5. fluids and electrolytes ncm 101

Fluids and ElectrolytesFluids and ElectrolytesNursingNursing

PAUL E. MANAIG, MAEd. M.D

To maintain good health, a balance of fluids and electrolytes, acids and bases must be normally regulated for metabolic processes to be in working state.

A cell, together with its environment in any part of the body, is primarily composed of FLUID. Thus fluid and electrolyte balance must be maintained to promote normal function.

Fluids and Electrolytes Outline

Fluids Electrolytes Acids and Bases

3 concepts

THE BODY FLUIDS A solution of solvent and solutes Our body is made up of fluids and

solids About 50-60% of the body weight is

WATER In a 70 Kg adult male: 60% X 70= 40-

42 Liters Note that 1 kg body weight= 1 liter of

THE BODY FLUIDS

The body has two major compartments:

1 Intracellular

2. Extracellular

Intracellular

THE BODY FLUIDS

The Extracellular can be divided into:– Intravascular

- Interstitial– Trans-cellular

THE BODY FLUIDS

The Proportion of Body Fluids

Intracellular fluid

Interstitial

Intravascular

5% Transcellular

The Intracellular Fluid

Found inside the cell surrounded by a membrane

This is compartment with the highest percentage of water in adults

The Extracellular Fluid Fluid found outside the cells

1. INTERSTITIAL FLUIDFound in between the cells

2. INTRAVASCULAR FLUIDFound inside the blood vessels and

lymphatic vessels 3. TRANSCELLULAR FLUID

Found inside body cavities like pleura, peritoneum, CSF

Fluid Compartment in the Body

VolumeAdult Male (L)

Male (%) Female (%)

Infant (%)

Intracellular Fluid 28 40 33 40

Extracellular Fluid Plasma Interstitial Fluid Other

15(4.5)

(10.5)

(15)(1)

17(4)(9)(1)

(25)(1)

TOTAL Water 43 60 50 70

FLUID BALANCE

TOTAL BODY WATER (AS PERCENTAGE OF BODY WEIGHT) IN RELATION TO AGE AND SEX

AGE MALE FEMALE

UNDER 18 65% 55%

18-40 60% 50%

40-60 50-60% 40-50%

OVER 60 50% 40%

Functions of Body Fluids Transporter of nutrients, wastes,

hormones, proteins and etc Medium or milieu for metabolic

processes Body temperature regulation Lubricant of musculoskeletal joints Insulator and shock absorber

Composition of body fluids Composed of solute, solvents,

Electrolytes, proteins, etc Plasma and interstitial fluids contain

essentially the same electrolytes and solutes, but plasma has a higher protein content

The major ICF electrolytes are potassium, phosphates and magnesium

The major ECF electrolytes are sodium, bicarbonates and chloride

Sources of Fluids: Fluid Input

1. Exogenous sources– Fluid intake- water from foodstuffs– IVF– Medications– Blood products

2. Endogenous sources– By products of metabolism– secretions

Fluid Output: Fluid LossesRoutes of Fluid outputUrineFecal lossesSweat

Insensible losses though the skin and lungs as water vapor

Sensible losses

Sources and Losses of Water

Sources (mL) Losses (mL)

Liquids 1200 Urine 1400

Solid foods 1000 Feces 200

Cell metabolism 300 Insensible losses Lungs Skin

400500

TOTAL 2500 2500

Regulation of Extracellular Fluid Composition

Homeostasis requires that the intake of substances such as water and electrolytes equal their elimination.

Over a long period, the total amount of water and electrolytes in the body does not change unless the individual is growing, gaining weight, or losing weight.

The regulation of water and electrolytes involves the coordinated participation of several organ systems, especially the uroexcretory system.

Control of Fluid Balance is maintained By:

1. Thirst mechanism in the hypothalamus.

2. Antidiuretic Hormone (ADH)

3. Aldosterone

Fluid Dynamics

The movement of fluids (solutes and solvents) in the body compartment

DiffusionOsmosisFiltrationActive transport

The Concept of TONICITY

This is the concentration of solutes in a solution

Reflected by the concentration of the Sodium

A solution having the same tonicity as that of body fluid or plasma is considered ISOTONIC– 0.9% NaCl

A solution with high solute concentration is considered as HYPERTONIC

A solution with low solute concentration is considered as HYPOTONIC

Helpful Hints

In a HYPERTONIC solution, fluid will go out from the cell, the cell will shrink

In a HYPOTONIC solution, fluid will enter the cell, the cell will swell

In an ISOTONIC solution, there will be no movement of fluid.

Fluid Dynamics

The movement of fluids (solutes and solvents) in the body compartment

DiffusionOsmosisFiltrationActive transport

DIFFUSION

The movement of SOLUTES or particles in a solution from a higher concentration to a lower concentration

If a sugar is placed in plain water, the glucose molecules will dissolve and diffuse distribute in the solution

OSMOSIS

The force that draws water or solvent from a less concentrated solution into a more concentrated solution through a semi-permeable membrane

The pressure that draws water inside the vessel which is more concentrated is called Osmotic pressure

OSMOSIS

A special type of osmotic pressure is exerted by the proteins in the plasma.

It is called ONCOTIC PRESSSURE (COLLOID Pressure)

FILTRATION

The movement of both solute and solvent by hydrostatic pressure, ie, from an area of a higher pressure to an area of a lower pressure

An example of this process is urine formation

Hydrostatic pressure

Hydrostatic pressure is the pressure exerted by the fluid against the container

Increased hydrostatic pressure is one mechanism producing edema

Active transport

This is the movement of solutes across a membrane from a lower concentration to a higher concentration with utilization of energy

Example is the Sodium-Potassium pump- a primarily active transport process

FLUID EXCESS: Edema

Occurs in the extracellular compartment and may be isotonic, hypotonic, or hypertonic

Edema – refers to an excessive amount of fluid in the interstitial compartment, which causes swelling or enlargement of the tissues.

CAUSES OF EDEMA:

1.Increased capillary hydrostatic pressure

2.Loss of plasma proteins (albumin).

3.Obstruction of the Lymphatic circulation

4.Increased capillary permeability

Effects of Edema:

1.Local area of swelling

2.Pitting edema

3.Significant increased in body weight

4.Functional impairment

5.Pain

6. Arterial circulation may be impaired

FLUID DEFICIT: Dehydration

Refers to insufficient body fluid resulting from inadequate intake or excessive loss or a combination of the two.

Causes of Dehydration:

1.Vomiting and diarrhea

drainage or suction of any portion of Digestive system

2. Excessive sweating with loss of sodium and water

3. Diabetic ketoacidosis with loss of fluid, electrolytes and glucose in the urine

4. Insufficient water intake an elderly or unconscious person

Effects of Dehydrartion:

1.Dry mucous membranes in the mouth/decreased skin turgor

2.Lower blood pressure, weak pulse, and a feeling of fatigue, and

3.Increased hematocrit, indicating a higher proportion of red blood cells compared to water in the blood.

Compensatory Mechanisms:

1.Increasing thirst

2.Increasing the heart rate

3.Constricting the cutaneous blood vessels leading to pale and cool skin,

4.Decreasing urine output (water retention) leading to high specific gravity of urine (more concentrated) as a result of renal vasoconstriction and increased secretion of ADH and Aldosterone.

Comparison of Signs And Symptoms of Fluid Excess and Fluid Deficit

Fluid Excess (edema) Fluid Deficit (Dehydration)

Localized swelling (feet, hands, periorbital area, ascites)

Sunken, soft eyes

Pale, gray, or red skin color Decreased skin turgor, dry mucous membranes

Weight gain Thirst, weight loss

Slow, bounding pulse, high blood pressure

Rapid, weak, thready pulse; low b lood pressure; orthostatic hypotension

Lethargy, possible seizures Fatigue, weakness, dizziness, possible stupor

Pulmonary congestion, cough, rales Laboratory values Decreased hematocrit Decreased serum sodium Urine: Low specific gravity, high volume

Increased body temperature Laboratory values Increased hematocrit Increased electrolyte or (variable) Urine: High specific gravity; low volume

Regulation of Body fluid balance

1. The Kidney Regulates primarily fluid output by

urine formation Releases RENIN Regulates sodium and water balance

2. Endocrine regulation Regulates primarily fluid intake by thirst

mechanism ADH increase water reabsorption on

collecting duct Aldosterone increases Sodium

retention in the distal nephron ANF Promotes Sodium excretion and

inhibits thirst mechanism

3. Gastro-intestinal regulationThe GIT digests food and absorbs

water Only about 200 ml of water is

excreted in the fecal material per day

The ELECTROLYTES

Electrolytes are charged ions capable of conducting electricity and are solutes in all compartment

The ELECTROLYTES

Sources of electrolytesFoods and ingested fluids Medications IVF and TPN solutions

The ELECTROLYTES

Functions of Electrolytes Maintains fluid balance Regulates acid-base balance Needed for enzymatic secretion and

activation Needed for proper metabolism and

effective processes of muscular contraction, nerve transmission

The ELECTROLYTES

ECF and ICF vary in their electrolyte distribution and concentration

Cation and Anion

CATIONS- positively charged ions; examples are sodium, potassium, calcium

ANIONS- negatively charged ions; examples are chloride and phosphates

Cation and Anion

The major ICF cation is potassium (K+); the major ICF anion is Phosphates

The major ECF cation is Sodium (Na+); the major ECF anion is Chloride (Cl-)

Factors which influence the concentration of water and solutes inside the cells:– Transport mechanisms– Permeability of the cell membrane– Concentration of water and solutes in the extracellular fluid

NORMAL VALUES AND MASS CONVERSION FACTORS

Normal Plasma Values Mass Conversion

Sodium (Na+) 135 – 145 meq/L 23 mg = 1 meq

Potassium (K+) 3.5 – 5.0 meq/L 39 mg = 1 meq

Chloride (Cl-) 98 – 107 meq/L 35 mg = 1 meq

Bicarbonate (HCO3-) 22 – 26 meq/L 61 mg = 1 meq

Calcium (Ca2+) 8.5 – 10.5 mg/dL 40 mg = 1 mmol

Phosphorus 2.5 – 4.5 mg/dL 31 mg = 1 mmol

Magnesium (Mg2+) 1.8 – 3.0 mg/dL 24 mg = 1 mmol

Osmolality 285 – 295 mosm/kg -

Sodium

Dominant extracellular ion. About 90 to 95% of the osmotic pressure of the

extracellular fluid results from sodium ions and the negative ions associated with them.

Recommended dietary intake is less than 2.5 grams per day.

Kidneys provide the major route by which the excess sodium ions are excreted.

Sodium

In the presence of aldosterone, the reabsorption of sodium ions in the loop of Henle is very efficient. When aldosterone is absent, the reabsorption of sodium in the nephron is greatly reduced and the amount of sodium lost in the urine increases.

Also excreted from the body through the sweat mechanism.

Sodium

Primary mechanisms that regulate the sodium ion concentration in the extracellular fluid:– Changes in the blood pressure– Changes in the osmolality of the extracellular fluid

Sodium Regulation

NORMAL Na+

INCREASED SODIUM

DECREASED SODIUM

Increased ADH secretion, Decreased urine volume and increased plasma

volume

Decreased aldosterone secretion, decreased sodium reabsorption

DECREASED SODIUM

INCREASED SODIUM

Decreased ADH secretion, Increased urine volume and decreased plasma

volume

Increased aldosterone secretion, increased sodium reabsorption

Potassium

Electrically excitable tissue such as muscle and nerves are highly sensitive to slight changes in extracellular potassium concentration.

The ECF concentration of potassium must be maintained within a narrow range for tissues to function normally.

Potassium

Aldosterone also plays a major role in regulating the concentration of potassium ions in the ECF.

Circulatory system shock resulting from plasma loss, dehydration, and tissue damage causes extracellular potassium ions to become more concentrated than normal. In response, aldosterone secretion increases and causes potassium secretion to increase.

Potassium Regulation

NORMAL K+

INCREASED POTASSIUM

DECREASED POTASSIUM

Increased aldosterone secretion with increased potassium secretion by the kidneys and increased potassium in

DECREASED POTASSIUM

INCREASED POTASSIUM

Decreased aldosterone secretion with decreased potassium secretion by the

kidney and decreased potassium in the urine

Calcium

Extracellular concentration of calcium ions is maintained within a narrow range.

Increases and decreases in ECF concentration of calcium ions have dramatic effects on the electrical properties of excitable tissues.

Parathyroid hormone (PTH) secreted by the parathyroid glands increases extracellular calcium levels.

Calcium

Calcitonin is secreted by the thyroid gland. It reduces blood levels of calcium when they are too

Calcium Regulation

NORMAL Ca++

INCREASED CALCIUM

DECREASED CALCIUM

Increased Calcitonin secretion with decreased bone resorption

Decreased parathyroid hormone secretion with decreased bone resorption, decreased intestinal

calcium absorption, and decreased kidney calcium reabsorption

DECREASED CALCIUM

INCREASEDCALCIUMIncreased parathyroid hormone

secretion with increased bone resorption, increased intestinal

calcium absorption, and increased renal calcium reabsorption

Phosphate and Sulfate

Phosphate and sulfate are reabsorbed by active transport in the kidneys.

Rate of reabsorption is slow, so that if the concentration of these ions in the filtrate exceeds the ability of the nephron to reabsorb them, the excess is excreted in the urine.

Helpful mnemonics

PI-SO Potassium is inside Phosphate is inside

Sodium is outside Chloride is outside

Regulation of Electrolyte Balance

1. Renal regulation Occurs by the process of glomerular

filtration, tubular reabsorption and tubular secretion

Urine formation– If there is little water in the body, it is

conserved– If there is water excess, it will be eliminated

2. Endocrinal regulation Hormones play a role in electrolyte

regulation Aldosterone promotes Sodium retention

and Potassium excretion ANF promotes Sodium excretion Parathormone promotes Calcium

retention and Phosphate excretion Calcitonin promotes Calcium excretion

and Phosphate excretion

3. GIT Regulation- electrolytes are absorbed and secreted and some are excreted thru the stool

THE CATIONS

SODIUM POTASSIUM CALCIUM MAGNESIUM

SODIUM

Normal range is 135-145 mEq/L Major contributor of plasma

osmolarity

FUNCTIONS 1. participates in the Na-K pump 2. assists in maintaining blood volume 3. assists in nerve transmission and

muscle contraction

POTASSIUM

MOST ABUNDANT cation in the ICF Normal range is 3.5-5.0 mEq/L

FUNCTIONS 1. maintains ICF Osmolality 2. nerve conduction and muscle

contraction 3. metabolism of carbohydrates, fats and

proteins

CALCIUM Majority of calcium is in the bones and

teeth Normal serum range 8.5-10 mg/dL

FUNCTIONS 1. formation and mineralization of

bones/teeth 2. muscular contraction and relaxation 3. cardiac function 4. blood clotting 5. enzyme activation

CALCIUM

Regulation: GIT absorbs Ca+ in the intestine with

the help of Vitamin D Kidney Ca+ is filtered in the

glomerulus and reabsorbed in the tubules

PTH increases Ca+ by bone resorption, Ca+ retention and activation of Vitamin D

Calcitonin released when Ca+ is high, it decreases Ca+ by excretion in the kidney

MAGNESIUM Second to K+ in the ICF Normal range is 1.3-2.1 mEq/LFUNCTIONS 1. intracellular production and

utilization of ATP 2. protein and DNA synthesis 3. neuromuscular irritability

THE ANIONS

CHLORIDE PHOSPHATES BICARBONATES

CHLORIDE The MAJOR Anion in the ECF Normal range is 95-108 mEq/L

FUNCTIONS 1. major component of gastric juice

aside from H+ 2. together with Na+, regulates

plasma osmolality 3. participates in the chloride shift 4. acts as chemical buffer

PHOSPHATES The MAJOR Anion in the ICF Normal range is 2.5-4.5 mg/LFUNCTIONS 1. component of bones 2. needed to generate ATP 3. components of DNA and RNA PTH decreases PO4 in blood by

renal excretion Calcitonin increases renal

excretion of PO4

BICARBONATES

Present both in ICF and ECF Normal range- 22-26 mEq/L

FUNCTIONS 1. regulates acid-base balance 2. component of the bicarbonate-

carbonic acid buffer system

IMBALANCE: EXCESS

1. HYPERNATREMIA More than 145 mEq/L Fluid moves out of cell crenation Etiology:↑ sodium intake, IVF, water

loss in excess of water, diarrhea S/SX: dry, sticky tongue, thirst

IMBALANCE: EXCESS2. HYPERKALEMIA K+ more than 5.0 mEq/L Etiology: IVF with K+, acidosis,

Hyper-alimentation and K+ replacement

ECG: peaked T waves and wide QRS

IMBALANCE: EXCESS3. HYPERCALCEMIA Serum calcium more than 10.5 mg/dL Etiology: Overuse of calcium

supplements, excessive Vitamin D, malignancy, prolonged immobilization, thiazide diuretic

ECG: Shortened QT interval

IMBALANCE: EXCESS

4. HYPERMAGNESEMIA Serum magnesium more than 2.1 mEq/L Etiology: use of Mg antacids, Renal

failure, Mg medications S/SX: depressed tendon reflexes,

oliguria, ↓RR

IMBALANCE: EXCESS

5. HYPERCHLOREMIA Serum chloride more than 108 mEq/L Etiology: sodium chloride excess

IMBALANCE: EXCESS

6. HYPERPHOSPHATEMIA Serum PO4 more than 4.5 mg/dL Etiology: Tissue trauma, chemotherapy.

PO4 containing medications, osteoporosis

IMBALANCE : DEFICIENCY1. HYPONATREMIA Na level is less than 135 mEq/L Water is drawn into the cell cell

swelling Etiology: prolonged diuretic therapy,

excessive burns, excessive sweating, SIADH, plain water consumption

S/SX: nausea, vomiting, seizures

IMBALANCE : DEFICIENCY2. HYPOKALEMIA K+ level less than 3.5 mEq/L Etiology: use of diuretic, vomiting

and diarrhea ECG: flattened , depressed T waves,

presence of “U” waves

IMBALANCE : DEFICIENCY3. HYPOCALCEMIA Calcium level of less than 8.5 mg/dL Etiology: removal of parathyroid gland

during thyroid surgery, Vit. D deficiency, Furosemide, infusion of citrated blood

S/SX- Tetany, (+) Chvostek’s (+) Trousseaus’s

ECG: prolonged QT interval

ACID-BASE CONCEPTS

Acid- substance that can donate or release hydrogen ions–Carbonic acid, Hydrochloric acid

ACID-BASE CONCEPTS

Base- substance that can accept hydrogen ions–Bicarbonate

ACID-BASE CONCEPTS

Buffer- substance that can accept or donate hydrogen–Hemoglobin buffer–Bicarbonate : carbonic acid buffer

–Phosphate buffer

ACID-BASE CONCEPTS

Bicarbonate : carbonic acid buffer Most important buffer system Must maintain the balance of 20:1 Immediate but limited

ACID-BASE CONCEPTS

pHMeasures the hydrogen

concentration in a solutionMeasures the degree of acidity

and alkalinity

Acid and Base

pH measures the degree of acidity and alkalinity. It is inversely related to Hydrogen. Normal ph 7.35-7.45

Decreased pH- ACIDIC-increased Hydrogen—pH below 7.35

Increased pH- ALKALOSIS-decreased hydrogen—pH above 7.45

SUPPLY AND SOURCES OF ACIDS AND BASES

Sources of acids and bases are from:

1. ECF, ICF and body tissues

2. Foodstuff

3. Metabolic products of cells like CO2, lactic acids, ammonia

ABG analysis

This test helps to evaluate gas exchange in the lungs by measuring the gas pressures and pH of an arterial sample

ABG analysis Pre-test: choose site carefully, perform

the Allen’s test, secure equipments- syringe, needle, container with ice

Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial)

Post-test: Apply firm pressure for 5 minutes, label specimen correctly, place in the container with ice

Nursing care

Explain procedure to the client Obtain a heparinized syringe or vacuum

container tube Perform Allen’s test before obtaining

specimen (assessment of collateral circulation before radial artery puncture)

ABG analysis

ABG normal values PaO2 80-100 mmHg PaCO2 35-45 mmHg pH 7.35- 7.45 HCO3 22- 26 mEq/L O2 Sat 95-99%

Value Normal Acidosis

Alkalosis

pH 7.35-7.45 Below 7.35

Above 7.45

paO2 95-100 mmHg

SaO2 95-98%

paCO2 35-45 mmHg

Respiratory >45

Respiratory<35

HCO3 22-26 mEq/L Metabolic<22

Metabolic>26

remember

a high hydrogen acidic pH is low a low hydrogen alkalosis pH is

a high CO2may mean acidic a low CO2 may mean alkalosis

Dynamics of Acid and bases Acids and bases are constantly

produced in the body They must be constantly regulated CO2 and HCO3 are crucial in the

balance A ratio of 20:1 is maintained

(HCO3:H2CO3)

Respiratory and renal system are active in regulation

Ways to balance the acids and bases

ExcretionAcid can be excretedHydrogen can be excreted Bicarbonate can be excreted

ProductionBicarbonate can be producedHydrogen can be produced Acid can be produced

Neutralization Acids can be neutralized by bicarbonate Bicarbonate can be neutralized by acids

Regulation of acids and bases

Respiratory SystemRenal SystemBuffer System

The respiratory system compensates for metabolic problems

CO2 (acid) can be exhaled from the body to normalize the pH in ACIDOSIS

CO2 (acid) can be retained in the body to normalize the pH in ALKALOSIS

The kidney can compensate for problems in the respiratory system

The Kidney reabsorbs and generates Bicarbonate (alkaline) in ACIDOSIS

The Kidney can excrete H+ excess (Acidosis) to normalize the pH in ACIDOSIS

The kidney can excrete bicarbonate (alkali) in conditions of ALKALOSIS

The kidney can retain H+ (acid) in conditions of ALKALOSIS

Chemical buffers can also participate in the balance of acid-base

1. Carbonic acid- bicarbonate buffer 2. Phosphate buffer 3. protein buffer- ICF and hemoglobin

The action is immediate but very limited

FACTORS AFFECTING BODY FLUIDS, ELECTROLYTES AND ACID-

BASE BALANCE

AGE Infants have higher proportion of body

water than adults Water content of the body decreases

with age Infants have higher fluid turn-over due

to immature kidney and rapid respiratory rate

BASE BALANCE

GENDER AND BODY SIZE Women have higher body fat content

but lesser water content Lean body has higher water content

BASE BALANCE

ENVIRONMENT AND TEMPERATURE Climate and heat and humidity affect

fluid balance

BASE BALANCE

DIET AND LIFESTYLE Anorexia nervosa will lead to nutritional

depletion Stressful situations will increase metabolism,

increase ADH causing water retention and increased blood volume

Chronic Alcohol consumption causes malnutrition

BASE BALANCE

ILLNESS Trauma and burns release K+ in the

blood Cardiac dysfunction will lead to edema

and congestion

BASE BALANCE

MEDICAL TREATMENT,

MEDICATIONS AND SURGERY Suctioning, diuretics and laxatives may

cause imbalances

Fluid Imbalances

Fluid volume deficit– Occurs when the body lose BOTH

water and electrolytes– HYPOVOLEMIA

Fluid Imbalances

Fluid Volume excess – Occurs when the body retains BOTH

water and electrolytes– Called HYPERVOLEMIA

In Summary

A balance of Fluids, Electrolytes and Acids-Bases is necessary for health and homeostasis

Fluid is a solution of solvent and solutes The body fluid is located in TWO

compartments: Intracellular and Extracellular

In Summary

Most of body fluid is in the intracellular compartment

The movement of fluids is governed by four mechanisms: Diffusion, Osmosis, Filtration and Active transport

50-60% of body weight is water

In Summary

Electrolytes are charged particles in a solution

CATIONS are positive (Na, K, Mg, Ca) ANIONS are negative (Cl, HCO3, PO4) The concentration of these electrolytes

varies in the compartments

In Summary

Potassium (+) and Phosphates (-) =ICF

Sodium (+) and Chloride (-) = ECF

In Summary

Acids are hydrogen donors. Examples are carbonic acid, lactic acid, ketoacid

Alkalis are hydorgen acceptors. Examples are bicarbonate, NaOH

In Summary

Our body fluid is regulated by many mechanisms and body systems: Kidney, Gastro-intestinal tract and Endocrine

FLUID sources are INPUT coming from food, feeding and oral intake

FLUID OUTPUT can occur through excretion of urine, sweat and feces. insensible losses are water vapor

In Summary

The HYPOTHALAMUS regulates intake via the thirst mechanism

The KIDNEY regulates output via urine formation

Other hormones include ADH, aldosterone and ANF

In Summary Imbalances occur in the fluids and

electrolytes:– Hyper if excess– Hypo if deficient

Imbalances occur in the Acids and bases:– Acidosis or Alkalosis– Respiratory or Metabolic

Thank you!!!!

5. fluids and electrolytes ncm 101

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