Transcript The Pool of Fluid Balance

Table of Contents
Click on rectangle to get to content on topic
Body Solutions and
Compartments
Solute and Fluid Transport
Diffusion and Osmosis
Filtration, Hydrostatic and
colloidal osmotic forces
Fluid Volume Excess and Deficit
Fluid Volume Regulation
Genetics, Inflammation, and
Stress Effect on Fluid Balance
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 Farrington
MSN Student-MSN 621
April 2010
Question
Edema 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
Drag on
cylinder to
see if you
are right
Porth (2005) p 767
Trancellular
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
Think about these electrolytes importance in your
cell
patient assessment
• Intracellular fluid compartment (ICF) contained
within cell
ECF
ICF Major
Ion
Potassium
Cell
Cell membrane
ICF
ECF Major
Ion Sodium
Chloride
Heitz (2001) p.6
Body Fluid Composition and
Compartments
Body fluid composition is water and
dissolved substances consisting of solutes
and electrolytes
The 60-40-20 Rule:
60 % of body weight is water
40% of body weight is intracellular fluids
20% of body weight is extracellular fluid
Intracellular
Extracellular
Patlak (1999) Department of Physiology, University of Vermont.
Picture permission of Dreamscape Download
Cell
Extracellular Fluids
Interstitial
Transcellular
Intravascular
• 11-12 liters in adult
• Lymph fluid an example
• Specialized cavity fluids
such as cerebrospinal,
pericardial, pleural,
synovial, GI and
intraocular
• 2 liters in adult
• Blood vessels(including
plasma fluids)
• 5-6 liters
• Functions include delivery
of nutrients, transport of
waste products, delivery
of antibodies, transport of
hormones, circulation of
body heat
Heitz ( p.6
Body Fluid Compartments
Click on Box to see if your are right.
What are the major compartments for body
fluids?
Extracellular
Intracellular
Intravascular
Transcellular
Cell Membrane
Primary barrier to movement of substances
between ECF and ICF
Extracellular compartment
Volume (ECF)
Cell membrane
Cell
Intracellular compartment
Volume (ICF)
Heitz p.8
Cell Membrane Transport
Molecules and Ions depend on transport
mechanisms to go from ECF to ICF
Extracellular compartment
Volume (ECF)
Cell membrane
Cell
Pot
Porth p 762
Intracellular
compartment
Volume (ICF)
Solute Movement
• Solutes move by
– Diffusion
– Mediated passive transport (No energy required)
– Mediated active transport (Energy required)
Cell membrane
Extracellular compartment
Volume (ECF)
Porth p 762
Cell
Intracellular
compartment
Volume (ICF)
Passive Transport: Diffusion
Molecules move along concentration gradient
across cell membrane until there is a balanced
concentration and gradient is gone. Example:
diffusion of oxygen in alveoli allowing
(ECF)
replenishment
Permeable cell
(ICF)
membrane
Cell
Cell
Equal concentration
Low concentration
(ICF)
High
concentration
Permeable cell
membrane
(ECF)
Equal concentration
Porth p 762
Mediated Passive Transport
(Facilitated Diffusion)
Large molecules moves along concentration gradient
and are assisted by the carrier protein to cross cell
membrane. Example glucose
High concentration
Semi permeable Cell membrane
Cell
(ECF)
(ICF)
glucose
Low
concentration
Heitz p.10
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
M
ATP
Semipermeable
Cell membrane
Cell
(ECF)
(ICF)
High concentration gradient on membrane
Porth p.75
Active Transport: Sodium Potassium
Pump
• Maintains the differences between intracellular &
extracellular Na & K. (Very active in the heart)
(ECF)
ATP
Cardiac
Cell
Na
(ICF)
Na
Na
http://quizlet.com/1916557/fluid-balance-flash-cards
k
k
A
concentration difference
between high level of
concentration and low level
of concentration
B
necessary for active
transport and facilitated
diffusion
C
particles or molecules move
area of high concentration to
low concentration until
BALANCED
Quiz :
Is it A, B, or C
Click on Shape to
See if You Are Right
Protein Carrier
B
Diffusion
C
Concentration
Gradients
A
Water Movement
• Osmotic forces
Cell membrane
Intracellular
compartment
Volume (ICF)
– Osmosis
– Osmotic Pressure
Cell
• Oncotic Pressure
– Isotonic
– Hypotonic
– Hypertonic
Extracellular compartment
Volume (ECF)
• Filtration & Hydrostatic pressure
Porth p 762
Osmosis-Passive
Movement of water across semipermeable membrane
from an area of lower solute concentration to higher
solute concentration
Extracellular compartment
Volume (ECF)
Cell membrane
Notice
Osmosis 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
Cell
Greater number of
particles-Less water
Fewer particlesMore water
Porth p.762
Intracellular
compartment
Volume (ICF)
Osmosis Pressure
Hydrostatic pressure (HP) required to stop
osmotic flow of water
water
Extracellular compartment
Volume (ECF)
HP
Cell
Greater number of
particles-Less water
Fewer particlesMore water
Porth p 762
Intracellular
compartment
Volume (ICF)
Semipermeable
Cell membrane
Osmolarity
Measure of solutions ability to create osmotic
pressure of force and affect water movement
Serum Osmolality
Number of solutes per KG of water IN the body
Serum Isotonic concentration=275-295 mOsm/Kg
Serum Hypotonic concentration=<275 mOsm/Kg
Serum Hypertonic concentration=>295 mOsm/Kg
Heitz p.12 picture microsoft clip art
Osmolality of Solutions
• Isotonic-same osmolality as body
0.9% NACL
fluids
• Hypotonic-osmolality less then body
0.45% NACL
fluids
• Hypertonic-osmolality greater than
D5LR
body fluids
Do you know a example of IV solution for each osmolality.
Click on word osmolality to see if you are right.
Heitz p.13
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
Filtration
Movement 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.
30mmHg
10mmHg
IF pressure -3 mm Hg
Porth p 766
Picture retrieved from Dreamstime March
25,2010
Hydrostatic Pressure
Pressure created by weight of fluid and is impacted by distance from heart
pump and amount of fluid. Moves fluid out of capillary bed
30mmHg
10mmHg
Interstitial Fluid pressure -3 mm Hg
Porth p.766
Picture retrieved with approval Dreamstime
March 25,2010
Colloidal Osmotic Pressure
Responsible for moving fluid back to capillary with colloids. Assists in
retaining fluids in plasma
Click here to
return to FVE
28mmHg
IF pressure 8 mm HG
Porth p 766
Picture retrieved with approval Dreamstime March 25,2010
28mmHg
Lymph System
Excessive interstitial fluid that can be returned to circulatory system
Excessive
fluid and
proteins
not
absorbed
in capillary
Porth p. 767
Picture retrieved with approval
Dreamstime March 25,2010
Filtration A
Quiz :
Is it A, B, or C
Click on Rectangle to
See if You Are Right
Hydrostatic
Pressure B
Pressure created by weight
of fluid. Impacted by
distance from heart and
amount of fluid.
B
Excessive fluid and proteins
not absorbed in capillary
C
Movement of water and
solutes from an area of high
hydrostatic pressure to an
area of low hydrostatic
pressure
A
Lymphatic
Drainage C
http://quizlet.com/1916557/
fluid-balance-flash-cards
Fluid Volume Excess(FVC)-Increase In
ECF Compartment Volume
Why 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)
Click here
– Increased corticosteroid level
Porth p 778-779
Fluid Volume Excess Assessment and
Management
Signs Symptoms
• Hypertension
• Tachycardia
• Tachypnea
• Weight Gain
• Intake measured is
greater then output
• Hypotension, Heart
sound gallop and
hypoxemia with
progressed state of
cardio respiratory
failure
Signs Symptoms of
Increased Interstitial
Fluid volume
• Dependent edema
• Generalized edema
• Pitting/nonpitting
edema
Signs and Symptoms
of Increased
Intravascular
• Pulmonary edema
evidenced by
shortness of breath,
dyspnea , crackles,
and cough
• Full bounding pulse
• Venous distention
Porth p 778-779
Management
• See Next slide
FVE Outcomes/Interventions
Patient 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 Volume
Why 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
Signs Symptoms-General
• Constipation
• Decreased urine
output
• Increased osmolarity
and specific gravity
• Thirst
• Acute weight loss
• Intake measured is less
then output
• Decreased urine
output or oliguria
• Elevated temperature
Signs Symptoms of
Decreased Extracellular
Fluid volume
• Sunken eyes and soft
eyeballs
• Dry mucosa
• Decreased skin turgor
Signs and Symptoms of
Decreased Intravascular
• Dizziness
• Weakness
• Orthostatic
hypotension or
hypotension
• Tachycardia
• Weak thready pulse
• Decreased vein filling
Porth p 778-779
Outcomes Interventions
• See Next slide
FVD Outcomes/Interventions
Patient 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
Increased vascular volume or
increased blood pressure
leading to increased atrial
stretch
Increased release of atrial natriuretic factor
Direct vasodilatation
Increased excretion of NA +
H2O by the kidney secondary to
increased filtration
Decreased
renin/angiotensin/aldosterone
Decreased
release of ADH
Decreased vascular volume and or blood
pressure
Heitz 18. microsoft clip art
Regulation of Fluid Volume Deficit
Loss of hypotonic fluid
Decreased plasma volume
Increased plasma
osmolality
Increased thirst
Decreased cardiac output
Increased ADH
Secretion
Decreased blood pressure
Decreased renal perfusion
Decreased water and
sodium filtered by the
kidney
Increased reabsorption of
filtered water by the kidney
Increased renin release
Increased angiotensin I/II
Increased aldosterone secretion by adrenal cortex
Decreased water excretion
Decreased sodium and
water excretion
Increased water intake
Increased volume of sodium
and water
Increased plasma volume and decreased osmolality
Heitz 16. microsoft clip art
Regulation of Fluid Volume DeficitHemorrhage
Hemorrhage
Decreased arterial
pressure(decreased renal
perfusion)
Release of renin by the
kidneys
Renin substrate
Angiotensin I
converting enzyme
( lung)
Angiotensin II
Release of aldosterone
Vasoconstriction
Retention of sodium and water
Increased vascular volume
Increased arterial pressure
Heitz 15. microsoft clip art
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
Aldosterone
Click on
box for
hormone
name
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 I
76 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
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)
2. Would urine osmolality increase or decrease if patient dehydrated?
Click for answer
Increase
3. What monitoring will be important for the patient in post operative
period?
Click for answer Consideration of preop fluid status,
Surveillance of cardio respiratory status,
Surveillance of urine output, goal of I=O, Daily
weight.
microsoft clip art
Case Study II
A 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.
1. What monitoring will be important for the patient in the post
operative period? 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
2. If urine output drops what assessment information would you want to
report to physician? Click for answer
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
microsoft clip art
References
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•
•
•
•
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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