Unit NineUnit Nine

Ahmad Ata Ahmad Ata

Objectives:Objectives: Discuss the function, distribution, movement Discuss the function, distribution, movement

and regulation of fluid in the body.and regulation of fluid in the body. Identify factors affecting normal body fluid.Identify factors affecting normal body fluid. Discuss the risk factors and causes and Discuss the risk factors and causes and

effect of the fluid.effect of the fluid. Select appropriate nursing diagnosis for Select appropriate nursing diagnosis for

client’s with altered fluid. client’s with altered fluid. Implement measures to correct imbalances Implement measures to correct imbalances

of fluid.of fluid. Evaluate the effect of nursing and Evaluate the effect of nursing and

collaborative intervention on the client’s collaborative intervention on the client’s fluid.fluid.

Body fluid and electrolyte:Body fluid and electrolyte:

About 46 to 6o % of the average About 46 to 6o % of the average adult weight is water.adult weight is water.

Water may serve as:Water may serve as:

Medium of metabolic reaction with Medium of metabolic reaction with cells.cells.

Transporter for nutrients, waste Transporter for nutrients, waste products, and other substance.products, and other substance.

A lubricant.A lubricant. Shock absorber.Shock absorber. Regulate and maintain body Regulate and maintain body

temperature. temperature.

The proportion of water The proportion of water decreases with aging because decreases with aging because fat, age and sex effect of total fat, age and sex effect of total body water.body water.

(Infant 70 – 80%).(Infant 70 – 80%).

Distribution of body Distribution of body fluids:fluids:

The body fluid divided in two The body fluid divided in two major compartments:major compartments:

A) Intracellular fluid (ICF):A) Intracellular fluid (ICF): Is found with on the cells of the Is found with on the cells of the

body. its constitute 2/3 of the total body. its constitute 2/3 of the total body fluid in the adult.body fluid in the adult.

b) Extracelluar fluid (ECF):b) Extracelluar fluid (ECF): is found out side of cell and account is found out side of cell and account

1/3 of the total body fluid it’s 1/3 of the total body fluid it’s subdivided into three subdivided into three compartments:compartments:

1) Intravascular fluid or plasma: is found 1) Intravascular fluid or plasma: is found within vascular system.within vascular system.

2) Interstitial fluid: is found surrounding 2) Interstitial fluid: is found surrounding the cell and includes lymph.the cell and includes lymph.

3) Transcellular: includes cerebrospinal 3) Transcellular: includes cerebrospinal fluid, pleural, peritoneal and synovial fluid, pleural, peritoneal and synovial fluid. fluid.

Composition of FluidsComposition of Fluids plasmaplasma interstitialinterstitial intracellularintracellularCationsCationsNaNa 140140 146146 1212KK 44 44 150150CaCa 55 33 1010MgMg 22 11 77AnionsAnionsClCl 103103 104104 33HCOHCO 2424 2727 1010SO4SO4 11 11 --HPO4HPO4 22 22 116116ProteinProtein 1616 55 4040

Function of ICF & ECF:Function of ICF & ECF: ICF: is vital organ to normal cell ICF: is vital organ to normal cell

function, its contain solutes such as function, its contain solutes such as oxygen, electrolytes and glucose. It oxygen, electrolytes and glucose. It provides a medium in which metabolic provides a medium in which metabolic process.process.

ECF: it is the transport system that ECF: it is the transport system that carries nutrients and waste product carries nutrients and waste product from the cell.from the cell.

Movement of body fluid and Movement of body fluid and electrolyte:electrolyte:

OsmosisOsmosis:: Is the movement of water across Is the movement of water across

cell membranes, from the less cell membranes, from the less concentrated solution to more concentrated solution to more concentrated solution. In other word concentrated solution. In other word water move toward higher water move toward higher concentration.concentration.

– Solutes are substance dissolved in Solutes are substance dissolved in liquid.liquid.

– Solvent: is the component of solution Solvent: is the component of solution that can dissolve in the solutes.that can dissolve in the solutes.

– Crystalloid: salts that dissolved readily Crystalloid: salts that dissolved readily in to true solution.in to true solution.

– Colloids: substance such as large protein Colloids: substance such as large protein molecules that do not dissolved in true molecules that do not dissolved in true solution.solution.

Sodium is the major determinant of Sodium is the major determinant of serum osmolality.serum osmolality.

Diffusion:Diffusion: Is the continual intermingling of Is the continual intermingling of

molecules in liquid, gases by molecules in liquid, gases by random movement of the random movement of the molecules.molecules.

FiltrationFiltration: : Is the process where by fluid and Is the process where by fluid and

solutes moved together across a solutes moved together across a membrane from one compartment membrane from one compartment to another.to another.

– Hydrostatic pressure: is the pressure Hydrostatic pressure: is the pressure exerted by fluid with closed system on exerted by fluid with closed system on the wall of container in which it the wall of container in which it contained.contained.

Active transportActive transport:: substance can move across cell substance can move across cell

membranes from a less membranes from a less concentrated solution to amore concentrated solution to amore concentrated one by active concentrated one by active transport.transport.

Regulating body fluid:Regulating body fluid:

The average adult drinks about The average adult drinks about 1500ml per day but need to 2500ml 1500ml per day but need to 2500ml per day this added volume is acquired per day this added volume is acquired by the food.by the food.

The thirst center is located in the The thirst center is located in the brain, this center trigger by osmotic brain, this center trigger by osmotic pressure and angiotensin II .pressure and angiotensin II .

Hormonal regulation Hormonal regulation

Regulation of ECFRegulation of ECF

Fluid out put:Fluid out put:

Urine:Urine: normal urine out put 1500ml normal urine out put 1500ml per 24hrs or at least 30ml per hours.per 24hrs or at least 30ml per hours.

Insensible lossInsensible loss through the skin as through the skin as perspiration and through the lung a perspiration and through the lung a water vapor in the expired air.water vapor in the expired air.

Loss through the intestine Loss through the intestine (feces)(feces)

Obligatory losses: approximately Obligatory losses: approximately 500ml of fluid must be exerted 500ml of fluid must be exerted through the kidney to eliminate through the kidney to eliminate metabolic waste product and feces, metabolic waste product and feces, respiration and perspiration to respiration and perspiration to maintain body temperature.maintain body temperature.

The average daily fluid out put for an The average daily fluid out put for an adult 2500ml/ day.adult 2500ml/ day.

Client at risk for fluid and Client at risk for fluid and electrolyte imbalance:electrolyte imbalance:

Post operative client.Post operative client. Client with sever trauma or burn.Client with sever trauma or burn. Client with chronic disease as Client with chronic disease as

congestive heart failure.congestive heart failure. Client who are permitted NPO.Client who are permitted NPO. Client with intravenous infusion.Client with intravenous infusion. Client with special drainage.Client with special drainage. Client who receiving diuretic Client who receiving diuretic

Factor effecting fluid and Factor effecting fluid and electrolyte balance:electrolyte balance:

Age: infant have greater water need Age: infant have greater water need and greater loss due to greater and greater loss due to greater metabolic rate.metabolic rate.

Environment excess heat stimulates Environment excess heat stimulates the sympathetic nervous system the sympathetic nervous system and cause person to sweat.and cause person to sweat.

Diet: in nutritional deficiency, the Diet: in nutritional deficiency, the body preserved the protein by body preserved the protein by breaking down the fat and glycogen.breaking down the fat and glycogen.

Stress: water retention and increase Stress: water retention and increase the production antiduritic hormone.the production antiduritic hormone.

Illness: burn, renal disorder Illness: burn, renal disorder

Disturbances in fluid and Disturbances in fluid and electrolyte:electrolyte:

Hypovolemia: result from in oligurea Hypovolemia: result from in oligurea to anurea to anurea

Hypovolemic shock when Hypovolemic shock when intravascular fluid is depleted.intravascular fluid is depleted.

Hypervolimia: when increase blood Hypervolimia: when increase blood volume.volume.

Type of edma:Type of edma:

Dependent edma: found in the Dependent edma: found in the lowest part body.lowest part body.

Pitting edma: edema that leaves a Pitting edma: edema that leaves a depression or pit after finger depression or pit after finger pressure is applied on the swollen pressure is applied on the swollen area.area.

Sodium (Na):Sodium (Na): Is the most abundant cation in the Is the most abundant cation in the

extracelluar fluid and major extracelluar fluid and major contributor to serum osmolality.contributor to serum osmolality.

Function of sodium:Function of sodium: controlling and regulating water controlling and regulating water

balance.balance. Maintaining blood volume Maintaining blood volume Transmitted nerve impulses.Transmitted nerve impulses.

Normal level is 135 – 145 mg/dl.Normal level is 135 – 145 mg/dl. Hyponatremia: sodium deficit in the Hyponatremia: sodium deficit in the

blood.blood. Hypernatremia: sodium excess in the Hypernatremia: sodium excess in the

blood. blood. Sodium is found in many foods, such Sodium is found in many foods, such

as processed cheese, table salt.as processed cheese, table salt.

Potassium:Potassium:

Is the major cation in intracellular fluid.Is the major cation in intracellular fluid.

Function of potassium:Function of potassium: Maintain ICF osmolality.Maintain ICF osmolality. Transmitting nerve impulses.Transmitting nerve impulses. Regulate cardiac impulses.Regulate cardiac impulses. Skeletal and smooth muscle function.Skeletal and smooth muscle function. Regulate acid base balance Regulate acid base balance

– Potassium is found in many fruits and Potassium is found in many fruits and vegetables, meat, fish, milk.vegetables, meat, fish, milk.

– Normal level of potassium is 3.5 – 5.3meq/l.Normal level of potassium is 3.5 – 5.3meq/l.– Hypokalemia: potassium deficit in the blood.Hypokalemia: potassium deficit in the blood.– Hyperkalemia: potassium excess in the blood.Hyperkalemia: potassium excess in the blood.

Hypocalcemia: calcium deficit in the blood.Hypocalcemia: calcium deficit in the blood. Hypercalcemia: calcium excess in the Hypercalcemia: calcium excess in the

blood.blood.

Loss of water and Loss of water and electrolyte:electrolyte:

Vomiting.Vomiting. Diarrhea.Diarrhea. Excessive sweating.Excessive sweating. Ployuria.Ployuria. Fever.Fever. Nasogastric suction.Nasogastric suction. Abnormal drainage.Abnormal drainage. Anorexia.Anorexia. NauseaNausea Impaired swallowing.Impaired swallowing.

Finding associated with Finding associated with fluid and electrolyte fluid and electrolyte

imbalance:imbalance: Skin: dry pale, cool skin, reduce skin Skin: dry pale, cool skin, reduce skin

Turgor. Turgor. Oral cavity: dry mucous membrane, Oral cavity: dry mucous membrane,

absence of salivation.absence of salivation. Weak rapid pulse.Weak rapid pulse. Decreased blood pressure.Decreased blood pressure. Decreased central venous pressure Decreased central venous pressure

Decreased urine out put.Decreased urine out put. Increased hematocrit.Increased hematocrit. Thirst.Thirst. Flat neck vein.Flat neck vein.

Fluid volume excess:Fluid volume excess:

Excess intake of sodium – containing Excess intake of sodium – containing intravenous fluid.intravenous fluid.

Excess of ingestion of sodium in Excess of ingestion of sodium in diet.diet.

Heart failure.Heart failure. Renal failure.Renal failure. Liver cirrhosis.Liver cirrhosis.

Clinical manifestation:Clinical manifestation:

Weight gain.Weight gain. Fluid intake greater than out put.Fluid intake greater than out put. Moist mucous membrane.Moist mucous membrane. Tachycardia.Tachycardia. Increased blood pressure.Increased blood pressure. Distended neck vein.Distended neck vein. Dyspnea and crackles.Dyspnea and crackles. Mental confusion.Mental confusion.

Nursing care planNursing care plan

Assessment:Assessment:– Nursing history:Nursing history:

Date include fluid and food intake, Date include fluid and food intake, output.output.

Recent fluid losses.Recent fluid losses. Sign of fluid deficit.Sign of fluid deficit. Common sign of electrolyte disturbance.Common sign of electrolyte disturbance. Medication.Medication.

– Clinical measurement:Clinical measurement:

Daily weights, vital sign, fluid intake Daily weights, vital sign, fluid intake and output (I&O), serum electrolyte, and output (I&O), serum electrolyte, complete blood count (CBC). Serum complete blood count (CBC). Serum osmolality, urine specific gravity.osmolality, urine specific gravity.

Nursing diagnosis:Nursing diagnosis:

Fluid volume deficit related to dehydration.Fluid volume deficit related to dehydration. Fluid volume excess related to heart failure.Fluid volume excess related to heart failure. Altered oral mucous membrane related to Altered oral mucous membrane related to

fluid volume defict.fluid volume defict. Impaired skin integrity related to Impaired skin integrity related to

dehydrationdehydration Decreased cardiac output related to Decreased cardiac output related to

hypovolemia.hypovolemia. Altered tissue perfusion related to Altered tissue perfusion related to

decreased cardiac output.decreased cardiac output.

Implementation:Implementation:

Assess clinical manifestation of hypo or Assess clinical manifestation of hypo or Hypervolimia. Hypervolimia.

Provide fluid and electrolyte orally.Provide fluid and electrolyte orally. Foods.Foods. Intravenous therapy can prescribed for Intravenous therapy can prescribed for

those reason those reason Provide salts if needed.Provide salts if needed. Provide glucose for metabolism.Provide glucose for metabolism. Provide water soluble vitaminsProvide water soluble vitamins

Monitor intake & output.Monitor intake & output. Monitor lapratory finding.Monitor lapratory finding. Provide frequent oral care.Provide frequent oral care. Monitor weight.Monitor weight. Assess for edma.Assess for edma. Place patient in fowler position.Place patient in fowler position. Assess breathing sound, inspiration Assess breathing sound, inspiration

and expiration (crackles).and expiration (crackles). Provide safety for client Provide safety for client