CELLFluid and Electrolytes Presentation .ppt

FLUID AND ELECROLYTES

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CELL,FLUID AND
ELECTROLYTES

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OBJECTIVES
1) To understand a cell, organelles & their
functions.
1) Differentiate between osmosis, diffusion,
filtration, and active transport.
2). Describe the role of the kidneys, lungs,
and endocrine glands in regulating the
body’s fluid composition and volume.

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3). Care of pts with the following
imbalances: Fluid volume deficit and
excess, hypo
&hypernatremia,hypo&hyperkalemia

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Cell Types
•Prokaryotic
•Eukaryotic

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Prokaryotic Cells
•First cell type on earth
•Cell type of Bacteria and Archaea

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Prokaryotic Cells
•No membrane bound nucleus
•Nucleoid = region of DNA concentration
•Organelles not bound by membranes

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Eukaryotic Cells
•Nucleus bound by membrane
•Include fungi, protists, plant,
and animal cells
•Possess many organelles
Protozoan

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Characteristics of All Cells
•A surrounding membrane
•Protoplasm – cell contents in thick fluid
•Organelles – structures for cell function
•Control center with DNA

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Representative Animal Cell

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Plasma Membrane
•Contains cell contents
•Double layer of phospholipids & proteins

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Phospholipids
•Polar
–Hydrophylic head
–Hydrophobic tail
•Interacts with water

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Movement Across the Plasma Membrane
•A few molecules move freely
–Water, Carbon dioxide, Ammonia, Oxygen
•Carrier proteins transport some molecules
–Proteins embedded in lipid bilayer
–Fluid mosaic model – describes fluid nature of
a lipid bilayer with proteins

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Membrane Proteins
1.
Channels or transporters
–Move molecules in one direction
2. Receptors
–Recognize certain chemicals

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Membrane Proteins
3. Glycoproteins
–Identify cell type
4. Enzymes
–Catalyze production of substances

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•Read more on cells
•Differences
between
prokaryotic and
eukaryotic types of
cells.

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Fluid and Electrolytes
Homeostasis
•State of equilibrium in body
•Naturally maintained by adaptive
responses
•Body fluids and electrolytes are
maintained within narrow limits

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Why nurses need to understand
fluid and electrolytes?
•Important to anticipate the potential for
alterations in fluid and electrolyte balance
associated with certain disorders and
medical therapies, to recognize the signs
and symptoms of imbalances, and to
intervene with the appropriate action.

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Enhanced understanding and
management of fluids and
electrolytes
•Composition of body fluids
•Fluid compartments/Extracellular fluid osmolality
•Factors that affect movement of water and
solutes
•Regulation of vascular volume
•Facilitated by clinical condition understanding,
nursing assessment, lab analysis

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Composition of body fluids
(water content of body)
•60% of body weight in adult
•45% to 55% in older adults
•70% to 80% in infants
–Varies with gender, body mass, and age

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Changes in Water Content with
Age
Fig. 17-1

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Composition of body fluids
•In addition to water, the body contains solutes;
substances the separate in solution and conduct
electrical current.
•Concentration of solutes in solution=osmolality or
osmolarity.
•May by electrolytes or non-electrolytes:
•Cations(+), Na, K
•Anions (-), CL, HCO-3 (bicarbonate), PO
•Non-electrolytes (glucose, urea, creatinine, bilirubin)

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Fluid Compartments
•Intracellular fluid (ICF): Located within
cells
42% of body weight
•Extracellular fluid (ECF)-found outside cell
–Intravascular (plasma)
–Interstitial
–lymph
–Transcellular
30% of body weight

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Fluid Compartments of the Body
Fig. 17-2

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Transcellular Fluid
•Part of ECF
•Small but important/Approximately 1
Includes fluid in
–Cerebrospinal fluid
–Pericardial fluid
–Pleural spaces
–Synovial spaces
–Intraocular fluid
–Digestive secretions

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Factors that affect Fluid and
Electrolyte Movement
•Membranes
•Osmosis
•Diffusion
•Facilitated diffusion
•Active transport
•Hydrostatic pressure
•Oncotic pressure

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Transport process
•Osmosis
•Diffusion
•Active transport
•filtration

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Osmosis
•Movement of water between two
compartments by a membrane permeable
to water but not to solute
•Moves from low solute to high solute
concentration
•Requires no energy

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Terms associated with osmosis
•Osmotic Pressure: amount of pressure
required to stop osmotic flow of water.
Determined by concentration of solutes in
solution
•Oncotic pressure: pressure exerted by
colloids (proteins, such as albumin)
•Osmotic diuresis: increased urine output
(caused by substances such as mannitol,
glucose or contrast medium)

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Osmotic movement of fluids
•Cells affected by osmolality of the fluid that
surrounds them.
•Isotonic-fluid with same osmolality as cell interior
•Hypotonic (hypoosmolar)-solutes are less
concentrated than cells.
•hypertonic (hyperosmolar)-solutes more
concentrated than cells.

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Diffusion
•Random movement of particles in all
directions from an area of high
concentration to low concentration.

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Active transport
•Relies on availability of carrier substances,
utilizes energy (ATP), to transport solutes
in and out of cells.
•Na, K, hydrogen, glucose, amino-acids,

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Filtration
•Movement of water and solutes from area
of high hydrostatic pressure to area of low
hydrostatic pressure that is created by
“weight” of fluid. Kidney is example; (filters
180L/day plasma)

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Hydrostatic Pressure
•Force within a fluid compartment
•Major force that pushes water out of
vascular system at capillary level

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Fluid Movement between
ECF and ICF
•Water deficit (increased ECF)
–Associated with symptoms that result from
cell shrinkage as water is pulled into vascular
system

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Fluid Movement between
ECF and ICF (Cont’d)
•Water excess (decreased ECF)
–Develops from gain or retention of excess
water

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Fluid Spacing
•First spacing
–Normal distribution of fluid in ICF and ECF
•Second spacing
–Abnormal accumulation of interstitial fluid
(edema)

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Fluid Spacing (Cont’d)
•Third spacing
–Fluid accumulation in part of body where it is
not easily exchanged with ECF; fluid trapped
and unavailable for functional use (ascites)

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3
rd
spacing, fluid shift from
intravascular to interstitial space;
edema

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Regulation of Water Balance
•Hypothalamic regulation
•Pituitary regulation
•Adrenal cortical regulation
•Renal regulation
•Cardiac regulation
•Gastrointestinal regulation
•Insensible water loss

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Normal fluid balance
• Intake: fluids, food, oxidation=~2500ml
•Output: skin and lungs (insensible loss)-900ml, feces-100ml,
urine-1500ml=~2500ml/day

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Hypothalamic Regulation
•Osmoreceptors in hypothalamus sense
fluid deficit or increase
–Stimulates thirst and antidiuretic hormone
(ADH) release
–Result in increased free water and decreased
plasma osmolarity

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Pituitary Regulation
•Under control of hypothalamus, posterior
pituitary releases ADH
•Stress, nausea, nicotine, and morphine
also stimulate ADH release

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Adrenal Cortical Regulation
•Releases hormones to regulate water and
electrolytes
–Glucocorticoids
•Cortisol
–Mineralocorticoids
•Aldosterone

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Factors Affecting Aldosterone
Secretion
Fig. 17-9

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Renal Regulation
•Primary organs for regulating fluid and
electrolyte balance
–Adjusting urine volume
•Selective reabsorption of water and electrolytes
•Renal tubules are sites of action of ADH and
aldosterone

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Cardiac Regulation
•Natriuretic peptides are antagonists to the
RAAS
–Produced by cardiomyocytes in response to
increased atrial pressure
–Suppress secretion of aldosterone, renin, and
ADH to decrease blood volume and pressure

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Gastrointestinal Regulation
•Oral intake accounts for most water
•Small amounts of water are eliminated by
gastrointestinal tract in feces
•Diarrhea and vomiting can lead to
significant fluid and electrolyte loss

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Insensible Water Loss
•Invisible vaporization from lungs and skin
to regulate body temperature
–Approximately 600 to 900 ml/day
is lost
–No electrolytes are lost

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Gerontologic Considerations
•Structural changes in kidneys decrease
ability to conserve water
•Hormonal changes lead to decrease in
ADH and ANP
•Loss of subcutaneous tissue leads to
increased loss of moisture

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Fluid and Electrolyte
Imbalances
•Common in most patients with illness
–Directly caused by illness or disease (burns or
heart failure)
–Result of therapeutic measures
(IV fluid replacement or diuretics)

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Extracellular Fluid Volume
Imbalances
•ECF volume deficit (hypovolemia)
–Abnormal loss of normal body fluids (diarrhea,
fistula drainage, hemorrhage), inadequate
intake , or plasma-to-interstitial fluid shift
–Treatment: replace water and electrolytes with
balanced IV solutions

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Extracellular Fluid Volume
Imbalances (Cont’d)
•Fluid volume excess (hypervolemia)
–Excessive intake of fluids, abnormal retention
of fluids (CHF), or interstitial-to-plasma fluid
shift
–Treatment: remove fluid without changing
electrolyte composition or osmolality of ECF

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Nursing Management
Nursing Diagnoses
•Hypovolemia
–Deficient fluid volume
–Decreased cardiac output
–Potential complication: hypovolemic shock

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Nursing Management
Nursing Implementation
(Cont’d)
•Neurologic function
–LOC
–PERLA
–Voluntary movement of extremities
–Muscle strength
–Reflexes

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Nursing Management
Nursing Diagnoses (Cont’d)
•Hypervolemia
–Excess fluid volume
–Ineffective airway clearance
–Risk for impaired skin integrity
–Disturbed body image
–Potential complications: pulmonary edema,
ascites

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Nursing Management
Nursing Implementation
•I&O
•Monitor cardiovascular changes
•Assess respiratory status and monitor
changes
•Daily weights
•Skin assessment

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Electrolytes
•Substances whose molecules dissociate
into ions (charged particles) when placed
into water
–Cations: positively charged (Na, K, Ca2, Mg2)
–Anions: negatively charged (HCO3, CL, PO4 3)
–Measurement; International standard is millimoles per liter
(mmol/L), U.S. uses milliequivalent (mEq)
–Ions combine mEq for mEq

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Electrolyte Composition
•ICF
–Prevalent cation is K
+
–Prevalent anion is PO
4
3
•ECF
–Prevalent cation is Na
+
–Prevalent anion is Cl


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Sodium
•Serum levels; 135-145mEq/L
•Responsible for water balance and
determination of plasma osmolality
•Cation+,plays a major role in
–ECF volume and concentration (movement of Cl-
closely associated with Na+)
•Imbalances can exist in different volume
states: euvolemia (normal volume), hypovolemia (low volume),
hypervolemia (increased volume)

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Potassium
•Major cation of ICF
•Serum level: 3.5-5.0mEq/L
•Necessary for
–Transmission and conduction of nerve and
muscle impulses
–Control via sodium-potassium pump (contained
within cell membrane of all cells/utilizes ATP)
–Inverse relationship between Na+ and K+reabsorption in the
kidney; factors that cause Na+ retention cause K+ loss in the
urine.

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Calcium (Ca2+)
•Function: transmission of nerve impulses,
muscle/myocardial contraction, blood clotting, formation
of teeth and bones
•Balance controlled by PTH, calcitonin, vitamin D
•Obtained from diet, daily need: 1-1.5G/d
•More than 99% combined with phosphorus
and concentrated in skeletal system
•Inverse relationship with phosphorus
• Serum Level:8.5-10.5 mg/dl

64. Tests for Hypocalcemia
Fig. 17-15

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Phosphate/phosphorus (PO4-/P+)
•Serum Level: 2.5-4.5mg/dL
•Primary anion in ICF
•Essential to function of muscle, red blood
cells, nervous system and Ca+levels
•Deposited with calcium for bone and tooth
structure, Ca+ and P+ exist in a reciprocal balance
•Required for release of O2 from
hemoglobin

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PO4- (continued)
•Involved in acid–base buffering system
(phosphate buffer), ATP production, and cellular
uptake of glucose
•90% excreted by Kidneys; requires
adequate renal functioning
•Dietary level; intake via balanced diet,
daily need: 800-1600mg/dl

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Magnesium
•2
nd
most abundant cation in ICF
•Serum level: 1.4-2.1 mEq/L
•Daily need: 300-350mg (average Western diet
contains 170-720mg/day)
•Coenzyme in metabolism of protein,
carbohydrate and Ca+ absorption and
utilization (Factors that regulate calcium balance appear to
influence magnesium balance)

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Mg+ (continued)
•Acts directly on myoneural junction to
transmit electrical impulses (relaxes lung muscles
that open airways)
•Important for normal cardiac function
•Powers Na+/K+ pump
•Plays essential role in secretion and action
of insulin (impacts BG)

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Chloride
•Major ECF anion
•Serum level: 95-108 mEq/L
•Function; circulates with Na+ and H2O to
help maintain cellular integrity, fluid
balance and osmotic pressure
•Affects acid/base balance (enzyme activator,
serves as buffer in exchange of O2 and CO2 in RBC’s)

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CL- (continued)
•In conjunction with Ca+, Mg+, helps maintain
nerve transmission/muscle function
•Vital role in production of HCL
•Obtained primarily from foods (processed) and
table salt, daily need: ~750mg.
•90% excreted by kidney

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IV Fluids
•Purposes
1.Maintenance
•When oral intake is not adequate
2.Replacement
•When losses have occurred

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IV Fluids (Cont’d)
•Hypotonic
–More water than electrolytes
•Pure water lyses RBCs
–Water moves from ECF to ICF by osmosis
–Usually maintenance fluids
•Isotonic
–Expands only ECF
–No net loss or gain from ICF

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IV Fluids (Cont’d)
•Hypertonic
–Initially expands and raises the osmolality of
ECF
–Require frequent monitoring of
•Blood pressure
•Lung sounds
•Serum sodium levels

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D5W
•Isotonic
•Provides 170 cal/L
•Free water
–Moves into ICF
–Increases renal solute excretion
•Used to replace water losses and treat
hyponatremia
•Does not provide electrolytes

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Normal Saline (NS)
•Isotonic
•No calories
•Expands IV volume
–Preferred fluid for immediate response
•Does not change ICF volume
•Compatible with most medications/blood
administration

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Lactated Ringer’s
•Isotonic
•More similar to plasma than NS
–Has less NaCl
–Has K, Ca, PO
4
3
, lactate (metabolized to
HCO
3)
•Expands ECF

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D5 ½ NS
•Hypertonic
•Common maintenance fluid
•KCl added for maintenance or
replacement

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D10W
•Hypertonic
•Provides 340 kcal/L
•Free water
•Limit of dextrose concentration may be
infused peripherally

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Plasma Expanders
•Stay in vascular space and increase
osmotic pressure
•Colloids (protein solutions)
–Packed RBCs
–Albumin
–Plasma

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Diuretics
•Act by increasing volume of urine
production in tx of hypertension, heart
failure, and kidney disorders.
•Electrolyte depletion common
(hypokalemia)

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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
81

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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)
82

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Clinical manifestations
of Hypernatremia
•Thirst
•Lethargy
•Neurological dysfunction due to
dehydration of brain cells
•Decreased vascular volume
83

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Treatment of Hypernatremia
•Lower serum Na+
–Isotonic salt-free IV fluid
–Oral solutions preferable
84

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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
85

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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
86

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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
•β – adrenergic drugs or epinephrine
88

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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
89

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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
•Treatment-
–Increase K
+
intake, but slowly, preferably by
foods
90

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Hyperkalemia
•Serum K+ > 5.5 mEq / L
•Check for renal disease
•Massive cellular trauma
•Insulin deficiency
•Addison’s disease
•Potassium sparing diuretics
•Decreased blood pH
•Exercise causes K+ to move out of cells
91

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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
92

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Treatment of Hyperkalemia
•If time, decrease intake and increase renal
excretion
•Insulin + glucose
•Bicarbonate
•Ca
++
counters effect on heart
93

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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
94

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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
95

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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
96

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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
97

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Hypocalcemia
•Diagnosis:
–Chvostek’s sign
–Trousseau’s sign
•Treatment
–IV calcium for acute
–Oral calcium and vitamin D for chronic
98

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Tests for Hypocalcemia
Fig. 17-15