Table of ContentsClick on rectangle to get to content on topic

Body Solutions and Compartments

Solute and Fluid TransportDiffusion and Osmosis Fluid Volume Regulation

Fluid Volume Excess and Deficit

Genetics, Inflammation, and Stress Effect on Fluid BalanceFiltration, Hydrostatic and

colloidal osmotic forces

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 FarringtonMSN Student-MSN 621

April 2010

QuestionEdema 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 Trancellular

Porth (2005) p 767

Drag on cylinder to see if you are right

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

cell• Intracellular fluid compartment (ICF) contained

within cell

CellICF Major

Ion Potassium Cell membrane

Heitz (2001) p.6

ICF

ECF

ECF Major Ion Sodium

Chloride

Think about these electrolytes importance in your patient assessment

Body Fluid Composition and Compartments

Intracellular

Extracellular

The 60-40-20 Rule: 60 % of body weight is water40% of body weight is intracellular fluids20% of body weight is extracellular fluid

Cell

Patlak (1999) Department of Physiology, University of Vermont.Picture permission of Dreamscape Download

Body fluid composition is water and dissolved substances consisting of solutes and electrolytes

Extracellular Fluids

Heitz ( p.6

Body Fluid CompartmentsClick on Box to see if your are right.

What are the major compartments for body fluids?

Extracellular Intravascular

TranscellularIntracellular

Cell Membrane

Primary barrier to movement of substances between ECF and ICF

Cell

Extracellular compartment Volume (ECF)

Cell membrane

Intracellular compartment Volume (ICF)

Heitz p.8

Cell Membrane Transport Molecules and Ions depend on transport

mechanisms to go from ECF to ICF

Cell

Extracellular compartment Volume (ECF) Cell membrane

Intracellular compartment Volume (ICF)

Porth p 762

Pot

Solute Movement• Solutes move by

– Diffusion – Mediated passive transport (No energy required)– Mediated active transport (Energy required)

CellExtracellular compartment Volume (ECF)

Cell membrane

Intracellular compartment Volume (ICF)

Porth p 762

Passive Transport: DiffusionMolecules move along concentration gradient

across cell membrane until there is a balanced concentration and gradient is gone. Example: diffusion of oxygen in alveoli allowing replenishment

Cell

(ECF)

Permeable cell membrane (ICF)

Porth p 762

High concentration

Low concentration

Permeable cell membrane

(ECF) (ICF)

CellEqual concentration

Equal concentration

Mediated Passive Transport (Facilitated Diffusion)Large molecules moves along concentration gradient

and are assisted by the carrier protein to cross cell membrane. Example glucose

Cell(ECF)

(ICF)

Heitz p.10

Lowconcentration

High concentration Semi permeable Cell membrane

glucose

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

Cell

(ECF)

(ICF)

Semipermeable Cell membrane

Porth p.75

M

ATP

High concentration gradient on membrane

Active Transport: Sodium Potassium Pump

• Maintains the differences between intracellular & extracellular Na & K. (Very active in the heart)

Cardiac Cell

(ECF)

(ICF)

http://quizlet.com/1916557/fluid-balance-flash-cards

ATP

k

Na

NaNa

k

Quiz :Is it A, B, or C

Click on Shape to See if You Are Right

Concentration Gradients

Protein Carrier

Aconcentration difference

between high level of concentration and low level

of concentration

Diffusion

Bnecessary for active

transport and facilitated diffusion

Cparticles or molecules move area of high concentration to

low concentration until BALANCED

A

C

B

Water Movement• Osmotic forces

– Osmosis– Osmotic Pressure

• Oncotic Pressure– Isotonic– Hypotonic– Hypertonic

• Filtration & Hydrostatic pressure

Cell

Extracellular compartment Volume (ECF)

Cell membrane

Intracellular compartment Volume (ICF)

Porth p 762

Osmosis-PassiveMovement of water across semipermeable membrane

from an area of lower solute concentration to higher solute concentration

Cell

Extracellular compartment Volume (ECF)

Cell membrane

Intracellular compartment Volume (ICF)

Porth p.762

Fewer particles-More water

Greater number of particles-Less water

NoticeOsmosis 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

Osmosis PressureHydrostatic pressure (HP) required to stop

osmotic flow of water

Cell

Extracellular compartment Volume (ECF)

Semipermeable Cell membrane

Intracellular compartment Volume (ICF)

Porth p 762

Fewer particles-More water

Greater number of particles-Less water

HP

water

OsmolarityMeasure of solutions ability to create osmotic

pressure of force and affect water movement

Heitz p.12 picture microsoft clip art

Serum OsmolalityNumber of solutes per KG of water IN the bodySerum Isotonic concentration=275-295 mOsm/KgSerum Hypotonic concentration=<275 mOsm/KgSerum Hypertonic concentration=>295 mOsm/Kg

Osmolality of Solutions

• Isotonic-same osmolality as body fluids• Hypotonic-osmolality less then body fluids• Hypertonic-osmolality greater than body fluids

Heitz p.13

0.9% NACL

0.45% NACL

D5LR

Do you know a example of IV solution for each osmolality. Click on word osmolality to see if you are

right.

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

FiltrationMovement 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.

Porth p 766 Picture retrieved from Dreamstime March

25,2010

30mmHg 10mmHg

IF pressure -3 mm Hg

Hydrostatic PressurePressure created by weight of fluid and is impacted by distance from heart pump and amount of fluid. Moves fluid out of capillary bed

Porth p.766Picture retrieved with approval Dreamstime March 25,2010

30mmHg 10mmHg

Interstitial Fluid pressure -3 mm Hg

Colloidal Osmotic PressureResponsible for moving fluid back to capillary with colloids. Assists in retaining fluids in plasma

Porth p 766Picture retrieved with approval Dreamstime March 25,2010

28mmHg

IF pressure 8 mm HG

28mmHg

Click here to return to FVE

Lymph SystemExcessive interstitial fluid that can be returned to circulatory system

Porth p. 767 Picture retrieved with approval Dreamstime March 25,2010

Excessive fluid and proteins

not absorbed

in capillary

Quiz :Is it A, B, or C

Click on Rectangle to See if You Are Right

Lymphatic Drainage C

Filtration APressure created by weight

of fluid. Impacted by distance from heart and

amount of fluid.

Hydrostatic Pressure B

Excessive fluid and proteins not absorbed in capillary

Movement of water and solutes from an area of high hydrostatic pressure to an

area of low hydrostatic pressure

http://quizlet.com/1916557/fluid-balance-flash-cards

B

A

C

Fluid Volume Excess(FVC)-Increase In ECF Compartment VolumeWhy 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) – Increased corticosteroid level

Porth p 778-779

Click here

Fluid Volume Excess Assessment and Management

Porth p 778-779

FVE Outcomes/InterventionsPatient 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 VolumeWhy 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

Porth p 778-779

FVD Outcomes/InterventionsPatient 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

Heitz 18. microsoft clip art

Increased vascular volume or increased blood pressure leading to increased atrial stretch

Increased release of atrial natriuretic factor

Direct vasodilatationIncreased excretion of NA + H2O by the kidney secondary to increased filtration

Decreased release of ADH

Decreased renin/angiotensin/aldosterone

Decreased vascular volume and or blood pressure

Regulation of Fluid Volume Deficit

Heitz 16. microsoft clip art

Loss of hypotonic fluidDecreased plasma volume

Decreased cardiac output

Decreased water and sodium filtered by the kidney

Increased renin release

Decreased renal perfusion

Increased plasma volume and decreased osmolality

Increased plasma osmolality

Decreased blood pressure

Decreased sodium and water excretion

Increased volume of sodium and water

Increased angiotensin I/II

Increased aldosterone secretion by adrenal cortex

Increased thirst

Increased water intake

Increased reabsorption of filtered water by the kidney

Increased ADH Secretion

Decreased water excretion

Regulation of Fluid Volume Deficit-Hemorrhage

Heitz 15. microsoft clip art

Decreased arterial pressure(decreased renal perfusion)

Release of renin by the kidneys

Increased arterial pressure

Release of aldosterone

Renin substrate Angiotensin I converting enzyme ( lung)

Hemorrhage

Vasoconstriction

Angiotensin II

Retention of sodium and water

Increased vascular volume

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

Click on box for

hormone name

Aldosterone

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 I76 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

2. Would urine osmolality increase or decrease if patient dehydrated?Click for answer3. What monitoring will be important for the patient in post operative

period?Click for answer

microsoft clip art

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)

Consideration of preop fluid status, Surveillance of cardio respiratory status, Surveillance of urine output, goal of I=O, Daily weight.

Increase

Case Study IIA 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.

microsoft clip art

1. What monitoring will be important for the patient in the post operative period? Click for answer

2. If urine output drops what assessment information would you want to report to physician? 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

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

References

• 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