CNUR823 - Module 2

CNUR823, Module 2 - Introduction 2014-03-27, 11:35 AM
In a healthy individual, fluid volume and electrolyte concentrations are kept in homeostatic equilibrium through the
interaction of several organ systems. Electrolyte concentrations and pH are maintained within a narrow range.
Balance is maintained through renal, hormonal, and neural controls. Alterations in the composition of electrolytes
influence the electrical potentials of excitatory cells and cause fluids to shift from one compartment to another.
Changes in fluid balance affect blood volume and cellular function. Disturbances in pH disrupt the normal cellular
function of enzyme systems.
Learning Objectives
1.Differentiate intracellular from extracellular compartments in terms of distribution and composition of water,
electrolytes, and other osmotically active solutes
2. Describe the control of cell volume and the effect of isotonic, hypotonic, and hypertonic solutions on cell size.
3. Discuss the pathophysiology and manifestations of fluid volume deficit and fluid volume excess.
4. Describe the causes, signs and symptoms, diagnosis, and treatment of hyponatremia and hypernatremia;
hypokalemia and hyperkalemia; hypomagnesemia and hypermagnesemia; and hypophosphatemia and
hyperphosphatemia.
5. List the normal range of Na+, K+, HCO3-, Cl- in serum and indicate how these ranges change in perspiration,
gastric juice, bile and ileostomy contents.
6. Describe the regulation of acid–base balance in the body, including the roles of the lungs, the kidneys, and
buffers
7. Identify factors affecting normal body fluid, electrolyte, and acid–base balance.
Concepts in Fluid and Electrolyte Management
Fluid needs are altered by a patient's functional heart, liver, lung, and kidney status. Fluid needs increase with fever,
diarrhea, hemorrhage, surgical drains, and loss of skin integrity such as burns and open wounds.
There are three key concepts to consider in fluid and electrolyte management: cell membrane permeability,
osmolarity, and electroneutrality. Cell membrane permeability is the ability of the cell membrane to allow certain
substances such as water and urea to pass freely, while charged ions such as sodium cannot cross the membrane
and are trapped on one side of it. Osmolarity is a property of particles in solution. If a substance can dissociate in
solution, it may contribute more than one equivalent to the osmolarity of the solution. For instance, NaCl will
dissociate into two osmotically active ions: Na and Cl. One millimolar NaCl yields a 2 milliosmolar solution. The
principle of electroneutrality refers to the fact that the overall number of positive and negative charges balance.
Total Body Water
Total body water (TBW) is separated by cell membranes into two main compartments in the body: the fluid outside
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cells (extracellular fluid, ECF) and the fluid inside cells (intracellular fluid, ICF). After the first year of life, the ICF
makes up approximately 2/3 of total body water while the remaining 1/3 is found in the ECF compartment. The ECF
is further divided into the intravascular (plasma) and the interstitial (between the cells also referred to as tissue
spaces) compartments. The ECF is also comprised of transcellular fluids: cerebrospinal, lymphatic, synovial, and
eye fluids. A capillary membrane separates the two ECF compartments such that fluids can move freely between
the fluid compartments to maintain fluid balance. Fluid within the cells tends to be the most stable and resists major
fluid shifts while vascular fluid tends to be more susceptible to changes in intake or output. Interstitial fluid is the
reserve such that it replaces fluid in the vascular or cells according to need.
Fluid Compartments
The three major fluid compartments:

Intracellular fluid (ICF) is the fluid within cells; also known as cytosol.
Extracellular fluid (ECF) is the fluid found outside of cells.
There are two major kinds of extracellular fluid:
Interstitial Fluid is the fluid surrounding the cells

Plasma is the fluid component of blood
This is a link for a learning object for a review of osmotic pressure involving the major components of
ECF: http://www.wisc-online.com/Objects/ViewObject.aspx?ID=NUR4004
Crystalloids?
Colloids
Osmolarity of Solutions
Crystalloids are isotonic, hypotonic, or hypertonic.
What occurs with the infusion of an isotonic solution?
Isotonic solution: When cells are in isotonic solution, movement of water out of the cell is balanced exactly by
movement of water into the cell (see image below). A 0.9% solution of NaCl (saline) is isotonic to human cells. An
isotonic solution such as Ringer's buffered saline is useful to prevent osmotic effects and consequent damage to
cells.
What occurs with the infusion of a hypotonic solution?
Hypotonic solution: If concentrations of dissolved solutes are less outside the cell than inside, the concentration of
water outside is correspondingly greater. When a cell is exposed to such hypotonic conditions, there is net water
movement into the cell. Cells without walls will swell and may burst (lyse) if excess water is not removed from the
cell. Cells with walls often benefit from the turgor pressure that develops in hypotonic environments.
Result: For example. The effect on RBCs is important. So, RBC will swell and rupture (see image below). Also can
result in brain edema.
What occurs with the infusion of a hypertonic solution?
Hypertonic solution: If concentrations of dissolved solutes are greater outside the cell, the concentration of water
outside is correspondingly lower. As a result, water inside the cell will flow outwards to attain equilibrium, causing
the cell to shrink. As cells lose water, they lose the ability to function or divide. Hypertonic environments such as
concentrated brines or syrups have been used since antiquity for food preservation because microbial cells that
would otherwise cause spoilage are dehydrated in these very hypertonic environments and are unable to
function. Hypertonic solutions are used in hypernatremia.

Result: RBC will shrink (see image below)
Major Electrolytes
The major electrolytes that will be discussed are sodium, potassium, magnesium, and phosphorus.
Sodium, the major cation (90% of total cations) of the ECF, is the most important ion in regulating water volume,
osmolality, and the distribution of the ECF. As well, it is important in regulating neuromuscular activity, particularly
the voltage of action potential; transmission of impulses in nerve and muscle fibres. It also helps to maintain acid-
base balance. Normal value is 135-145 mmol/L. Sodium pairs with Cl- and HCO3- to neutralize charge.
Sodium is regulated by aldosterone, the renin/angiotensin system, and the atrial natriuretic peptide.
Hypernatremia (value exceeding 145 mmol/L) results from a gain of Na in excess of water or a loss of water in
excess of Na. Hypernatremia occurs in patients who are deprived of water (most common), have watery diarrhea,
increased insensible water loss from a burn or fever, kidney failure, polyuria with hyperglycemia. It is a problem with
water not sodium homeostasis. Consequently, cells dehydrate (water moves from the cells to the extracellular).
Because cells quickly respond to counterbalance cell shrinkage and the osmotic force, electrolytes are transported
across the cell membrane. The effects are most commonly seen in the central nervous system because of the
stretching of shrunken neurons and alterations of membrane potentials from the electrolyte influx resulting in brain
injury. If sufficient shrinking occurs, veins may stretch and rupture resulting in an intracranial hemorrhage.
Hyponatremia (value less than 135 mmol/L) is uncommon. Generally there are two types: depletional and dilutional.
Potassium is the major intracellular cation with a concentration of 140-150 mmol/L. Serum levels are 3.5-4.5
mmol/L; consequently serum levels are a poor indicator of total body stores. The significant difference between the
intracellular and extracellular fluid maintains the resting membrane potential of nerve and muscle cells. Balance of
potassium is maintained through dietary sources.
Potassium plays a critical role in cell metabolism and cardiac and neuromuscular function. Imbalances can affect
transmission and conduction of nerve impulses, maintenance of normal heart rhythms, as well as contraction of
smooth and skeletal muscle.
Potassium shifts constantly in and out of the cells which can significantly affect serum potassium levels. There are
many factors that regulate potassium distribution in the intracellular and extracellular space.
Think
Explain how each of the factors identified above influence potassium movement across the cell
membrane.
Causes of Potassium Imbalances
Manifestations of Potassium Disorders
Please Note
Remember the sodium-potassium pump:

http://otter.middlebury.edu/ns-media/svl/biology/NaKpump/NaKnormal.mov
Pause and Reflect
Potassium is a high alert medication. This means it has "a heightened risk of causing significant patient
harm when...used in error" (Institute for Safe Medication Practices Canada). Remember that potassium
has a narrow range in the serum and minimal changes in potassium concentration can result in major
alterations in the body. The most common cause of cause of death of hyperkalemia is cardiac
dysrhythmia. Hypokalemia is a common imbalance in individuals with alcoholism even if they consume
sufficient daily dietary intake because of a lack of absorption via the intestine (potassium is absorbed via
the intestine and excreted by the kidneys).
A bit of trivia: KCl is the last drug injected during lethal injection (this takes place in the United States,
not in Canada) as it causes death by stopping the heart.
In patients taking digoxin, hypokalemia increases the heart muscle's sensitivity to the drug which can
result in digoxin toxicity.
The dose and rate of administration are dependent upon the specific condition of each patient.
If the serum potassium level is greater than 2.5 mmoL/L, potassium can be given at a rate not to exceed
10 mmoL/h in a concentration of up to 40 mmoL/L. The 24 hour total dose should not exceed 200
mmoL.
Magnesium is a crucial participant in numerous intracellular reactions. Magnesium is the fourth most abundant
mineral in the body and is essential to good health. Approximately 60% of the body's magnesium is found in bone,
while the remaining is found predominantly inside cells of body tissues and organs (20% is in muscle and 20% is in
soft tissue and the liver). One percent is found in the interstitial compartment and in the blood. The electrolyte
magnesium is required for normal muscle, nerve, and enzyme function. Magnesium antagonizes calcium affecting
its uptake and distribution. Magnesium also modulates sodium and potassium currents, thus influencing the
membrane potential.
Magnesium plays a fundamental role in many cellular functions; consequently there is increasing interest in its role
in preventing and managing disorders such as hypertension, cardiovascular disease, migraines, osteoporosis, and
diabetes. Magnesium maintains normal muscle and nerve function, regulates heart rhythm, supports a healthy
immune system, maintains the strength of bones and also exhibits depressant effects in the central nervous system.
Magnesium also helps regulate blood sugar levels, promotes normal blood pressure, and is known to be involved in
energy metabolism and protein synthesis. It may relieve premenstrual symptoms associated with mood changes
and be associated with insomnia. For these reasons, magnesium replacement is frequently recommended as an
approach to maintaining normal physiological concentrations.

Dietary magnesium is absorbed in the small intestines modulated by vitamin D and is excreted through the kidneys
(modulated by parathormone). Insulin may decrease kidney excretion of magnesium and enhance its cellular
uptake.
A deficit in magnesium is more common than an excess.
Causes of Magnesium Deficit

Source: B. Swart
Symptoms of Magnesium Deficit

Source: B. Swart
Individuals are highly vulnerable to hypermagnesia with loss of kidney function; however hypermagnesia is not a
common clinical finding.
Almost all enzymatic processes using phosphorus as an energy source require magnesium for activation.
Phosphate provides strength to bone (85% of phosphate is found in bones). Phosphorus is an integral component
of the nucleic acids that make up DNA and RNA. It is primarily found intracellularly where phosphorus is involved in
the production of ATP. It serves as a buffer in acid-base balance. Phosphate is critical to red blood cell development
and oxygen delivery to tissues.
About 60% to 70 % of dietary phosphorus is is absorbed via the jejunum from dietary phosphorus, and excreted via
the kidneys.
Systemic Assessment of Arterial Blood Gases

Here is a video that you may find helpful on interpreting acid-base balance:
http://www.austincc.edu/adnlev2/rnsg1443online/fluid_electrolytes_acid_base/abg7a7.html
These steps are recommended as a tool to evaluate arterial blood gases. They are based on the assumption that
the average (so taking a middle value) values are:
Mid-Range Values of Blood
Source: B. Swart
Steps in Determining Arterial Blood Gases
Acid-base disturbances are either metabolic or respiratory. In metabolic disturbances, the primary change is with
bicarbonate. In respiratory disturbances, the primary change is with carbonic acid.
You may find this booklet helpful: http://www.ed4nurses.com/resources/1/pdf/ABGebook.pdf
In metabolic acidosis, the amount of bicarbonate is decreased in relation to the amount of acid in the body (see
image below). This can occur as a consequence of excess accumulation of acids from excess acid production
(lactic acidosis) or reduced elimination by the kidney resulting in increased hydrogen ion production.
In metabolic alkalosis, there is an excess of bicarbonate compared with the amount of hydrogen ion concentration in
the blood. This can occur as a result of loss of hydrogen ions via gastric secretions or from a shift of hydrogen ions
into the cell. Excess bicarbonate usually occurs as a result of ingesting antacids that contain bicarbonate.
In respiratory acidosis, carbon dioxide is retained with subsequent retention of carbonic acid in the body. Usually
respiratory acidosis occurs from pneumonia or chronic respiratory obstructive disorders such as COPD.
In respiratory alkalosis, is most often a consequence of anxiety-based hyperventilation as carbonic acid levels fall.
Think
In the following situations, indicate whether serum Na, K, HCO3, Cl and blood pH will remain stable (0),
rise considerably (++), rise moderately (+), fall moderately (-), or fall considerably (--):
excessive gastric losses
high volume pancreatic fistula
small intestine fistula
biliary fistula
diarrhea
In the following situations, indicate whether serum and urine Na, K, HCO3, Cl and osmolality will remain
stable (0), rise considerably (++), rise moderately (+), fall moderately (-), or fall considerably (--):
acute tubular necrosis
dehydration
secretion (SIADH)
diabetes insipidus
heart failure
Describe the concept of a “third space” and determine those conditions that can cause fluid
sequestration of this type.
Summary
Body fluid balance is maintained via a number of mechanisms: balance of fluid and electrolytes; elimination of water,
electrolytes and acids via the kidneys; and hormonal influences. Alterations in any of these factors can manifest in
an imbalance.
References
Craig, S. (2010). Hyponatremia in emergency medicine. Retrieved from

http://emedicine.medscape.com/article/2038394
Fulop, T. (2012). Hypermagnesemia. Retrieved from

Lederer, E. (2009). Hypokalemia. Retrieved from http://emedicine.medscape.com/article/242008
Lederer, E. (2011). Hyperkalemia. Retrieved from

LeMone, P., Burke, K., & Bauldoff, G. (2011). Medical-surgical nursing: critical thinking in
patient care (5th ed., pp. 186-237). Toronto, ON: Pearson.
Lukitsch, I. (2012) Hypernatremia. Retrieved from
Reed, B. N., Zhang, S., Marron, J. S., & Montague, D. (2012). Comparison of intravenous and
oral magnesium replacement in hospitalized patients with cardiovascular disease.
American Journal of Health-System Pharmacy, 69(14), 1212-1217.
Schuh, S., Zemek, R., Plint, A., Black, K. J. L., Freedman, S., Porter, R.,...Johnson, D. W.
(2012). Magnesium use in asthma pharmacotherapy: A pediatric emergency research

Canada study. Pediatrics, 129(5), 852-859.
Semenovskaya, Z. (2012). Hypernatremia in emergency: Medicine treatment & management.

Retrieved from http://emedicine.medscape.com/article/766683
Pain..a challenging yet important topic for you to conquer.

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CNUR823, Module 2 - Introduction 2014-03-27, 11:35 AM

Concepts in Fluid and Electrolyte Management

Total Body Water

The three major fluid compartments:

There are two major kinds of extracellular fluid:

Interstitial Fluid is the fluid surrounding the cells

Crystalloids are isotonic, hypotonic, or hypertonic.

What occurs with the infusion of an isotonic solution?

What occurs with the infusion of a hypotonic solution?

What occurs with the infusion of a hypertonic solution?

function. Hypertonic solutions are used in hypernatremia.

Causes of Potassium Imbalances

Manifestations of Potassium Disorders

Remember the sodium-potassium pump:

Pause and Reflect

approach to maintaining normal physiological concentrations.

A deficit in magnesium is more common than an excess.

Causes of Magnesium Deficit

Symptoms of Magnesium Deficit

Systemic Assessment of Arterial Blood Gases

Mid-Range Values of Blood

Steps in Determining Arterial Blood Gases

You may find this booklet helpful: http://www.ed4nurses.com/resources/1/pdf/ABGebook.pdf

Craig, S. (2010). Hyponatremia in emergency medicine. Retrieved from

Fulop, T. (2012). Hypermagnesemia. Retrieved from

Lederer, E. (2009). Hypokalemia. Retrieved from http://emedicine.medscape.com/article/242008

Lederer, E. (2011). Hyperkalemia. Retrieved from

Lukitsch, I. (2012) Hypernatremia. Retrieved from

(2012). Magnesium use in asthma pharmacotherapy: A pediatric emergency research

Semenovskaya, Z. (2012). Hypernatremia in emergency: Medicine treatment & management.

Pain..a challenging yet important topic for you to conquer.

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