Fluids

Fluids By: Sonny M. Moreno, RN

Board Question 

Body weight of an adult represents how many percent of water? A. 40% B. 50% C. 60% D. 70%

Board Question 

Most accurate test to determine fluid status would be? A. BP readings B. HR and RR readings C. CVP readings D. all of the above

Board Question 

It is movement of particle from low to high area of concentration, with the help of ATP (energy) A. Active transport B. Passive transport C. Osmosis D. Diffusion

Board Question 

In response to FVD, RENIN secretions will: A. increase B. decrease C. remain normal D. increase and decrease

Intake and Output 

 



I and O must be equal 2.5 L per day Essential, Measurable, Sensible Non essential, Not Measurable, Insensible

I&O Imbalance Fluid Volume Excess  ↑ intake, normal output  Normal intake, ↓ output  No output Fluid Volume Deficit  ↑ output, normal intake  Normal output, ↓ intake  No intake

Facts About Fluids       

Body weight of an adult represents 60% Infants = ↑60% (more water) Elderly = ↓60% (less water) More fats = ↓water More muscles = ↑water Infants and elderlies are prone to fluid imbalance 1% fluid loss triggers thirst mechanism

Water Auto Regulation      

THIRST ADH ANP RENIN BARORECEPTOR ALDOSTERONE

Decreased Blood Volume      

THIRST mechanism ADH secretion is increased ANP secretion is decreased RENIN secretion is increased BARORECEPTOR vasoconstricton ALDOSTERONE secretion is increased

Increased Blood Volume      

NO THIRST mechanism ADH secretion is decreased ANP secretion is increased RENIN secretion is increased BARORECEPTOR vasodilation ALDOSTERONE decreased

ADH Regulation  





ADH is produced by the Hypothalamus ADH is stored and secreted by the posterior pituitary gland With less water in the plasma ADH is secreted, to conserve water by reducing urine output With fluid overload in the plasma ADH secretion stops, to excrete fluid in the

ADH Antidiuretic Hormone ↓ H20 IN T HE P LAS MA

↑ H20 IN T HE PL ASMA

↑ADH

↓ ADH

↑ H20 RE ABS ORP TION IN T HE KID NE YS

↓ H20 RE AB SORP TIO N

↑ BLO OD VO LUME

↓ BLO OD VO LUME

↓ ↓ ↓

↓ ↓

IN T HE KIDN EYS

↓

ADH Disorder 

SIADH     



Abnormally high ADH concentration urine output is reduced (oliguria) water retention (fluid overload) Urine SG is high (normal: 1.005 – 1.030) Hct is low (43-48%)

DI     

Abnormally low ADH urine output is increased (polyuria) water loss (fluid deficit) Urine SG is low Hct is high

ANP Atrial Natriuretic Peptide ↓ H20 IN T HE P LAS MA

↑ H20 IN T HE PL ASMA

↓ AN P

↑AN P

↓ URIN E FORMAT ION

OLIG URI A

↑ URIN E F ORMAT ION POLYU RIA

↑ BLO OD VO LUME

↓ BLOO D VO LUME

↓ ↓ ↓

↓ ↓ ↓

Aldosterone ↓ H20 IN T HE P LAS MA

↓

↑ H20 IN T HE PL ASMA

↓

↓ ALDOS TERONE

↑ ALDO STE RONE

↓ ↓

↑ Na RE ABS ORP TIO N ↑ SERUM Na

↑ Na and H20 E XC RE TION

↓

↓ BLO OD VO LUME

H20 R ETENT ION

↑ BLO OD VO LUME

↓

Aldosterone Disorders 

Addison’s Disease Abnormally low aldosterone  Serum Na is low, serum potassium is high  FVD 



Cushing’s Disease Abnormally high aldosterone  Serum Na is high, serum potassium is low  FVE 

Renin Angiotensin Aldosterone System Stimulates JGA RENIN AngiotenDec RTP JGA Releases combines sinogen LIVER RENIN Increasing Na and H20 in the BLOOD ↑ BV ↑ BP

Stimulates To release Adrenal Aldosterone Cortex

ANGIOTENSIN 1

Renin Angiotensin Aldosterone System JGA Stimulates RENIN AngiotenDec RTP Releases combines sinogen LIVER JGA RENIN ANGIOTENSIN 1 ↑ BV ↑ BP

BV CONSTRICTION

LUNGS

ANGIOTENSIN 2

Converted To

Renin Angiotensin Aldosterone System Stimulates JGA RENIN AngiotenDec RTP Releases combines sinogen JGA RENIN Increasing Na and H20 in the BLOOD ↑ BV ↑ BP

To release Stimulates Aldosterone Adrenal Cortex

BV CONSTRICTION

LUNGS

ANGIOTENSIN 2

LIVER

ANGIOTENSIN 1

Converted To

60% of Body Weight is Water Fluid Compartments: 1. ICF Intracellular Fluid 2. ECF Extracellular Fluid IVF Intravascular Fluid Arterial Fluid Venous Fluid ITF interstitial fluid 3. Transcellular Fluid Pleural Fluid Peritoneal Fluid Pericardial Fluid CSF

= = 2L = 3L

=

40L =

5L =

15L

20L

Distribution of Body Weight

Assessment of Fluid Imbalance 1. ICF compartment (cells) 

FVE cellular edema = ↓LOC  pulmonary edema = crackles (bibasilar) 



FVD 

cellular dehydration = Acid = Acidosis

Assessment of Fluid Imbalance 2. ITF compartment (skin) 

FVE skin = pitting edema  feet (bipedal) = ANASARCA (periorbital edema) 



FVD 

skin = poor skin turgor

Assessment of Fluid Imbalance 3. IVF compartment (blood volume) 

FVE artery = ↑BP, pulse (rapid bounding)  vein = ↑CVP, ↑PAWP 



FVD artery = ↓BP, pulse (rapid thready)  vein = ↓CVP, ↓PAWP 

Assessment of Fluid Imbalance 4. 3rd space Pleural sac Effusion Pericardial sac Effusion Peritoneal sac

=

Pleural

=

Pericardial

=

Ascites

              

Fluid status can be assessed through:

Mucus membrane Skin integrity Body weight Jugular vein BP, PAWP 6-12 mm Hg CVP (most accurate) 0-7 mm Hg or 5-10 cm of H2O I&O Pulse Temperature Lung sound and heart sound Urine output Urine SG 1.005-1.030 Hematocrit 48% Plasma osmolality

Transport Mechanism 



Take note that fluids from different compartments will always move from one compartment to another compartment to maintain balance. That movement is dictated by the transport mechanism principle. PASSIVE

Active Transport 

  

It is movement of particles from low to high area of concentration, with the help of ATP (energy) EXAMPLE: glucose amino acids potassium pump PISO “potassium in sodium out” Endocytosis = to the cells Exocytosis = out of the cells

Passive Transport 



It is movement from high to low area of concentration Dictated by pressure gradient (DALTON’S LAW) EXAMPLE: Osmosis Diffusion Ultrafiltration

Osmosis 

Movement of water from high to low pressure in order to maintain balance between compartments.

Diffusion 

Movement of solute from high to low concentratio n in order to maintain balance between compartment

Ultrafiltration Dictated by COP and HP  COP = colloidal osmotic pressure (holds water)  HP = hydrostatic pressure (water pressure)

EDEMA FORMATION: 1.

2.

3.

Increased HP Ex: CHF, CRF Decreased COP Ex: proteinuria, kwashiorkor, marasmus Lymphatic Obstruction Ex: Filariasis, Hodgkin’s and Non Hodgkins

Types of Fluids   

Isotonic = increases BV Hypotonic = hydrates the cells Hypertonic = attracts water from cells into the IV space

Isotonic Fluid

Hypotonic Fluid

Hypertonic Fluid

Isotonic Example   

 

D5W - 5% Dextrose in water isotonic (252 mOsm/L) 10% Dextran 40 in 5% Dextrose isotonic (252 mOsm/L) Ringer’s Solution isotonic (309 mOsm/L) replaces K, Na, Cl. and Ca does not contain lactate Lactated Ringer’s Solution isotonic (273 mOsm/L)   NS - 0.9% NaCl isotonic (308mOsm/L) replaces NaCl deficit

Hypotonic Example 





5% dextrose is hypotonic relative to extracellular fluid Half strength saline is a hypotonic solution. It is infrequently used by 1/2 NS 0.45%NaCl hypotonic (154 mOsm/L)

Hypertonic Example       

D10W - 10% Dextrose in water hypertonic (505 mOsm/L) D10W - 20% Dextrose in water hypertonic (1011 mOsm/L) D50W - 50% Dextrose in water hypertonic (1700 mOsm/L) D5NS - 5% Dextrose & 0.9NaCl hypertonic (559 mOsm/L) D10NS - 10% Dextrose & 0.9NaCl hypertonic (812 mOsm/L) 3%NS hypertonic (1026 mOsm/L) D5LR - 5% Dextrose in Lactated Ringers hypertonic (524 mOsm/L

FVD or Hypovolemia 



Isotonic fluid loss including solutes Body’s compensation is to ↑ ADH and Aldosterone level, OLIGURIA ↓ ANP atrial natriuretic peptide, OLIGURIA (produced from atrial muscle of the heart)

FVD 



Children and older patients are vulnerable If not detected early it may lead to hypovolemic shock (most common type of shock)

FVD Due to:  ECF loss (abdominal surgery, DM, DI, diuretics, laxative, ↑ sweating, fever, NGT, vomiting/diarrhea)  3rd space shifting (acute intestinal obstruction, acute peritonitis, burns during initial phase, ↓ COP)

FVD How FVD is treated?  Look for the cause and manage it. (apply direct pressure if there is bleeding)  Replace lost fluids with fluids of the same concentration (NSS or LR followed by plasma proteins)

FVD Fluid and hemodynamic derangements ↓ H2O:↑ solute = hyperosmolality → sluggish blood flow → ↑ coagulation → thrombosis  ↓ H2O:↑ RBC = ↑ hematocrit → easy to coagulate (hemoconcentration)  ↓ blood volume → ICF moves out from the cell to ↑ blood volume = cellular dehydration

FVE or Hypervolemia  



Is an excess of isotonic fluid and sodium in the ECF Body’s compensation is to ↓ ADH and Aldosterone level, POLYURIA ↑ ANP atrial natriuretic peptide, POLYURIA (produced from atrial muscle of the heart) Elderly and patients with kidney or heart problems are prone to

FVE 





↑ H2O=↑ HP → cerebral edema → ↑ ICP and pulmonary edema → respiratory arrest ↑ blood volume → venous congestion → CHF ↑ H2O:↓ RBC → hemodilution or pseudoanemia

FVE Due to:  Excessive intake of Na and H2O (diet, IV replacement, blood or plasma transfusion)  ARF, CRF and CHF  Liver Cirrhosis  Nephrotic Syndrome  Hyperaldosteronism  SIADH  Low intake of dietary CHON  Remobilization of fluid after burn treatment (1ST PHASE)

FVE How FVE is treated?  Look for the cause and manage it. (restrict Na and H20 intake)  Diuretics or dialysis if kidneys are not working properly  Morphine and NTG to dilate blood vessels  Dopamine & Dobutamine (diuresis effect & ↑ CO)  Digoxin for CHF (+inotropic, chronotropic)  Mannitol for cerebral edema (monitor

Related Disorders         

ARDS = intravascular fluid excess Cerebral Edema = swelling of the cells ARF/CRF = fluid accumulation Burns = IVF to outside from it VICE VERSA Blood Pooling = lower extremities 3rd space fluid shift = burns Lymphatic vessel obstruction = Hodgkins CHF = blood pooling Portal Hypertension = congestion of abdominal organs

QUIZ    

1. ↑ ADH 2. ↓ ADH 3. ↑ ANP 4. ↓ ANP

A. INCREASED URINE B. DECREASED URINE

  

  

5. 6. 7.

ISOTONIC AXN A. HYDRATE HYPOTONIC AXN B. ↑ BV HYPERTONIC AXN C. ↓ EDEMA

8. OSMOSIS 9. DIFFUSION 10. ACTIVE

A. USES ATP B. WATER C. SOLUTES









11. SPECIFIC TEST FOR FLUID STATUS? 12. ABNORMAL ACCUMULATION OF FLUID IN THE PERITONEAL CAVITY? 13. TWO MAIN ACTIONS OF DIGOXIN? 14. MOVEMENT OF FLUID FROM INTRAVASCULAR SPACE TO TRANSCELLULAR SPACE IS





EDEMA FORMATION: 16. HP increased or decreased? 17. COP increased or decreased? 18. extravasated fluid from filtrate will be collected initially by A. lymphatic B. venous C. artery D. all of the above

19. Cushings Disease A. FVE B. FVD 20. Addisons Disease A. FVE B. FVD 21. SIADH a. Polyuria and FVE b. Polyuria and FVD c. Oliguria and FVE d. oliguria and FVD 22. Diabetes Insipidus a. Polyuria and FVE b. Polyuria and FVD c. Oliguria and FVE d. oliguria and FVD

23. Isotonic will swell the cell? True or false 24. Hypertonic will lead to cellular edema? True or false 25. Hypotonic will improve cellular edema s/sx? True or false

Tnk u Po…