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Table of Contents

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Body Solutions and

Compartments

Solute and Fluid TransportDiffusion and Osmosis

Fluid Volume Regulation

Fluid Volume Excess and Deficit

Genetics, Inflammation, and

Stress Effect on Fluid BalanceFiltration, Hydrostatic and

colloidal osmotic forces



Objectives

Identify body fluid composition and

compartments

Review basic pathophysiology around water and

solute movement Identify altered fluid balance states

Discover age, genetic, stress, and inflammation

factors that have an effect on fluid balance Recognize outcomes and interventions for fluid

volume excess and fluid volume deficit



The Ins and Outs of Fluid Balance

Mary Farrington

MSN Student-MSN 621April 2010



Q uestion

Edema is present when one of the following

compartments is expanded by 2.5 to 3 liters.

In which body fluid compartment does edema

reside?

Intravascular Interstitial Trancellular

Porth (2005) p 767

Drag on

cylinder to

see if you

are right



The Goal of Human Fluid Balance

To reach euvolemia where loss and intake of fluids is balanced

Pathology that can alter fluid balance

Surgical disturbances Organ failure

Inflammation Renal dysfunction

Loss of extracellular fluid Liver failure

Evaporation and loss of fluid Heart failure

Hemorrhage Pancreas

Restricted fluid before surgery Skin



Compartments Where Fluid Resides

Extracellular fluid compartment (ECF)surrounds the

cell

Intracellular fluid compartment (ICF) contained

within cell

CellICF Major

Ion

PotassiumCell membrane

Heitz (2001) p.6

ICF

ECF

ECF Major

Ion Sodium

Chloride

Think about these electrolytes importance in your

patient assessment



Body Fluid Composition and

Compartments

Intracellular

Extracellular

The 60-40-20 Rule:

60 % of body weight is water

40% of body weight is intracellular fluids

20% of body weight is extracellular fluid

Cell

Patlak (1999) Department of Physiology, University of Vermont.Picture permission of Dreamscape Download

Body fluid composition is water and

dissolved substances consisting of solutes

and electrolytes



Extracellular Fluids

Interstitial

11-12 liters in adult Lymph fluid an example

Transcellular

Specialized cavity fluidssuch as cerebrospinal,pericardial, pleural,synovial, GI andintraocular

2 liters in adult

Intravascular

Blood vessels(includingplasma fluids)

5-6 liters

Functions include deliveryof nutrients, transport of waste products, deliveryof antibodies, transport of hormones, circulation of body heat

Heitz ( p.6



Body Fluid Compartments

Click on Box to see if your are right.

What are the major compartments for body

fluids?

Extracellular Intravascular

TranscellularIntracellular



Cell Membrane

Primary barrier to movement of substances

between ECF and ICF

Cell

Extracellular compartment

Volume (ECF)Cell membrane

Intracellular compartment

Volume (ICF)

Heitz p.8



Cell Membrane Transport

Molecules and Ions depend on transportmechanisms to go from ECF to ICF

Cell


Volume (ECF) Cell membrane

Intracellular

compartment

Volume (ICF)

Porth p 762

Pot



Solute Movement

Solutes move by ± Diffusion

± Mediated passive transport (No energy required)

± Mediated active transport (Energy required)

Cell


Volume (ECF)

Cell membrane

Intracellular

compartment

Volume (ICF)

Porth p 762



Passive Transport: Diffusion

Molecules move along concentration gradientacross cell membrane until there is a balanced

concentration and gradient is gone. Example:

diffusion of oxygen in alveoli allowing

replenishment

Cell

(ECF)

Permeable cell

membrane(ICF)

Porth p 762

High

concentration

Low concentration

Permeable cell

membrane

(ECF)(ICF)

Cell

Equal concentration

Equal concentration



Mediated Passive Transport

(Facilitated Diffusion)Large molecules moves along concentration gradient

and are assisted by the carrier protein to cross cell

membrane. Example glucose

Cell(ECF)

(ICF)

Heitz p.10

Low

concentration

High concentration Semi permeable Cell membrane

glucose



Active Transport

Requires energy (ATP) to move molecule with carrier protein Involves action against the cells electrical or chemical gradient

Molecules need to move uphill thus require energy

Cell

(ECF)

(ICF)

Semipermeable

Cell membrane

Porth p.75

M

ATP

High concentration gradient on membrane



Active Transport: Sodium Potassium

Pump

Maintains the differences between intracellular &extracellular Na & K. (Very active in the heart)

Cardiac

Cell

(ECF)

(ICF)

http://quizlet.com/1916557/fluid-balance-flash-cards

ATP

k

Na

Na

Na

k



Q uiz :

Is it A, B, or C

Click on Shape toSee if You Are Right

ConcentrationGradients

Protein CarrierA

concentration difference

between high level of concentration and low level

of concentration

DiffusionB

necessary for activetransport and facilitated

diffusion

Cparticles or molecules move

area of high concentration to

low concentration until

BALANCED

A

C

B



Water Movement

Osmotic forces ± Osmosis

± Osmotic Pressure

Oncotic Pressure ± Isotonic

± Hypotonic

± Hypertonic Filtration & Hydrostatic pressure

Cell


Volume (ECF)

Cell membrane

Intracellular

compartment

Volume (ICF)

Porth p 762



Osmosis-PassiveMovement of water across semipermeable membrane

from an area of lower solute concentration to highersolute concentration

Cell


Volume (ECF)

Cell membrane

Intracellular

compartment

Volume (ICF)

Porth p.762

Fewer particles-

More water

Greater number of particles-Less water

Notice

Osmosis is movement of water to lower volume of

water and greater number of solutes.

Diffusion is movement of solutes to higher volume of water and lower number of solutes



Osmosis PressureHydrostatic pressure (HP) required to stop

osmotic flow of water

Cell


Volume (ECF)

Semipermeable

Cell membrane

Intracellular

compartment

Volume (ICF)

Porth p 762

Fewer particles-

More water

Greater number of particles-Less water

HP

water



OsmolarityMeasure of solutions ability to create osmotic

pressure of force and affect water movement

Heitz p.12 picture microsoft clip art

Serum OsmolalityNumber of solutes per KG of water IN the body

Serum Isotonic concentration=275-295 mOsm/Kg

Serum Hypotonic concentration=<275 mOsm/Kg

Serum Hypertonic concentration=>295 mOsm/Kg



Osmolality of Solutions

Isotonic-same osmolality as body

fluids

Hypotonic-osmolality less then bodyfluids

Hypertonic-osmolality greater than

body fluids

Heitz p.13

0.9% NACL

0.45% NACL

D5LR

Do you know a example of IV solution for each osmolality.

Click on word osmolality to see if you are right.



Capillary

Capillary Membrane separates IntravascularSpace(IVS) from Interstitial Space

Capillary Interstitial Fluid Exchange is transfer

of water between vascular and interstitialcompartments

Capillary

Capillary Membrane

Porth p 765



FiltrationMovement of water and solutes from area of higher hydrostatic pressure to an

area of low hydrostatic pressure. Pushes fluid out of arterial end of capillary to

interstitial space.

Porth p 766

Picture retrieved from Dreamstime March25,2010

30mmHg 10mmHg

IF pressure -3 mm Hg



Hydrostatic PressurePressure created by weight of fluid and is impacted by distance from heart

pump and amount of fluid. Moves fluid out of capillary bed

Porth p.766

Picture retrieved with approval Dreamstime

March 25,2010

30mmHg 10mmHg

Interstitial Fluid pressure -3 mm Hg



Colloidal Osmotic PressureResponsible for moving fluid back to capillary with colloids. Assists in

retaining fluids in plasma

Porth p 766

Picture retrieved with approval Dreamstime March 25,2010

28mmHg

IF pressure 8 mm HG

28mmHg

Click here to

return to FVE



Lymph SystemExcessive interstitial fluid that can be returned to circulatory system

Porth p. 767

Picture retrieved with approval

Dreamstime March 25,2010

Excessive

fluid and

proteins

not

absorbed

in capillary



Q uiz :

Is it A, B, or C

Click on Rectangle to

See if You Are Right

Lymphatic

Drainage C

Filtration APressure created by weight

of fluid. Impacted by

distance from heart and

amount of fluid.

Hydrostatic

Pressure B

Excessive fluid and proteinsnot absorbed in capillary

Movement of water and

solutes from an area of high hydrostatic pressure to an

area of low hydrostatic

pressure

http://quizlet.com/1916557/fluid-balance-flash-cards

B

A

C



Fluid Volume Excess(FVC)-Increase In

ECF Compartment Volume

Why it happens-Movement of water exceeds theCompartment space

Excessive fluid intake

± Over-hydration ± Excessive sodium intake

Water retention caused by disease states ± Renal dysfunction

± Liver dysfunction ± Congestive heart failure (Remember hydrostatic andcolloid forces)

± Increased corticosteroid level

Porth p 778-779

Click here



Fluid Volume Excess Assessment and

Management

Signs Symptoms

Hypertension

Tachycardia Tachypnea

Weight Gain

Intake measured isgreater then output

Hypotension, Heartsound gallop andhypoxemia with

progressed state of cardio respiratoryfailure

Signs Symptoms of Increased Interstitial

Fluid volume

Dependent edema

Generalized edema Pitting/nonpittingedema

Signs and Symptomsof IncreasedIntravascular

Pulmonary edemaevidenced byshortness of breath,dyspnea , crackles,and cough

Full bounding pulse

Venous distention

Management

See Next slide

Porth p 778-779



FVE Outcomes/InterventionsPatient demonstrates adequate

fluid volume status:

Normotensive blood pressure (BP)

Below 120/80

Heart rate (HR) 100 beats/min

Respiratory rate 20 or below

Clear lung sounds

Pulmonary congestion absent on

x-rayConsistency of weight( absence of

upward trend from baseline)

Resolution of edema or decrease

in edema

Instruct patient to follow fluid and restriction

intake as prescribed by physician team. This helps

decrease extracellular fluid volume

In case of organ dysf unction etiologies of FVE

instruct patient to take daily weight for detecting

fluid volume increase

Monitor intake and output

Instruct to elevate edematous extremities to

promote venous return of fluid decreasing edemaInstruct on medications and dietary

recommendations for sodium and potassium

Hospitalized patient considerations: concentrate IV

fluids and prepare for possible ultra filtration or

hemofiltration

Assess degree of edema and cardio respiratorystatus

Communicate patient changes to physician

Outcomes Interventions

http://www1.us.elsevierhealth.com/MERLIN

/Gulanick/Constructor/



Fluid Volume Deficit-Decrease In ECF

Compartment VolumeWhy it happens? Remember Solute and Fluid Transport Dehydration Decreased fluid intake

± NPO ± Swallowing problems ± Malaise malnutrition

GI loss

± Nausea vomiting ± Diarrhea ± GI suction

Fluid loss via integumentary system ± Fever ± Severe wounds form burns

Renal loss

± Effect of drugs ± Kidney disease ± Endocrine imbalance

Third space fluid loss

Porth p 778-779



Fluid Volume Deficit(FVD) Assessment

and Management

Signs Symptoms-General

Constipation

Decreased urineoutput

Increased osmolarityand specific gravity

Thirst

Acute weight loss

Intake measured is lessthen output

Decreased urineoutput or oliguria

Elevated temperature

Signs Symptoms of Decreased Extracellular

Fluid volume

Sunken eyes and soft

eyeballs Dry mucosa

Decreased skin turgor

Signs and Symptoms of Decreased Intravascular

Dizziness

Weakness Orthostatic

hypotension orhypotension

Tachycardia

Weak thready pulse

Decreased vein filling


See Next slide

Porth p 778-779



FVD Outcomes/Interventions

Patient demonstrates adequate

fluid volume status:

Urine output greater than 30

ml/hr

Normotensive blood pressure (BP)

Below 120/80

Heart rate (HR) 100 beats/min

Respiratory rate 20 or below

Consistency of weight( absence of

lower trend from baseline)

Normal skin turgor.

Encourage patient to drink prescribed fluid

amounts. Assess for patients preference and keep in

reach

Remind to drink and assist to drink as needed for

cognitive and mobility dysf unction

Deliver parenteral fluid replacement as ordered if

volume deficit severe

If deficit causes hemodynamic instability anticipate

need for large bore intravenous catheter for rapid

inf usion of crystalloid and possible colloids if loss of

intravascular fluids

Assess for sighs and symptoms of fluid overload. If

present, stop fluid and support body position for

optimization of thoracic cavity to promote breathingMonitor I/O and daily weights

Communicate patient changes to physician team


http://www1.us.elsevierhealth.com/MERLIN

/Gulanick/Constructor/



Regulation of Body Fluid Volume

Major organ in water sodium balance is kidney Kidneys conserve water by concentrating urine

relative to plasma

Kidneys rid body of excessive water by dilute urinerelative to plasma

Control of water excretion in kidney is regulatedby anti-diuretic hormone (ADH) The hormone issecreted by hypothalamus.

ADH aids in water absorption at kidney collecting

ducts Hypothalamus and atria of heart have stretch

receptors sensitive to plasma osmolality

http: berkley.edu course kidney fluid2010

Microsoft clip art



Regulation of Fluid Volume Excess

Heitz 18. microsoft clip art

Increased vascular volume or

increased blood pressure

leading to increased atrial

stretch

Increased release of atrial natriuretic factor

Direct vasodilatationIncreased excretion of NA +

H2O by the kidney secondary to

increased filtration

Decreased

release of ADH

Decreased

renin/angiotensin/aldosterone

Decreased vascular volume and or blood

pressure



Regulation of Fluid Volume Deficit


Loss of hypotonic fluidDecreased plasma volume

Decreased cardiac output

Decreased water and

sodium filtered by the

kidney

Increased renin release

Decreased renal perfusion

Increased plasma volume and decreased osmolality

Increased plasma

osmolality

Decreased blood pressure

Decreased sodium and

water excretion

Increased volume of sodium

and water

Increased angiotensin I/II

Increased aldosterone secretion by adrenal cortex

Increased thirst

Increased water intake

Increased reabsorption of filtered water by the kidney

Increased ADH

Secretion

Decreased water excretion



Regulation of Fluid Volume Deficit-

Hemorrhage


Decreased arterial

pressure(decreased renal

perfusion)

Release of renin by the

kidneys

Increased arterial pressure

Release of aldosterone

Renin substrate Angiotensin I

converting enzyme

( lung)

Hemorrhage

Vasoconstriction

Angiotensin II

Retention of sodium and water

Increased vascular volume



Q uiz: Name Regulatory Hormones for Water and

Sodium Balance by Function Defined

Receptors in hypothalamus note

increasing plasma osmolality resulting

in stimulation of which hormone? It

causes water to be reabsorbed by

renal tubes.

Regulates sodium balance thus

water . Increases Plasma

volume. Increased BP,

Decreased urine

ADH-Anti-Diuretic

hormoneClick on

box for

hormone

name

Aldosterone

http://quizlet.com/1916557/fluid

-balance-flash-cards



Age Effect on Fluid Balance-Deficit

Total body water decreases due toincreased adipose tissue. Adipose

tissue has less water.

Unknown mechanism for decreasedthirst in elderly

Decreased thirst =decreased water

intake

Rolls 137. microsoft clip art



Age Effect on Fluid Balance-Excess

Aged heart has less stretch andefficiency for pumping

This puts aged at risk for heart failure

and fluid volume excess Elderly are more at risk for fluid

overload due to decreased kidney

function

Rolls 137. microsoft clip art



Genetics Effect on Fluid Balance Plasma renin, plasma aldosterone

concentrations , blood pressure, renalexcretion of K and NA following volumeexpansion and contraction withmonozygotic and dizygotic twins

studied for trends ± Conclusion: genetic/ heredity influence K

and NA excretion

Current research with worms shows

there are genetic receptors onhypodermis that regulate fluid balancehomeostasis

Grim 583 Huang 2595. microsoft clip art



Genetics Effect on Fluid Balance Genetic origins for fluid balance

pathologies

Chronic kidney disease(CKD) in

model of urinary fibrosis caused by

urinary obstruction Two inbred genetic marked mice

tested for CKD after reversible

unilateral ureteral obstruction ± C57BL developed CKD in 3 or more days

± BALB resistant to CKD up to ten days

Puri TS (2010) Microsoft clip art



Surgical Perioperative Considerations

on Fluid Balance

Pre-existing conditions such as

diabetes, renal insufficiency can

exacerbate with stress of surgery

Patient may start at negative fluid

balance due to NPO, preps that cause

GI and urine loss

Heitz p.207 microsoft clip art



Stress Response Influence on Fluid

Balance A Stress state causes the body to adapt to

reach homeostasis

Fluid regulatory hormones andneurotransmitters are released to aid in

adaptation of fluid balance from stressresponse (Remember slides 35-38)

ADH reabsorbs water in kidney tubulesdue to circulating volume decrease

Stress response of surgery can increaseADH to cause retention of water 48-72hours.

Porth 205 + 772 microsoft clip art



Inflammation Response Fluid Balance

Inflammation process causes plasma and

leukocytes to move from intravascular space

to injured tissue resulting in swelling (edema),increased temperature-redness (blood flow)

and pain



Surgical Inflammation Response Fluid

Balance

Release of Injury to skin and tissue (surgical incision)causing inflammation which results in loss of ions andprotein from plasma

Increase in tissue catabolism (breakdown) results inreactive oxidation greater amount of water fromreactive oxidation process

Potential for third spacing to occur with loss of plasma

proteins and colloid to cause leaking in transcellularspace

d



Case Study I76 year old female admitted to hospital for TAH, BSO, and bilateral

oopherectomy. hysterectomy and colon resection due to suspected

cancer. Patients medical history includes weight loss, heart failure, anddecreased appetite.

1. What baseline assessment would be helpful in managing the patient fluid

balance in perioperative operative care? Click below for answer

2. Would urine osmolality increase or decrease if patient dehydrated?

Click for answer

3. What monitoring will be important for the patient in post operative

period?

Click for answer

microsoft clip art

Assess if weight loss or gain, assess for signs of dehydration, check preop and

daily electrolytes to see if correction required, specific gravity(1.010-1.020)

Consideration of preop fluid status,

Surveillance of cardio respiratory status,

Surveillance of urine output, goal of I=O, Daily

weight.

Increase



Case Study IIA forty two year old woman Gravida 3 Para 2. Last delivery resulted

in gynecological and urological damage with stress

incontinence. Patient has decided to have elective bladder necksuspension, including colposuspension, and closure of a fistula

involving the bladder neck and urethra plus vaginal

reconstruction. Preoperative assessment of nutrition and weight

within normal limits.

microsoft clip art

1. What monitoring will be important for the patient in the postoperative period? Click for answer

2. If urine output drops what assessment information would you want to

report to physician? Click for answer

Surveillance if I=O with consideration of preop fluid status,

Surveillance of cardio respiratory status, Surveillance of urine output

Use bladder scan to confirm low urine output, Daily weights

Previous interventions related to IV fluids and IV bolus and response of urine output,

total intake and output, vital signs, unexpected bloody drainage, cardio respiratory

status changes, Trend of vital signs compared to baseline, Excruciating pain



References

Gulanick, M. (2007). Nursing Care Plans: Nursing Diagnosis & Intervention, 6 ed .

Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/

Heitz, U.E., Horne M.M.(2001). Pocket guide to fluid, electrolyte and acid-base balance .St.Louis: Mosby.

Huang P., Stern MJ. (2004). FGF signaling function in the hypodermis to regulate fluid

balance in C. elegans. [ Abstract]. NIH grant support , Yale University School of

Medicine. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed

Patlak, J. (1999), Fluid compartments in the body. Department of Physiology ,

University of Vermont. Retrieved from http://physioweb.med.uvm.edu/bodyfluids /March 21, 2010

Porth, C.M., (2005). Pathophysiology, 7th edition. Philadelphia: Lippincott.

Puri, TS., Shakib, MI., Mathew, L., Olayinka, O., Minto, AW., Sarav, M. Et. AL. (2010).

Chronic kidney disease induced in mice by reversible unilateral ureteral

obstruction is dependent on genetic background. Amer Journal of Physiology. Renal

Physiology 298 (4) 1024-1032

Undisclosed (2005-2010) Fluid balance flashcard s. retrieved from http://quizlet.com

March 2010

Undisclosed Department of molecular and cell biology.(2010) Fluid and electrolyte

balance. Retrieved http://mcb.berkeley.edu/courses/mcb135e/kidneyfluid.html

April 2010

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