Table of ContentsClick on rectangle to get to content on topic
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 FarringtonMSN Student-MSN 621
April 2010
QuestionEdema 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 Potassium Cell 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 water40% of body weight is intracellular fluids20% 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
Heitz ( p.6
Body Fluid CompartmentsClick 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 transport
mechanisms to go from ECF to ICF
Cell
Extracellular compartment 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)
CellExtracellular compartment Volume (ECF)
Cell membrane
Intracellular compartment Volume (ICF)
Porth p 762
Passive Transport: DiffusionMolecules move along concentration gradient
across 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)
CellEqual 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
Lowconcentration
High concentration Semi permeable Cell membrane
glucose
Active Transport • Requires energy (ATP) to move molecule with carrier protein• Involves action against the cell’s 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
NaNa
k
Quiz :Is it A, B, or C
Click on Shape to See if You Are Right
Concentration Gradients
Protein Carrier
Aconcentration difference
between high level of concentration and low level
of concentration
Diffusion
Bnecessary for active
transport 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
Extracellular compartment 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 higher solute concentration
Cell
Extracellular compartment Volume (ECF)
Cell membrane
Intracellular compartment Volume (ICF)
Porth p.762
Fewer particles-More water
Greater number of particles-Less water
NoticeOsmosis 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
Extracellular compartment 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 bodySerum Isotonic concentration=275-295 mOsm/KgSerum Hypotonic concentration=<275 mOsm/KgSerum Hypertonic concentration=>295 mOsm/Kg
Osmolality of Solutions
• Isotonic-same osmolality as body fluids• Hypotonic-osmolality less then body fluids• 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 Intravascular
Space(IVS) from Interstitial Space• Capillary Interstitial Fluid Exchange is transfer
of water between vascular and interstitial compartments
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 March
25,2010
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.766Picture 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 766Picture 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
Quiz :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 proteins not 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 VolumeWhy it happens-Movement of water exceeds the
Compartment space• Excessive fluid intake
– Over-hydration– Excessive sodium intake
• Water retention caused by disease states – Renal dysfunction– Liver dysfunction– Congestive heart failure (Remember hydrostatic and
colloid forces) – Increased corticosteroid level
Porth p 778-779
Click here
Fluid Volume Excess Assessment and Management
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-ray•Consistency 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 dysfunction 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 edema•Instruct 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 respiratory status•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
Porth p 778-779
FVD Outcomes/InterventionsPatient 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 patient’s preference and keep in reach•Remind to drink and assist to drink as needed for cognitive and mobility dysfunction•Deliver parenteral fluid replacement as ordered if volume deficit severe •If deficit causes hemodynamic instability anticipate need for large bore intravenous catheter for rapid infusion 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 breathing•Monitor I/O and daily weights•Communicate patient changes to physician team
Outcomes Interventions
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 urine
relative to plasma• Control of water excretion in kidney is regulated
by anti-diuretic hormone (ADH) The hormone is secreted 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
Heitz 16. microsoft clip art
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
Heitz 15. microsoft clip art
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
Quiz: 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 hormone
Click 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 to
increased adipose tissue. Adipose tissue has less water.
• Unknown mechanism for decreased thirst in elderly
• Decreased thirst =decreased water intake
Rolls 137. microsoft clip art
Age Effect on Fluid Balance-Excess• Aged heart has less stretch and
efficiency 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, renal excretion of K and NA following volume expansion and contraction with monozygotic and dizygotic twins studied for trends– Conclusion: genetic/ heredity influence K
and NA excretion • Current research with worms shows
there are genetic receptors on hypodermis that regulate fluid balance homeostasis
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 and
neurotransmitters are released to aid in adaptation of fluid balance from stress response (Remember slides 35-38)
• ADH reabsorbs water in kidney tubules due to circulating volume decrease
• Stress response of surgery can increase ADH to cause retention of water 48-72 hours.
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 and protein from plasma
• Increase in tissue catabolism (breakdown) results in reactive oxidation –greater amount of water from reactive oxidation process
• Potential for third spacing to occur with loss of plasma proteins and colloid to cause leaking in transcellular space
Case Study I76 year old female admitted to hospital for TAH, BSO, and bilateral
oopherectomy. hysterectomy and colon resection due to suspected cancer. Patient’s medical history includes weight loss, heart failure, and decreased 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 answer3. 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 neck suspension, 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 post operative 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 flashcards. 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