardiovascular system, acting peripherally to produce vasodilation.Thought to Normal serum magnesium level is 1.5 to 2.5 mg/dl. It have a direct effect on peripheral arteries and . arterioles. Hypomagnesemia Causes- (Mg< 1.5mg/dl) - Chronic Alcoholism - Diarrhea Clinical manifestations - Neuromuscular irritability - Positive Chvosteks and Trousseaus sign - ECG changes with prolonged QRS, depressed ST segment, and cardiac dysrhythmias - May occur with hypocalcemia and hypokalemia Medical/Nursing management - IV/PO Magnesium replacement, including Magnesium Sulfate - Give Calcium Gluconate if accompanied by hypocalcemia - Monitor for dysphagia, give soft foods -Measure vital signs closely -Foods high in Magnesium: Green leafy vegetables Hypermagnesemia Causes - Renal failure - Untreated diabetic ketoacidosis

32

Excessive use of antacids and laxatives

Clinical manifestations - Flushed face and skin warmth - Mild hypotension

Phosphorus - Normal serum phosphorus level is 2.5 to 4.5 mg/dL - Essential for the function of muscle and red blood cells, maintanence of acid-base balance, and nervous system - Phosphate levels vary inversely to calcium levels - High Calcium = Low Phosphate - Causes - Most likely to occur with overzealous intake or administration of simple carbohydates - Severe protein-calorie
-

malnutrition (anorexia or alcoholism)

33

Clinical manifestations Muscle weakness Seizures and coma Irritability Fatigue Confusion Numbness

Medical/Nursing management - IV Phosphorus in severe cases. - Monitor phosphorus levels - Increase oral intake of phosphorus rich foods

Hyperphosphatemia Serum Phosphorus level greater than 4.5 mg/dl Causes Renal failure Chemotherapy Hypoparathyroidism High phosphate intake Clinical manifestations Tetany Muscle weakness Similar to Hypocalcemia because of reciprocal relationship

CONCLUSION Stabilizing ECF and ICF involves

34

1. Fluid balance 2. Electrolyte balance 3. Acid base balance so, the minimium water requirement for fluid replacement for 70 kg human in temperate zone is 3 litre /day and in tropical zone is 4.1 litre/day. REFERENCES Essentials of medical physiology-Ksembulingam and sembulingam. Textbook of medical physiology- Guyton, Hall. Fluer strand physiology- A Regulatory Approach Macmillan. Fluid and Electrolyte disorders Dr. c.k pandey Indian J. Anaeth2003, 47(5) 380-387. Amy warenda czura, Ph.D Nutrients in drinking water WHO 2003 Report

35

36

37

38

39

40

41