unit vii fluids and electrolytes youtube n141

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Unit VII Fluids and ElectrolytesUnit VII Fluids and ElectrolytesN141N141

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YouTubeFluid & Electrolytes Part 1 through 3 10”each CampbeliteachingOsmosis and Diffusion Part 1-4 10”Rec’d Acid-Base Balance Part 1,2, 3 davidlaw888 (ATI)

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Fluid & ElectrolytesFluid & ElectrolytesFunction of fluidFunction of fluid

Transport of nutrients to & wastes from Transport of nutrients to & wastes from cellscellsHelps maintain normal body temp.Helps maintain normal body temp.Lubricates & cushionsLubricates & cushionsFacilitates digestion & eliminationFacilitates digestion & eliminationMaintains vascular volumeMaintains vascular volumeSolvent for electrolytesSolvent for electrolytes

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Fluid & ElectrolytesFluid & Electrolytes

Function of electrolytesFunction of electrolytesBody water regulation & Body water regulation & osmolalityosmolalityAcidAcid--base balancebase balanceEnzyme activityEnzyme activityNeuromuscular activityNeuromuscular activity

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Fluid & ElectrolytesFluid & ElectrolytesBody fluid distributionBody fluid distribution

Water & electrolytesWater & electrolytes60% of weight (adult & children>2yrs.)60% of weight (adult & children>2yrs.)

ICF ICF –– intracellular fluid = 40%intracellular fluid = 40%ECF ECF –– extracellular fluids = 20%extracellular fluids = 20%

Intravascular 5%Intravascular 5%Interstitial 15%Interstitial 15%

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ElectrolytesElectrolytesPlasmaPlasma CationsCations + = 154+ = 154

Sodium (Na) 142Sodium (Na) 142Potassium (K) 5Potassium (K) 5Calcium (CaCalcium (Ca22) 5) 5Magnesium (MgMagnesium (Mg22) 2) 2

Plasma AnionsPlasma Anions –– =154=154Chloride (Chloride (ClCl) 104) 104Bicarbonate(HCOBicarbonate(HCO33) 26) 26Phosphate (HPOPhosphate (HPO44) 2) 2Sulfate (SOSulfate (SO44

22) 1) 1Organic acids & Organic acids & proteinateproteinate 2222

ICF CationsCations += 200PotassiumPotassium 150150Magnesium 40Magnesium 40Sodium 10Sodium 10

ICF Anions ICF Anions -- = 200= 200Phosphates Phosphates Sulfates (150)Sulfates (150)Bicarbonate 10Bicarbonate 10ProteinateProteinate 4040

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AcidAcid--Base BalanceBase BalancepH – H+ ion concentration in bloodHydrogen is a product of metabolismNormal pH 7.35 – 7.45Chemical buffer systems

Remove or release Hydrogen ionsECF buffers – phosphates & plasma proteinsICF buffers – phosphates, proteins, & HemoglobinBicarbonate – Carbonic acid buffer system Acid – donates H+ ionsBase – accepts H+ ions

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AcidAcid--Base Base

AlkalosisAcidosis

DeathDeath

7.35 7.45

7.806.80

1 part acid 20 parts baseH2CO3

1.2mEq/LHCO3

24mEq/L

H2O + CO2 H2CO3 H + HCO3

K I DNEYS

LUNGS

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Body Fluid BalanceBody Fluid BalanceRoutes of Gains & LossesRoutes of Gains & Losses

GainsFood 800-1000mlFluid intake 1100-1400mlOxidative metabolism

300ml

LossesLungs 400mlSkin 500-600mlG.I tract 100-200

Small intestine absorbs fluid

Kidneys – 1200-1500

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Fluid RegulationFluid RegulationOsmolalityOsmolality (Tonicity) = concentration(Tonicity) = concentration

IsoIso--osmolarosmolar, hypo, hypo--osmolarosmolar, , hyperosmolarhyperosmolarNormal serum Normal serum osmolalityosmolality = 280= 280--295mOsm/kg 295mOsm/kg of Hof H22OO

Semi permeable membrane

Isotonic

Iso-osmolar

Isotonic

Iso-osmolar

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Fluid Regulation Fluid Regulation -- OsmosisOsmosisOsmosisOsmosis

Osmotic pull by particles /unit of water Osmotic pull by particles /unit of water ((OsmolalityOsmolality))Movement of fluid from area of < Movement of fluid from area of < concentration to area of > concentrationconcentration to area of > concentration


Hypertonic

HyperosmolarHypotonic

Hypo-osmolar

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Fluid Regulation Fluid Regulation -- OsmosisOsmosisOsmosisOsmosis

Osmotic pull by particles /unit of water Osmotic pull by particles /unit of water ((OsmolalityOsmolality))Movement of fluid from area of < Movement of fluid from area of < concentration to area of > concentrationconcentration to area of > concentration


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Fluid RegulationFluid RegulationThirst mechanism

Thirst Center

Plasma Omolality

Angiotensin II

Dry oropharyngealMucous membranes

Plasma Volume

Psychologicalfactors

Dec.Potassiumor

Inc.Sodium

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Fluid Regulation Fluid Regulation –– KidneysKidneysRetention & ExcretionRetention & Excretion

Regulation of ECF volume & osmolalityby selective retention & excretionHydrostatic pressureFiltration = excretion of urine/waste productsGFR = 125ml/minuteNormal urine output – 20-30ml/hr

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ReninRenin--AngiotensinAngiotensin--AldosteroneAldosterone SystemSystem

Glomerulus

Renin secretion

BP or Na

Liver

Angiotensinconverted to Angiotensin I

Lungs

Angiotensin I converted to Angiotensin II

Adrenals produce aldosterone

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AldosteroneAldosteroneNa & H2O retention =

fluid volume & Na levels

Angiotensin II –adrenals* secrete aldosterone

*

Kidneys retain Na & H2O 18

AntidiureticAntidiuretic Hormone (ADH)Hormone (ADH)

Plasma Osmolality

Hypothalmus Osmoreceptors

BrainADH

Kidney

H2O retention

Urine volume

Urine concentration

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Electrolyte Balancing ActElectrolyte Balancing Act

Active transportActive transportATP ATP –– solutes move from solutes move from area of < concentration to area of < concentration to areas of > concentrationareas of > concentration

The body expands energy to The body expands energy to maintain the extracellular Na maintain the extracellular Na and the intracellular K by and the intracellular K by means of cell membrane means of cell membrane Sodium Sodium –– Potassium pump.Potassium pump.

+ -

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Sodium BalanceSodium BalanceNormal serum sodium (Na+)

135 –145 mEq/L (Cl 95 - 108)95% in ECF Primary role

Control H2O distribution & volumeNormal intake 50-90mEq as NaClKidney conserves or excretes Na prn

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Potassium ( KPotassium ( K++))FunctionFunction

Regulation of ICF osmolalityPromotes transmission/conduction of nerve impulsesPromotes contraction of skeletal, cardiac, & smooth muscleMaintenance of acid-base balance

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Potassium ( KPotassium ( K++))

Major intracellular cation–150mEq/LNormal se levels – 3.5–5mEq/LPoor storage – daily requirement needsKidneys excrete 80-90% of K+

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Dietary Sources of KDietary Sources of K

MeatsMeatsVegetablesVegetablesFruitsFruitsDried fruits, nuts, Dried fruits, nuts, seedsseedsChocolateChocolate

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CalciumCalcium

Se Ca++

Total 8.5 –10.5 mg/dL (100ml)Bound with protein & ionized

Ionized – 4 – 5 mEq/L99% in bones & teeth

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Calcium Calcium -- FunctionFunctionTransmission & conduction of nerve impulsesStimulates skeletal, smooth, & cardiac muscle contractionPromotes coagulationBone & teeth formationHormone secretion

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Calcium Calcium –– RegulationRegulation

Vitamin DPhosphates

PO3-

Inverse relationship with Calcium

PTHCalcitonin

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Magnesium Magnesium Distribution

2/3 found in bones1/3 found in ICF1% in ECF

Absorbed in small bowelExcreted by kidneysFunction

Intracellular metabolismNeuromuscular - similar to calcium

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BicarbonateBicarbonateHCO3-

Major chemical buffer in ECF & ICFRegulated by kidneysArterial measurement

20-26 mEq/LVenous measurement

CO2 content 24-30 mEq/L

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ABG ValuesABG ValuespH 7.35 – 7.45

<7.35 >7.45

PaCO2 35-45 mmHg<35 (hypocapnia)>45 (hypercapnia

HCO3 20-26 mEq/L<20 (acidosis)>26 (alkalosis)

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AcidAcid--Base Base

AlkalosisAcidosis

DeathDeath

7.35 7.45

7.806.80


1.2mEq/LHCO3

24mEq/L


K I DNEYS

LUNGS

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AcidAcid--Base Base --AcidosisAcidosis

AlkalosisAcidosis

DeathDeath

7.35 7.45

7.806.80

Gain of acid

H2CO3


HCO3

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AcidAcid--Base Base --AcidosisAcidosis

AlkalosisAcidosis

DeathDeath

7.35 7.45

7.806.80

Loss of baseHCO3


H2CO3

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Metabolic Acidosis Metabolic Acidosis ––MechanismMechanism

Accumulation of fixed acids

Lactic acidosisRenal failureKetoacidosisIngestion

ASAAntifreeze

Loss of baseLoss of baseRenal tubular acidosisCarbonic anhydraseinhibitors

DiamoxDiarrhea

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Metabolic Acidosis Metabolic Acidosis --SymptomsSymptoms

pH HCO3

Hyperventilation (PaCO2 )compensatoryLethargy/weaknessHyperkalemiaHypotension & myocardial depression

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Respiratory AcidosisRespiratory AcidosisCauses

Inadequate excretion of CO2

Acute or chronic respiratory alterationsRisk factors favoring hypoventilation

ObesityTight binders/dressingsPostoperative painAbdominal distention

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Respiratory Acidosis Respiratory Acidosis ––SymptomsSymptoms

ABG’spH PaCO2

HCO3 ( compensatory)HeadacheHypertensionHyperkalemiaHypoxemia

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AcidAcid--Base Base

AlkalosisAcidosis

DeathDeath

7.35 7.45

7.806.80


1.2mEq/LHCO3

24mEq/L


K I DNEYS

LUNGS

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AcidAcid--Base Base --AlkalosisAlkalosis

7.806.80 AlkalosisAcidosis

DeathDeath

7.35 7.45

Loss of acid

H2CO3HCO3


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AcidAcid--Base Base --AlkalosisAlkalosis

7.806.80

Gain of base

AlkalosisAcidosis

DeathDeath

7.35 7.45

H2CO3HCO3


Metabolic Alkalosis Metabolic Alkalosis --CausesCauses

Fixed acid lossVomiting/G.I suctionHypokalemia

Excess bicarbonate intakeAlkali ingestionI.V. NaHCO3

Excess bicarbonate reabsorption

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Metabolic Alkalosis Metabolic Alkalosis ––SymptomsSymptoms

ABG’spH HCO3

PaCO2 ( compensatory)HypoventilationDecreased LOCHypokalemiaHypochloremiaTetany/paresthesia

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Respiratory AlkalosisRespiratory AlkalosisCauses relate to hyperventilation

AnxietyHigh feverThyrotoxicosisHypoxemiaSalicylate intoxication (early)

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Respiratory AlkalosisRespiratory Alkalosis-- SymptomsSymptomsABG’s

pH PaCO2 HCO3 ( compensated)

Lightheadedness/confusionInability to concentrateParesthesiaPalpitationsDry mouth 44

Influencing Factors in Total Body WaterInfluencing Factors in Total Body WaterBody fatBody fat

Fat cells contain less waterSexSex

Women less body fluid than menAgeAge

Infants 70-80% body weight (Adult 60%)50% extracellular (Adult 20%)

Older adult% of body weight

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Influencing FactorsInfluencing Factors

ElderlyElderlyDiminished thirst responseDiminished thirst responseAltered ADH responseAltered ADH responseDecreased ability to concentrate urineDecreased ability to concentrate urineChronicityChronicityDebilitationDebilitationChanges in cognitionChanges in cognition

Infant Infant -- child, more risk for dehydration, child, more risk for dehydration, esp. if vomiting and diarrheaesp. if vomiting and diarrhea

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Risk FactorsRisk FactorsCompromised regulatory mechanismsCompromised regulatory mechanisms

Congestive heart failureCongestive heart failureRenal failureRenal failureCirrhosisCirrhosisSteroid excessSteroid excess

ADH stimulationADH stimulationExcess sodium containing fluids/foodsExcess sodium containing fluids/foodsIV solutionsIV solutions

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Alterations in fluid intake & Alterations in fluid intake & outputoutput

MedicationsMedicationsG.IG.I

DysphagiaDysphagiaNausea/vomitingNausea/vomitingDiarrheaDiarrheaInsufficient intakeInsufficient intakeG.I. suctionG.I. suction

RestraintsRestraints

SkinSkinDiaphoresisDiaphoresisWounds/burnsWounds/burns

FeverFeverIncrease in Increase in metabolismmetabolismTachypneaTachypnea

Blood lossBlood loss48

History and InterviewHistory and InterviewAgeAcute illnessRespiratory/Cardiovascular disordersChronic illnessRenal / G. I. disordersEnvironmentDiet/ lifestyleMedications

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Normal FindingsNormal FindingsGeneralVSWeightIntake & OutputUrineSkin turgor

Mucous membranesThirstEdemaNeck VeinsNeuromuscular signs

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Diagnostic TestsDiagnostic Tests

Serum electrolytes

SodiumPotassiumChlorideCO2

Serum osmolalityABG’sHematocrit

BUNCreatinineBUN:creatinineratioSpecific gravityUrine osmolality

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Isotonic Imbalance Isotonic Imbalance -- Fluid Fluid Volume Deficit (FVD)Volume Deficit (FVD)

Decrease in intravascular & Decrease in intravascular & interstitial fluids = interstitial fluids = hypovolemiahypovolemiaIsotonic FVD Isotonic FVD

Equal water & Equal water & lytelyte losslossHemorrhageHemorrhageDiaphoresisDiaphoresisDiureticsDiuretics

Na 140Na 140

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Fluid Volume Deficit Fluid Volume Deficit -- IsotonicIsotonicS&S

BPHeart rateMucous membranesSkin turgorWeightVenous fillingUrine outputLOC

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Assessment Assessment --FVD FVD ––SymptomsSymptoms

ThirstThirstMuscle weaknessMuscle weaknessDecreased skin Decreased skin turgorturgorDry mucous membranesDry mucous membranesSoft & sunken eyeballsSoft & sunken eyeballsDecreased temperature if no sepsisDecreased temperature if no sepsisTachycardiaTachycardiaNarrowed pulse pressureNarrowed pulse pressurePostural hypotensionPostural hypotensionDecreased urinary output, weight lossDecreased urinary output, weight lossNeurological changes Neurological changes –– apprehension, apprehension, headache, confusionheadache, confusion 54

FVD FVD -- Diagnostic TestsDiagnostic Tests

Serum Na+

BUN

⇒ or ⇑ 145

⇑ >25

Hematocrit ⇑ >50%

Specific gravity ⇑ > 1.025

Increased solute to solvent

Hemo-concentration

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Extracellular Fluid Volume Extracellular Fluid Volume Excess (FVE)Excess (FVE)

Abnormal fluid retention in intravascular & interstitial spacesSecondary to serum NaSodium & Water retained in proportion

NA 140mEq/L

ISOTONIC

FLUID

NORMAL VOLUME EXCESS VOLUME56

Isotonic Fluid Volume ExcessIsotonic Fluid Volume ExcessCauses

Congestive heart failureRenal failureExcessive sodium intakeIncreased serum aldosterone levelsSteroids

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Isotonic Fluid Volume ExcessIsotonic Fluid Volume ExcessS&S

WeightEdemaBPUrine outputVenous fillingBreath sounds

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FVE FVE –– ManifestationsManifestationsCardiovascularCardiovascular

B.P.B.P.Pulse qualityPulse qualityPitting edemaPitting edema

SacralSacralPeripheralPeripheral

Weight gainWeight gainDistended veinsDistended veinsSS33 heart soundheart sound

RespiratoryRespiratoryConstant, Constant, irritating coughirritating coughCrackles (Crackles (RalesRales))DyspneaDyspneaCyanosisCyanosisPleural effusionPleural effusion

NeurologicalNeurologicalLOCLOC

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FVE FVE –– Diagnostic TestsDiagnostic Tests

Serum sodiumSerum sodiumHematocritHematocrit (% (% RBCRBC’’ss in plasma)in plasma)Urine specific gravityUrine specific gravityBUNBUN

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OsmolarOsmolar ImbalancesImbalances

HyperosmolarHyperosmolar FVDFVDWater loss > Water loss > lytelyte lossloss

HypoHypo--osmolarosmolar FVEFVEWater gain > Water gain > lytelyte gaingain

Na 150Na 140

Water Excess

Dehydration

Na <135Na 140

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HypoHypo--osmolarosmolar Imbalance Imbalance ––HH22O excessO excess

CausesCausesExcessive amounts of hypotonic (hypo-osmolar)solutions

D5W0.45% saline

Excessive intake of free water

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Intracellular Fluid Volume Intracellular Fluid Volume Excess (ICFVE)Excess (ICFVE)

Fluid shift from extracellular spaces to intracellular Due to serum hypo-osmolalityCellular edema

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Effect of Na Imbalance on CellEffect of Na Imbalance on Cell

H2O

Hypernatremia:

Na > 145mEq/L

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Effect of Na Imbalance on CellEffect of Na Imbalance on Cell

H2O

Hypernatremia:

Na > 145mEq/L

Cell shrinks as water is pulled out into ECF

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Effect of Na Imbalance on CellEffect of Na Imbalance on CellHyponatremia:

Na < 135mEq/L Due to excess water gain or Na loss

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Effect of Na Imbalance on CellEffect of Na Imbalance on CellHyponatremia:

Na < 135mEq/L H2O

H2O

H2O

H2O

Cell swells as water is pulled in

from ECF

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HypernatremiaHypernatremia –– SymptomsSymptomsS&S of FVE or FVDS&S of FVE or FVDThirst?Thirst?Temperature?Temperature?Mucous membranes?Mucous membranes?Restlessness, weakness with mild to Restlessness, weakness with mild to moderate moderate NaNaDisorientation, delusions, hallucinations Disorientation, delusions, hallucinations with severe with severe NaNaLethargy, stupor, comaLethargy, stupor, comaMuscle irritability and convulsionsMuscle irritability and convulsions 68

HyponatremiaHyponatremia

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HyponatremiaHyponatremia –– SymptomsSymptomsRelate to Na levelRelate to Na level

120120--125mEq/L125mEq/LNauseaNauseaMalaiseMalaise

115115--120 120 mEqmEq/L/LHeadacheHeadacheLethargyLethargyObtundationObtundation

<110<110--115 115 mEqmEq/L/LSeizuresSeizuresComaComa

Volume statusECF depletion

WeaknessFatigueMuscle crampsPostural dizziness

Lab dataSe Na?Ua Na?Se osmolality?

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HYPOKALEMIAHYPOKALEMIASerum KSerum K+ + < 3. 5 < 3. 5 mEqmEq/L/LCausesCauses

Inadequate nutrient intakeInadequate nutrient intakeG.I. LossesG.I. LossesRenal lossesRenal lossesStress Stress –– increased increased cortisolcortisol levelslevelsSteroidsSteroidsAlkalosisAlkalosis

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HypokalemiaHypokalemia –– SymptomsSymptomsMusculoskeletal

WeaknessParalysisLeg cramps

G.I.IleusAnorexiaVomiting

RespiratoryRespirations?SOBApnea

RenalPolyuria

Cardiovascular

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HyperkalemiaHyperkalemia Se KSe K++> 5.0 > 5.0 mEqmEq/L/LCauses

Decreased potassium excretionOliguric renal failurePotassium sparing diuretics

High potassium intakeExcess oral potassium supplementsExcessive or rapid IV K+ replacement

Shift of K out of cellsAcidosis, tissue trauma, malignant cell lysis(chemotherapy)

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HyperkalemiaHyperkalemia –– SymptomsSymptomsCardiovascular

EKG changesDysrhythmiasWeakened contractilityTachycardia then bradycardiaCardiac arrest

GINauseaIntestinal colicHyperactive bowel sounds

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HyperkalemiaHyperkalemia -- SymptomsSymptoms

NeuromuscularVague muscle weaknessFlaccid muscle paralysisParesthesia

RenalOliguriaanuria

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HypercalcemiaHypercalcemia –– CausesCauses

Metastatic CancerImmobilizationHyperparathyroidismIntake

Thiazide diuretics, LithiumExcess intake of Ca2

+ antacidsExcess intake of Vitamins A or D

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HypercalcemiaHypercalcemia –– SymptomsSymptomsNeuromuscular weaknessRenal

Polyuria (DI)Hypercalcuria

GIN & V

peristalsisConstipation

CardiovascularImpaired cerebral functioning

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HypocalcemiaHypocalcemia –– SymptomsSymptomsNeuromuscular

Tetanythreshold potential – less stimulus

required for action potentialHyperexcitability of motor & sensory nervesParesthesiaTrousseau’s signChvostek’s sign

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HypermagnesemiaHypermagnesemia ––SymptomsSymptoms

Diminished neuromuscular transmissionDecreased muscle functionHypotensionRespiratory depressionCardiac arrest

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HypomagnesemiaHypomagnesemia <1.8mg/dL<1.8mg/dLCausesCauses

Losses from G.I tractAlcoholismRapid administration of citrated bloodMedications

Loop diureticsCisplatin

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Nursing DiagnosisNursing DiagnosisFluid volume excessFluid volume deficitIneffective breathing patternImpaired mobilityImpaired skin integrityAltered oral mucous membranes

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NursingNursing InterventionsInterventionsAssess fluid volume statusObtain daily weights

1 liter = 1 kg.(2.2lb.)Measure & calculate I & OMonitor lab valuesProvide frequent mouth careAdminister tube feedings &/or IV fluidsProtect skin integritySafety – implement measures to prevent fallsPulmonary toiletOffer fluids as appropriateMedications 82

Fluid TypesFluid TypesOral rehydration.Oral rehydration.Intravenous solutionsIntravenous solutions

Isotonic electrolyte solutions to treat Isotonic electrolyte solutions to treat hypotensive hypotensive patient patient –– expands plasma volume.expands plasma volume.

Lactated RingerLactated Ringer’’s.s.O.9% Normal Saline.O.9% Normal Saline.

Hypotonic solutions Hypotonic solutions –– provides free water & provides free water & lytes lytes ––allows kidneys to select & retain needed amounts. allows kidneys to select & retain needed amounts. Decreases intravascular Decreases intravascular osmolalityosmolality..

0.45%N.S.0.45%N.S.DD55%/0.2%N.S.%/0.2%N.S.

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Parenteral Parenteral FluidsFluidsPurposes of Fluid Therapy

Maintenance NeedsFluidsElectrolytes

ReplacementCorrection of electrolyte disturbances

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Parenteral Parenteral FluidsFluidsAssessment

I & ODaily body weightsVital signsSkin turgorUrinary specific gravityLaboratory valuesI.V. site

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CrystalloidsCrystalloidsDextrose Solutions

D5WIsotonic HypotonicD5W is 5% dextrose in water is hypotonic so it moves fluid into the cells out of the circulation

Free water to aid renal excretion of solutesCalories 50 grams DextroseAvoid excess

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CrystalloidsCrystalloidsSodium Chloride solutions

Isotonic Saline (0.9% NaCl)Expands extracellular fluidDoes not enter the ICFUse

ECF deficitsHyponatremiaHypochloremiaMetabolic alkalosis

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CrystalloidsCrystalloids0.45% NaCl

HypotonicProvides Na, Cl, free waterBasic fluid for maintenanceUses

MaintenanceHypovolemia with hypernatremia

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CrystalloidsCrystalloidsBalanced electrolyte solutions

Lactated Ringers (Na, Cl, K, Ca, lactate)Lactate BicarbonateMetabolic acidosisThird spacingFluid resuscitation

NormosolIsolytePlasma-Lyte

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ColloidsColloidsProtein or starch molecules in fluidIncrease osmotic pressure – volume expansionAlbumin

5%– equivalent to plasma25% - hyperoncoticPlasma expander

DextranLow molecular weight (dextran 40)High molecular weight (dextran 70)

HetastarchSupplemental fat emulsions (Lipids)

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Adverse effects of IV therapyAdverse effects of IV therapyFluid Volume Excess/DeficitActivity intoleranceImpaired skin integrityImpaired tissue perfusionRisk for dysrhythmiasRisk for injuryElectrolyte imbalances (specify)Altered nutritionIneffective breathing patterns

Study GuideList assessment findings for fluid volume deficit. List assessment findings for fluid volume excess. Identify fluid and electrolyte issues for infants and elderly.Know the compensating mechanisms most likely to occur in the presence of respiratory acidosis, respiratory alkalosis, metabolic acidosis, metabolic acidosis.Be aware of causes and symptoms of potassium imbalances, sodium imbalances.List ways to assess for fluid retention.Identify the signs that indicate that fluid replacement is needed.

unit vii fluids and electrolytes youtube n141

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