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FLUID &

ELECTROLYTES
Fundamnetal of
nursing 2

FUNGSI CAIRAN TUBUH


Sarana untuk mengangkut zat-zat makanan
ke sel-sel
Mengeluarkan buangan-buangan sel
Mmbantu dalam metabolisme sel
Sebagai pelarut untuk elektrolit dan non
elektrolit
Membantu memelihara suhu tubuh
Membantu pencernaan
Mempemudah eliminasi
Mengangkut zat-zat seperti (hormon, enzim,
SDP, SDM)

FLUIDS
50-60% of the human body is water (decreases with
age)
Body fluids are classified according to their location
with most of the bodys fluids found within the cell
Intracellular
Extracellular (mainly responsible for transport of nutrients
and wastes)

Fluid compartments are separated by selectively


permeable membranes that control movement of water
and solutes
The process of homeostasis involves delivery of oxygen
and nutrients to the cells and removal of waste

Body Fluid Compartments


2/3 (65%) of TBW is intracellular (ICF)
1/3 extracellular water
25 % interstitial fluid (ISF)
5- 8 % in plasma (IVF intravascular fluid)
1- 2 % in transcellular fluids CSF,
intraocular fluids, serous membranes, and
in GI, respiratory and urinary tracts
(third space)
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Fluid compartments are separated by


membranes that are freely permeable to
water.
Movement of fluids due to:
hydrostatic pressure
osmotic pressure\
Capillary filtration (hydrostatic) pressure
Capillary colloid osmotic pressure
Interstitial hydrostatic pressure
Tissue colloid osmotic pressure
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Balance

Fluid and electrolyte homeostasis is


maintained in the body
Neutral balance: input = output
Positive balance: input > output
Negative balance: input < output

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Solutes dissolved particles


Electrolytes charged particles
Cations positively charged ions
Na+, K+ , Ca++, H+
Anions negatively charged ions
Cl-, HCO3- , PO43-

Non-electrolytes - Uncharged
Proteins, urea, glucose, O2, CO2
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Body fluids are:


Electrically neutral
Osmotically maintained
Specific number of particles per
volume of fluid

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Homeostasis maintained by:


Ion transport
Water movement
Kidney function

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MW (Molecular Weight) = sum of the


weights of atoms in a molecule
mEq (milliequivalents) = MW (in mg)/
valence
mOsm (milliosmoles) = number of particles
in a
solution

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Tonicity
Isotonic
Hypertonic
Hypotonic

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Cell in a
hypertonic
solution

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Cell in a
hypotonic
solution

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Movement of body fluids


Where sodium goes, water follows.
Diffusion movement of particles down a
concentration gradient.
Osmosis diffusion of water across a
selectively permeable membrane
Active transport movement of particles up
a concentration gradient ; requires energy
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ICF to ECF osmolality changes in ICF not


rapid

IVF ISF IVF happens constantly due


to changes in fluid pressures and osmotic
forces at the arterial and venous ends of
capillaries

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Regulation of body water


ADH antidiuretic hormone + thirst
Decreased amount of water in body
Increased amount of Na+ in the body
Increased blood osmolality
Decreased circulating blood volume

Stimulate osmoreceptors in hypothalamus


ADH released from posterior pituitary
Increased thirst
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Regulation of Fluid Volume


Kidneys
Capillary pressure forces fluid through the
walls and into the tubule
At this point H2O or electrolytes are then
either retained or excreted
The urine becomes more dilute or more
concentrated based on the needs of the body

Regulation of Fluid Volume, cont.


Antidiuretic hormone (ADH)
Produced by the hypothalamus
Stored in the pituitary gland
Restores blood volume by increasing or decreasing
excretion of water
Increased osmolality or decreased blood volume
stimulates the release of ADH
Then the kidneys reabsorb water
Also may be released by stress, pain, surgery, and
some meds

Regulation of Fluid Volume, cont.


Renin-angiotensin-aldosterone system
Renin secreted in kidney
Amount of renin produced depends on blood flow
and amount of Na in the blood

Produces angiotensin II (vasoconstrictor)


Angiotensin causes peripheral vasoconstriction
Angiotensin II stimulates the production of
aldosterone

Regulation of Fluid Volume, cont.


Aldosterone
Secreted by the adrenal gland response to
angiotensin II
The adrenal gland may also be stimulated by the
amount of Na and K + in the blood
Causes the kidneys to retain Na and H2O
Leads to increases in fluid volume and Na levels
Decreases the reabsorption of K+
Maintains B/P and fluid balance

Regulation of Fluid Volume, cont


Atrial natriuretic peptide or factor (ANP) (ANF)
Cardiac hormone
Released in response to increased pressure in the
atria (increased blood volume)
Opposes the renin-angiotensin-aldosterone system
Stimulates excretion of Na and H2O
Suppresses renin level
Decreases the release of aldosterone
Decreases ADH release
Reduces vascular resistance by causing vasodilation

REGULATION OF FLUID
VOLUME

Result:
increased water consumption
increased water conservation
Increased water in body, increased
volume and decreased Na+ concentration

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Dysfunction or trauma can cause:


Decreased amount of water in body
Increased amount of Na+ in the body
Increased blood osmolality
Decreased circulating blood volume

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Edema is the accumulation of fluid within the


interstitial spaces.
Causes:
increased hydrostatic pressure
lowered plasma osmotic pressure
increased capillary membrane
permeability lymphatic channel obstruction

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Hydrostatic pressure increases due to:


Venous obstruction:
thrombophlebitis (inflammation of veins)
hepatic obstruction
tight clothing on extremities
prolonged standing
Salt or water retention
congestive heart failure
renal failure
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Decreased plasma osmotic pressure:


plasma albumin (liver disease or
protein malnutrition)
plasma proteins lost in :
glomerular diseases of kidney
hemorrhage, burns, open wounds
and cirrhosis of liver

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Increased capillary permeability:


Inflammation
immune responses

Lymphatic channels blocked:


surgical removal
infection involving lymphatics
lymphedema
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Volume Abnormalities
Edema
the accumulation of fluid within the interstitial
space
Causes:
increased hydrostatic pressure
venous obstruction, lymphedema, CHF, renal failure
lowered plasma osmotic pressure (protein loss)
liver failure, malnutrition, burns
increased capillary membrane permeability
Inflammation, SIRS, sepsis

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Volume Abnormalities
Edema
the accumulation of fluid within the interstitial space
Results in:

increased distance for diffusion


impaired blood flow
slower healing
increased risk of infection
pressure sores over bony prominences
impaired organ function (brain, liver, gut, kidney)
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Edema of specific organs can be life


threatening (larynx, brain, lung)

Water is trapped, unavailable for metabolic


processes. Can result in dehydration and shock.
(severe burns)

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Electrolytes

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Electrolyte balance
Na + (Sodium)
90 % of total ECF cations
136 -145 mEq / L
Pairs with Cl- , HCO3- to neutralize charge
Low in ICF
Most important ion in regulating water
balance
Important in nerve and muscle function
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Regulation of Sodium
Renal tubule reabsorption affected by
hormones:
Aldosterone
Renin/angiotensin
Atrial Natriuretic Peptide (ANP)

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Potassium
Major intracellular cation
ICF conc. = 150- 160 mEq/ L
Resting membrane potential
Regulates fluid, ion balance inside cell
pH balance

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Regulation of Potassium
Through kidney
Aldosterone
Insulin

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Isotonic alterations in water


balance
Occur when TBW changes are
accompanied by = changes in electrolytes
Loses plasma or ECF
Isotonic fluid loss
ECF volume, weight loss, dry skin and
mucous membranes, urine output, and
hypovolemia ( rapid heart rate, flattened
neck veins, and normal or B.P. shock)
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Isotonic fluid excess


Excess IV fluids
Hypersecretion of aldosterone
Effect of drugs cortisone
Get hypervolemia weight gain, decreased
hematocrit, diluted plasma proteins, distended
neck veins, B.P.
Can lead to edema ( capillary hydrostatic
pressure) pulmonary edema and heart failure

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Electrolyte imbalances: Sodium


Hypernatremia (high levels of
sodium)
Plasma Na+ > 145 mEq / L
Due to Na + or water
Water moves from ICF ECF
Cells dehydrate
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Hypernatremia Due to:


Hypertonic IV soln.
Oversecretion of aldosterone
Loss of pure water
Long term sweating with chronic
fever
Respiratory infection water vapor
loss
Diabetes polyuria
Insufficient intake of water (hypodipsia)
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Clinical manifestations
of Hypernatremia
Thirst
Lethargy
Neurological dysfunction due to
dehydration of brain cells
Decreased vascular volume

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Treatment of Hypernatremia
Lower serum Na+
Isotonic salt-free IV fluid
Oral solutions preferable

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Hyponatremia
Overall decrease in Na+ in ECF
Two types: depletional and dilutional
Depletional Hyponatremia
Na+ loss:
diuretics, chronic vomiting
Chronic diarrhea
Decreased aldosterone
Decreased Na+ intake

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Dilutional Hyponatremia:
Renal dysfunction with intake of hypotonic
fluids
Excessive sweating increased thirst
intake of excessive amounts of pure water
Syndrome of Inappropriate ADH (SIADH) or
oliguric renal failure, severe congestive heart
failure, cirrhosis all lead to:
Impaired renal excretion of water

Hyperglycemia attracts water

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Clinical manifestations of
Hyponatremia
Neurological symptoms
Lethargy, headache, confusion, apprehension,
depressed reflexes, seizures and coma

Muscle symptoms
Cramps, weakness, fatigue

Gastrointestinal symptoms
Nausea, vomiting, abdominal cramps, and
diarrhea

Tx limit water intake or discontinue meds


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Hypokalemia
Serum K+ < 3.5 mEq /L
Beware if diabetic
Insulin gets K+ into cell
Ketoacidosis H+ replaces K+, which
is lost in urine

adrenergic drugs or epinephrine


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Causes of Hypokalemia
Decreased intake of K+
Increased K+ loss
Chronic diuretics
Acid/base imbalance
Trauma and stress
Increased aldosterone
Redistribution between ICF and ECF
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Clinical manifestations of Hypokalemia


Neuromuscular disorders
Weakness, flaccid paralysis, respiratory
arrest, constipation
Dysrhythmias, appearance of U wave
Postural hypotension
Cardiac arrest
Others table 6-5
TreatmentIncrease K+ intake, but slowly, preferably by foods
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Hyperkalemia
Serum K+ > 5.5 mEq / L
Check for renal disease
Massive cellular trauma
Insulin deficiency
Addisons disease
Potassium sparing diuretics
Decreased blood pH
Exercise causes K+ to move out of cells
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Clinical manifestations of
Hyperkalemia
Early hyperactive muscles , paresthesia
Late - Muscle weakness, flaccid paralysis
Change in ECG pattern
Dysrhythmias
Bradycardia , heart block, cardiac arrest

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Treatment of Hyperkalemia
If time, decrease intake and increase
renal excretion
Insulin + glucose
Bicarbonate
Ca++ counters effect on heart

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Calcium Imbalances
Most in ECF
Regulated by:
Parathyroid hormone
Blood Ca++ by stimulating osteoclasts
GI absorption and renal retention
Calcitonin from the thyroid gland
Promotes bone formation
renal excretion
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Hypercalcemia
Results from:
Hyperparathyroidism
Hypothyroid states
Renal disease
Excessive intake of vitamin D
Milk-alkali syndrome
Certain drugs
Malignant tumors hypercalcemia of malignancy
Tumor products promote bone breakdown
Tumor growth in bone causing Ca++ release
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Hypercalcemia
Usually also see hypophosphatemia
Effects:
Many nonspecific fatigue, weakness, lethargy
Increases formation of kidney stones and
pancreatic stones
Muscle cramps
Bradycardia, cardiac arrest
Pain
GI activity also common
Nausea, abdominal cramps
Diarrhea / constipation

Metastatic calcification

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Hypocalcemia
Hyperactive neuromuscular reflexes and
tetany differentiate it from hypercalcemia
Convulsions in severe cases
Caused by:
Renal failure
Lack of vitamin D
Suppression of parathyroid function
Hypersecretion of calcitonin
Malabsorption states
Abnormal intestinal acidity and acid/ base bal.
Widespread infection or peritoneal inflammation
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Hypocalcemia
Diagnosis:
Chvosteks sign
Trousseaus sign

Treatment
IV calcium for acute
Oral calcium and vitamin D for chronic

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Hypochloremia
Most commonly from gastric losses
Emesis, gastric suctioning, EC fistula

Often presents as a contraction alkalosis


with paradoxical aciduria (Na+ retained
and H+ wasted in the kidney)
Rx: resuscitation with normal saline

Hyperchloremia
Most commonly from over-resuscitation
with normal saline
Often presents as a hyperchloremic
acidemia with paradoxical alkaluria (H+
retained and Na+ wasted in the kidney)
Rx: stop normal saline and replace with
hypotonic crystalloid