Compartments of ECF

FLUIDS & ELECTROLYTES 1. Intravascular fluid or plasma

IN CHILDREN – within the vascular system
2. INTERSTITIAL FLUID
Functions of Urinary System – surrounds cells
1. Urine formation 3. TRANSCELLULAR FLUID
2. Excretion of waste products – cerebrospinal, pericardial,
3. Regulation of electrolytes pancreatic, pleural,
4. Regulation of acid-base balance intraocular, biliary, peritoneal
5. Control of water balance and synovial fluids
6. Control of blood pressure 4. LYMPH
7. Renal clearance
8. Regulation of red blood cell Movement of Body Fluids and
production Electrolytes
9. Synthesis of vitamin D to active form 1. OSMOSIS
10. Secretion of prostaglandins – movement of water across cell
membranes from the less concentrated
Composition of Body Fluids solution to the more concentrated
1. Oxygen solution.
2. Dissolved nutrients
3. Carbon dioxide SOLUTES
4. Ions or electrolytes - substances dissolved in a liquid
- can be CRYSTALLOIDS (salts that
Body fluids and Electrolytes dissolve readily into true solutions) or
 46% - 60% of the average adult’s COLLOIDS (substances such as large
weight is WATER protein molecules that do not readily
 Infants – 70 – 80% of their body dissolve into true solutions).
weight
SOLVENT – component of a solution
 Premature infants – 90%
that can dissolve a solute.
 Older than 60 years old – 50%
 Age, sex, and body fat affects
total body water OSMOTIC PRESSURE
Functions of Water • power of a solution to draw water
1. Medium for metabolic reactions across a semipermeable membrane.
within the cells • pulling power of a solution.
2. Transporter of nutrients, waste • the higher the osmolality
products (concentration) of a solution, the
3. Lubricant greater is its pulling power for
4. An insulator and shock absorber water.
5. One means of regulating and
maintaining body temperature OSMOLALITY
• total solute concentration within a
Distribution of Body Fluids and fluid compartment and is measured
Electrolytes as a part of solute per kilogram of
Major fluid compartment water.
1. Intracellular Fluid (ICF) • expressed in milliosmols per
– found within the cells kilogram (mOsm/kg).
2. Extracellular Fluid (ECF)
– found outside the cells and MILLIOSMOLS
transport system within the • measure osmotic activity as a total of
body the number of particles present.
 • 275 – 295 mOsm/L – NORMAL concentrated solution to a more
SERUM OSMOLALITY concentrated with the expense of
metabolic energy
OSMOLARITY
• concentration of the solute per liter Example of Active Transport
of a solution. • Energy (Adenotriphosphate or
ATP) is used to move sodium and
TONICITY – refers to the potassium molecules across a
osmolality of a solution. semipermeable membrane against sodium’s
and potassium’s concentration radients.
SODIUM – is the greatest determinant of
serum osmolality, with glucose and urea Types of Solution
also contributing. 1. ISOTONIC
- same osmolality as normal plasma.
POTASSIUM, GLUCOSE AND - used to replace ECF losses and to expand
UREA are primary contributors vascular volume quickly
to the intracellular fluid osmolality.

2. DIFFUSION ISOTONIC SOLUTIONS

• molecules move from a solution of 1. NORMAL SALINE (NSS; 0.9 NaCl)
higher concentration to lower 2. RINGER’S SOLUTION
concentration. 3. LACTATED RINGER’S SOLUTION
(PLAIN
Rate of Diffusion of substances varies LR)
according to:
1. Size of molecules HYPOTONIC SOLUTION
2. Concentration of the solution - have lower osmolality than normal
plasma.
3. Temperature of the solution
- used to prevent or treat cellular
dehydration by providing free water to the
3. FILTRATION
cells.
• is the process whereby fluid and
- contraindicated in acute brain injuries
solutes move together across a
because cerebral cells are very sensitive to
membrane from one compartment to
free water,absorbing it rapidly and leading
another.
to cellular edema.

FILTRATION PRESSURE HYPOTONIC SOLUTIONS

• difference between the hydrostatic 1. 5% DEXTROSE IN WATER (D5W)
pressure and osmotic pressure. 2. 0.45% SALINE
3. Maintenance fluids: saline mixed with
HYDROSTATIC PRESSURE dextrose and water
• pushing pressure of a fluid against 4. D5½ NS and D5¼ NS
the wall it occupies 5. D5 NS

ONCOTIC/OSMOTIC PRESSURE HYPERTONIC SOLUTION

• pulling force exerted by the colloids • have higher osmolality than body
in a solution fluids causing water to be pulled
from the cells into the vessels,
4. ACTIVE TRANSPORT resulting to increased vascular
• passage of ions or molecules across volume and decreased cell water.
the cell membrane from a less
 • Also used to pull excess fluid from ANTIDIURETIC HORMONE
cells and promote osmotic diuresis • regulates water excretion from the
which causes RBC to shrink. kidney
• synthesized in the anterior pituitary
HYPERTONIC SOLUTION portion of hypothalamus
 Includes: 3% and 5% Saline, 10% • when serum osmolality rises, ADH is
and 50% Dextrose produced, causing the collecting
ducts to become more permeable to
REGULATING BODY FLUIDS water.
• In a healthy person, the volumes and • when serum osmolality decreases,
chemical composition of the fluid ADH is suppressed.
compartments stay within narrow • other factors affecting ADH: blood
safe limits. Illness can upset this volume, temperature, pain, and some drugs
balance so that body has little or too such as opiates, barbiturates, and nicotine.
much fluid. It is
also influenced by the person’s HEART AND BLOOD VESSELS
activity and temperature. • pumping actions of the heart
circulates blood through the kidneys
Fluid Intake under sufficient pressure to allow
Water in food 1,000 ml urine formation
Water from oxidation 300 ml
Water as liquid 1,200 ml Lung Functions
TOTAL 2,500 ml • Through inhalation, lungs remove
approximately 300 ml of water daily
Fluid Output in the normal adult.
Urine (kidneys) 1,500 ml • Hyperpnea (abnormally deep
Insensible losses respiration) or coughing increase this
Skin (inc. sweat-100 ml) 500 ml loss, mechanical ventilation with
Lungs 400ml excessive moisture also decreases it.
Feces 100 ml • If blood flow or pressure to the
TOTAL 2,500 ml kidney decreases, renin is released
which causes conversion of
Insensible fluid losses angiotensinogen to angiotensin I,
• usually not noticeable and measured. which is then converted to
It occurs in the skin through angiotensin II by angiotensin-
diffusion and perspiration. converting enzyme from the lungs.
• Angiotensin II acts directly on the
Obligatory losses nephrons to promote sodium and
• certain fluid losses that are required water retention and it also stimulates
to maintain normal body function the release of Aldosterone.
through respiration, kidneys, skin
and feces.(approximately 1,300 ml) Pituitary Functions
• Hypothalamus manufactures ADH,
Maintaining Homeostasis which is stored in the posterior
KIDNEYS pituitary and released as needed
• primary regulator of body fluids and • ADH is a water conserving hormone
Felectrolytes balance. because it causes body to retain
• 135-180 liters of plasma per day are water.
normally filtered in an adult but only • ADH functions include: maintaining
1.5 liters of urine is excreted. osmotic pressure of the cell by
controlling the retention or excretion
 of water by the kidneys and by ATRIAL NATRIURETIC
regulating blood volume. FACTOR
- is released from the cells in the
atrium of the heart in response to
excess blood volume and
stretching of the atrial walls.
Adrenal Function - ANF promotes sodium wasting
ALDOSTERONE and act as ampotent diuretic, thus
• mineralocorticoid secreted by the regulating vascular volume and
zona glomerulosa (outer zone ) of the inhibits thirst, thus reducing fluid
adrenal cortex- increase secretion intake.
causes sodium retention ( and thus
water retention) and potassium loss. BARORECEPTORS
• If osmolarity increases > decreased - small nerve receptors that detect
secretion of Aldosterone > decreased changes in pressure within blood
reabsorption of Na in distal tubule vessels and transmit this
information to the CNS.
And at the same time - responsible for monitoring the
• Increased ADH secretion >conserve circulating volume, sympathetic
water and parasympathetic neural
EFFECT: decreased urine excretion activity as well as endocrine
increased urine osmolarity activities.
• Reduced blood from trauma or - Aldosterone, decreases
surgery (the loses of Na and water glomerular filtration and
are proportionate to the composition increases sodium and water
of body fluids so, the body must reabsorption.
conserve both water and Na) >
increased ADH > increased water Factors Affecting Body Fluid,
reabsorption> increased body water. Electrolytes, and Acid-base balance:
In order to prevent osmolarity from 1. AGE
decreasing below normal > increased 2. GENDER AND BODY SIZE
aldosterone > increased reabsorption 3. ENVIRONMENTAL TEMPERATURE
of Na in distal tubule 4. LIFESTYLE

Parathyroid Functions The individual client with problems in

• Embedded in the thyroid gland; fluid & electrolyte balance
regulate calcium and phosphate RISK FACTORS
balance by means of parathyroid ► Potential factors for exceeding renal
hormone (PTH). reserve capacity
• PTH influences bone resorption, ► Dietary habits to include salt intake
calcium absorption from the ► Disease process – hypertension,
intestines and calcium reabsorption infection, diabetes (mellitus &
from the renal tubules. insipidus)

RENIN-
ANGIOTENSINALDOSTERONE Identifies significant subjective data from
SYSTEM(RAAS) the client history related to problems in
- specialized receptors in the fluid & electrolyte (nursing history)
juxtaglomerular cells of the  Chief complaints
kidney nephrons respond to  Relevant information, to include
changes in renal perfusion. eleven functional patterns
  Health perception management WBC 0 – 5/hpf
patterns Pus Absent
 Nutritional/metabolic pattern Glucose Absent
 Elimination pattern Ketones Absent
 Activity/exercise pattern Casts 0–4
 Cognitive/perceptual pattern
 Sleep-rest pattern Creatinine Clearance
 Self-perception-self-concept pattern - 24 hour urine specimen
 Role relationship pattern
 Coping-stress tolerance pattern Blood Studies
 Value-belief pattern BUN 10 – 20 mg/dl
Serum Creatinine 0.4 – 1.2 mg/dl Serum
Principles & techniques of physical Uric Acid 2.5 – 8 mg/dl Albumin
examination in newborn, children, adults, 3.2 – 5.5 mg/dl RBC
deviation from normal 4.5 – 5M/cu.mm. Hct
 Inspection – signs of dehydration & 38 – 54 vol %
over-hydration
 Palpation – edema, ascites, neck Serum Electrolytes
vein filling, hand vein filling, K 3.5 – 5 mEq/L
neuromuscular irritability & Na 135 – 145 mEq/L
characteristic of pulse Ca 4.5 – 5.5 mEq/L
 Percussion – abdomen for presence Mg 1.5 – 2.5 mEq/L Phosphor
of air & fluid 3.5 – 5.5 mEq/L
 Auscultation – rales Chloride 98 – 108 mEq/L

Results & implications of CYSTOSCOPY

diagnostic/laboratory examinations of - direct visualization of urethra,
clients with reference to problems in fluid bladder wall, trigone and ureteral
& electrolyte opening.
Physical Assessment
a. Measuring Intake and output PREPARATION FOR CYSTOSCOPY
b. Body Weight - – 1L of fluid loss or gain  Secure written consent
is equal to 1 kg weight gain or loss.  Force fluids
c. Diagnostic Laboratories  To inform when desired to void is
ASSESSMENT felt
NURSING HISTORY  Done under local/general anesthesia
 Includes unexplained anemia,  Place in lithotomy position
changes in voiding, pain and AFTER CYSTOSCOPY
gastrointestinal symptoms.  Bed rest until VS are stable
 Usual patterns of fluid intake and  Pink – tinged urine is normal (24 –
elimination 48 hours)
 Hydration status \  Dysuria, frequency, hematuria – due
 Disease process to tissue irritation
 Medication history OBSERVE
 Urine retention
DIAGNOSTIC LABORATORIES  Signs of infection
Routine Urinalysis  Prolonged /excessive hematuria
COLOR Amber / Straw
pH 4.5 – 8.0 (average 6) AFTER CYSTOSCOPY
Specific Gravity 1.010 – 1.025 Protein  Monitor output and VS
absent  Hot sitz bath to relieve pelvic
RBC 0 – 5/hpf discomfort
  Warm, moist, soak to relieve leg  Monitor VS
cramps  Observe ( urinary retention,
 Force fluids infection, prolonged / excessive
hematuria)
KIDNEY, URETER AND BLADDER
(KUB) VOIDING
 Abdominal X-ray Film
CYSTOURETHROGRAM FILM
 X – ray visualization of kidneys,
 Before Voiding – outlines bladder
ureters and bladder
wall
 Assure that it is PAINLESS
 During voiding – outlines urethra
 Bowel preparation to prevent gas /
and reflux of urine into ureters
feces interference with visualization
 After voiding – demonstrates if
bladder is emptied completely
INTRAVENOUS PYELOGRAM (IVP)
 Contrast medium is instilled into the
 X – ray visualization of kidneys,
bladder through cytoscope
ureters and bladder with the injection
-Nursing interventions same as RPG
of contrast medium
(HYPAQUE)
RENAL ARTERIOGRAM
PREPARATION - X – ray visualization of renal
 Secure written consent circulation as contrast medium is
 NPO 6 – 8 hours \ injected into renal artery through
 Bowel preparation catheter or per IV
 Assess allergy to seafood/ iodine
 Warm/ flushing sensation on IV
injection of dye is normal
 Prepare epinephrine (anaphylactic PREPARATION
shock may occur)  Cleanse bowel (laxative)
 Shave catheter insertion site
AFTER IVP  Locate and mark distal pulses
 Monitor VS
 Increase fluid intake to excrete the CARE AFTER ARTERIOGRAM
dye  VS until stable
 Burning sensation on voiding may be  Cold on puncture site to prevent
experienced bleeding
 Observe for signs and symptoms of  Check for swelling and hematoma
delayed allergic reaction (e.g. rashes,  Sandbag / tight dressing over
pruritus, dyspnea) catheter insertion site (lumbar/
femoral site)
 Palpate peripheral pulses
RETROGRADE PYELOGRAM
 Check color and temperature of
- outlines renal pelvis and ureters
extremity
- contrast medium through
 Bed rest for 24 hrs, no sitting
cytoscope
 Measure urine output
PREPARATION
 Written consent CYSTOMETOGRAM
 Check for allergy to the dye (Iodine)  Records pressure exerted at varying
 Prepare EPINEPHRINE – phases of filling of the bladder
anaphylactic shock is the most life  Helps evaluate neuro – sensory
threatening complication status, tonicity
 Assess time to initiate stream, degree
CARE AFTER RPG of hesitance, intermittence of
 voiding, presence of terminal
dribbling BLOOD and BLOOD PRODUCTS
 Retention catheter is inserted, Types of blood products:
residual volume is measured Whole Blood – acute massive blood loss
 Retention catheter is attached to  1 unit = 500ml (450 ml blood & 60 –
manometer, sterile NSS is introduced 70 ml of preservative or
into the bladder at prescribed rate anticoagulant
 Amounts of bladder volume and Blood Products
pressures are recorded at intervals, Packed RBC – consist of RBC ( 80%);
including first desire to void and plasma (20%)
feeling of maximum fullness  1 unit = 250 – 350 ml
 usually infused over 2 -3 hours
ULTRASOUND  Autologous RBC – used for
- detects tumors, cysts blood replacement ff. a planned
obstructions, abscesses elective surgery
 Autologous BT – a procedure of
collecting & storing of own blood
 Autologous Donation
– safest method of transfusion
PREPARATION
 Cleanse the bowel
Platelets (Thrombocytes)
 Distend the bladder ( 1L or water
- used in cases of
p.o.)
thrombocytopenia caused by
 Withhold voiding
lack of platelet production,
resulting in increased bleeding
RENAL BIOPSY time
 NPO for 6 – 8 hrs - 1 unit = 50 – 70 ml
 Check PTT, Pro time (bleeding is a
common complication)
Plasma or Fresh frozen Plasma
 Mild sedation
- fluid portion of the blood
 Prone position during the procedure
remaining after the RBC, plt’s &
 Local anesthesia
leukocytes has been removed
 Hold breath, remain still during the
- increase intravascular
procedure
compartment or factors expands
 X – ray of the kidney should be
blood volume
readily available
 Ultrasound to locate the kidney
Albumin
NURSING DIAGNOSES - volume expander that maintains
the colloid osmotic pressure 
 Fluid volume deficit
 Fluid volume excess - provides adequate tissue
perfusion
 Altered oral mucous membrane
- treat shock, dec.
hypoproteinemia; available in
PLANNING for RESTORATION and
MAINTENANCE 50% and 25% solution
 Dietary Modifications – depends on
the case of the client Clotting Factors & Cryoprecipitate
 Modification of fluid intake - prepared from fresh frozen
 Medication and Administration plasma and contains large
 IV therapy amounts of the clotting factor
 Blood and blood products VIII
replacement
Granulocyte (WBC)  Potassium and calcium on the other
- restore the leukocyte count & hand, are stored in the cells and
infuse slowly over 2-4 interval: bone.
 When serum levels drop, ions can
shift out of the storage “pool” into
the blood to maintain adequate
Antigen
serum levels for normal functioning.
- no. of protein found in the
surface of an individual’s RBC
Functions of Electrolyte:
that promote agglutination
 Maintaining fluid balance
(clumping of RBC’s)
 Contributing to acid- base regulation
- Cause the formation & react
 Facilitating enzyme reaction
specifically w/ antibodies
 Transmitting neuromuscular
reactions
Antibody
- immunoglobulin's produced by Fluid imbalances (Volume
the body in response to bacteria, Impairment)
viruses & other antigenic Two basic types:
substance
ISOTONIC IMBALANCES
- Neither present in people w/
- occur when water and
blood groups O
electrolytes are lost or gained in
equal proportions, so that
Agglutinogens osmolality of the body fluid
- substance that cause remains constant.
agglutination
OSMOLAR IMBALANCES
Agglutinins - involve the loss or gain of only
- are specific trends of antibody water, so that the osmolality of
whose interaction w/ antigens the serum is altered.

Pathophysiologic Mechanism FOUR CATEGORIES OF FLUID

Functions and regulation of Electrolytes IMBALANCES:
 Charged ions capable of conducting  Isotonic loss of water and
electricity electrolytes
 Anion ( negatively charged ) and  Isotonic gain of water and
cation (positively charged ) balance electrolytes
always exist  Hyperosmolar loss of water – water
 Cations: sodium ( Na+ ), potassium deficit ( ↓ in relation to Na or other
( K+ ), calcium solution ) and Na / solute excess ( ↑
(Ca+), and magnesium ( Mg+ ) in relation to water )
 Anion: chloride ( Cl ), bicarbonate  Hypoosmolar gain of water – water
( HCO3 ), phosphate ( HPO4 ), and excess and Na deficit
sulfate ( SO4 )
 Most electrolytes enter the body
through dietary intake and are
excreted in the urine. Types of Fluid Volume Deficit
 Some electrolytes such as sodium ISOTONIC FLUID VOLUME
and chloride, are not stored by the
DEFICIT (FVD)
body but and must consumed daily to
- occurs when the body losses both
maintain normal levels.
water and electrolytes from the
 ECF in similar proportion.
(HYPOVOLEMIA)
- Occurs as a result of:
o Abnormal losses through
the skin, gastrointestinal
tract, or kidney ( diuretics
)
o Decrease intake of water
o Bleeding
o Burns
o Movement of fluid in a
third shift

THIRD SPACE SYNDROME

- fluid shifts from a vascular space
into an area where it is nor
readily accessible as extracellular
fluid. Fluid remains in the body
but is essentially unavailable for
use. Fluid may be sequestered in
the bowel, in the interstitial space
as edema.
Common locations: Tissue spaces
( edema ), abdomen ( ascites ), pleural
spaces ( pleural effusion ), and pericardial
spaces ( pericardial effusion )
Causes: Injury or inflammation,
malnutrition or liver dysfunction, high
vascular hydrostatic pressure

HYPERTONIC /
HYPEROSMOLAR
DEHYDRATION
- more water is lost than solutes,
Na or solute excess and serum
osmolality is elevated. Water is
lost without electrolyte lost.