Homeostasis: Body fluids and electrolytes maintained in a narrow margin Anticipate: Potential for imbalances with certain medical

disorders and therapies Recognize: S/S of imbalances Intervene: Take appropriate action to correct Composition of Body Fluids: Adults: 60% Older Adults: 45-55% Infants: 70-80% Transcellular fluid is part of ECF: Small but important, this is where we see 3rd spacing-Dangerous!!!! Cerebrospinal fluid Pericardial fluid Pleural spaces Synovial spaces Intraocular spaces Digestive secretions Factors that effect Fluid and Electrolyte basics

Filtration: Movement of H20 and solutes from hydrostatic pressure to hydrostatic pressure, as long as hydrostatic pressure exceeds COP. Hydrostatic pressure normally higher in arteriole end -40 mmHg and COP is normally higher in venules- end, resulting in filtration in arterioles and reabsorption in venules. Hydrostatic pressure: The pressure from blood pushing against walls of capillaries, forces fluids and solutes through capillary walls. Reabsorption: When hydrostatic pressure fall below COP fluids and solutes are pulled back into capillaries. Colloid oncotic pressure: Albumin has a magnetic pull for H20. As the concentration of albumin increases the pull increases this is the COP. It averages 25 mmHg. Membrane permeability: Processes that affect the epithelium of the membrane increase permeability allowing fluids and solutes across especially K and impair nerve conduction along membrane e.g. diabetic neuropathy Terms associates with osmosis: Osmotic pressure: Pressure required to stop osmotic flow of H20, determined by concentration of solutes. Oncotic pressure: Pressure exerted by colloids. Osmotic diuresis: UOP caused by substances such as; Mannitol, glucose or contrast medium DM: Glucose in urine = polyuria; osmotic diuresis

Fluid movement in Capillaries: Capillary Hydrostatic pressure: Arteriole Venule Plasma oncotic pressure: Interstitial hydrostatic pressure: Interstitial oncotic pressure: Fluid shifts- KNOW THIS!!!! Plasma Interstitial = Edema hydrostatic pressure Plasma oncotic pressure interstitial oncotic pressure

40 mmHG 10 mmHG 25 mmHg 1 mmHg 1 mmHg

Interstitial Plasma plasma oncotic pressure Compression stocking peripheral edema Fluid movement between ECF and ICF: Water deficit - ECF Cell shrinkage as H20 pulled in vascular Water excess - ECF Gain/retention of excess H20 Fluid spacing: 1st: Normal balance between ICF and ECF 2nd: Excessive accumulation of interstitial fluid = edema 3rd: Accumulation in part of body where not easily exchanges with ECF, trapped and unavailable for function (ascites) Dangerous when in: Respiratory, pericardial, cerebral Periorbital edema = 3rd spacing ON TEST!!!!! Interventions:

o HOB, breath sounds, assess edema, elevate, Lasix, QD weight, I&O 24*, Lytes, Na diet, Wet; Holding fluid Dry: Lost fluid ON TEST!!!! K 3.5-5.5; cardiac dysrythmias Excreted during stress NA 135-145; Na rarely seen except in dehydration Thirst, BP, BUN Normal fluid balance: Intake 2500/Outake 2500

Skin: 600 ml Lungs: 400 ml Urination: 1.5L Feces: 100ml Hypothalamic regulation: ON TEST!!!!! Osmorecptors in hypothalamus sense fluid deficit or increase Stimulates thirst and ADH release Results in free water and plasma osmolarity

Pituitary regulation: Hypothalamus controls release of ADH fro posterior pituitary Stress: Cortisol and BG which osmolarity; saves fluid Nausea, nicotine, morphine also stimulate release in ADH

Adrenal Cortical Regulation: ON TEST!!!! Release hormones to regulate water and electrolytes Glucocorticoids Cortisol BG Mineralocorticoids ON TEST!!!! Aldosterone acts on receptor in Juxtaglomerular cells (P cells) in DCT unlocking genes o Gene 1: Inserts Na+/K+-ATPase also known as Na+/K+ pump into membrane. o Gene 2: Insert Na channels into apical membrane that allows Na to rush in to blood where H20 (loves Na) follows this blood volume and venous return and stretch contractility o Gene 3: Insert K channels which allow K to be secreted in urine RAAS stimulates Aldosterone production!!

Aldosterone is produced as a result of RAAS and acts to regulate fluid volume!!!

Renal regulation: Primary organ for regulating fluid/lytes balance by adjusting urine volume Selective reabsorption of fluid/lytes Renal tubules site of action for o ADH appetite for salt and thirst o Aldosterone Reabsorption of NA Excretion of K Cardiac regulation: ANP-Atrial natriuretic peptide Released when atrial pressure and stretch increases Suppresses secretion of Aldosterone, renin, ADH o BP and volume GI regulation: Oral intake for most H20 Insensible loss of 100 ml in feces Diarrhea and vomiting fluid and lytes loss Insensible H20 loss: Lungs and skin = 600-900ml/day No lytes lost!! Gerontologic Considerations: 1. Structural changes in kidneys ability to conserve H20 a. After age 50 there is 5-10%/year glomeruli loss b. By 80 year 80% loss c. Kidneys can fx on 20% 2. Hormonal changes ADH and ANP 3. SQ tissue lead to loss of moisture 4. Reduced thirst mechanism = H20 intake Fluid and Electrolyte imbalances: Common in patients /c illness Direct cause of disease o Burns, HF Indirect cause from therapeutic tx o IV fluids, diuretics

ECF deficit- Hypovolemia Abnormal body fluid loss o Dehydration, diarrhea, fistula, hemorrhage, intake o Ascites- 3rd spacing o Sepsis SIRS MODS Elderly with BP 120/80 = Hypotension because usually they have HTN o Plasma-interstitial fluid shift Not evident on labs and weights! Treatment o Replacement of H20/lytes with balanced IV solutions to puff up volume o Assess: VS, T, RR, 02sa LOC: Patient alert Airway: Clear, Breathing: Clear, Circulation: BP, P ECF excess Hypervolemia fluid intake, retention of fluids (CHF and renal dx) Interstitial plasma fluid shift Treatment o Remove fluid without changing lytes composition or osmolality! o 24* I&O o Fluid restriction o Lasix, after fluid restriction not successful! o Assess: Edema and skin integrity Elevate, SCD, Monitor fluids and UOP VS Lab: Na, K, Bun, Cr, GFR, H/H Meds, Teach diet and meds Nursing management: Hypovolemia o Fluid volume deficit, CO Potential complication: Hypovolemic shock Implementation o Neurological function LOC, PERLA, voluntary movement of extremities, muscle strength, reflexes Hypervolemia o Excess fluid volume o Ineffective airway clearance o Risk for impaired skin integrity o Disrupted body image o Potential complication: Pulmonary edema, Ascites

Implementation o I&O, monitor CV changes, assess/monitor respiratory changes, QD weights, Skin assessment

Electrolytes: Substances whose molecules dissociate into ions (charged particles) when placed in H20 Electrolyte composition: ICF: K, Po4 ECF: Na, Cl Na: Normal 135-145 meq/L Function: H20 balance, Osmolality, Generation/transmission nerve impulses, Acid/base balance (combine /c HCo3 and CL Major role: Primary ECF cation volume, concentration Relationship: Cl- move together Control: Hormonal (Aldosterone and ADH) Dietary: 500-2300 mg/day K: Normal Function: Major role: excretion Control: Dietary: Ca: Normal Function: Major role: Control: Dietary:

Anions

Cations

3.5-5.5 meq/L Transmission/conduction of nerve/muscle impulses, cardiac rhythms, acid/base balance Primary ICF cation Relationship: Inverse with Na reabsorption, Na retention = K Na-K atpase pump 40-60 meq/day Excreted: 90% kidneys, levels in renal impairment

8.5-10.5 meq/L Transmission nerve impulses, muscle/myocardial contraction, blood clotting, teeth/bones Combined /c phosphorous in skeletal system Relationship: Inverse to phosphorous Balanced by PTH, calcitonin, vitamin D 1-1.5 g/day

Phosphate: Normal 2.5-4.5 meq/L Function: Acid/base buffer, ATP production, cellular glucose uptake. Essential to function of muscle, RBC, nervous system and Ca levels Required for 02 to release from Hgb Major role: Primary anion in ICF Relationship: Inverse to Ca Control: See above Dietary: 800-1600 mg/dl Excreted: 90% kidneys, levels in renal impairment Mg: Normal 1.4-2.1 Function: Coenzyme in metabolism of protein, CHo3 and Ca absorption/utilization Cardiac function, powers Na k atpse pump, secretion/action of insulin (impacts BG) Major role: 2nd most in ICF cation Relationship: Powers Na k atpse pump, cant have regulated levels of Na, K without Mg Control: Same factors that regulate Ca Dietary: 300-350 meq/L Excreted: Kidneys, levels in renal impairment Cl: Function: Normal 95-108 meq/L Circulates /c Na and H20 to maintain cellular integrity, fluid balance, osmotic pressure Acid/base balance (enzyme activator, buffer in exchange of 02 and Co2 in RBCs) With Ca, Mg maintains nerve transmission/muscle function

Major role: Control:

Vital to HCL production Primary ECF anion Relationship: Na move together Moves with Na Dietary: 750mg Excreted:

90% excreted by kidneys

Hypotonic: H20 than lytes H20 lyses RBCs H20 fro ECF to ICF Usually maintenance fluids

Isotonic: Expands only ECF No loss/gain from ICF

Hypertonic: Expands osmolality of ECF Frequent monitoring BP, Lung sounds, Na levels

Plasma expanders: Stay in vascular space and osmotic pressure Colloids (proteins): RBCs, albumin, plasma Diuretics: volume of UOP to treat: HTN, HF, renal disorders Lyte(potassium) depletion common Nursing Interventions: I&O, nutritional status, Liver and kidney function, edema, labs LOC, Hearing and vision (Loop = ototoxic, thiazide = vision),

Observe for hypersensitivity, Light exposure ETOH and caffeine (diuretic), Safety(Orthostatic hypotension), Administer in am to decrease excessive nighttime UOP