Table of Contents Click on rectangle to get to content on topic

1. Body Solutions and Compartments Fluid Volume Excess and Deficit Table of ContentsClick on rectangle to get to content on topic Solute and Fluid Transport Diffusion and Osmosis Fluid Volume Regulation Filtration, Hydrostatic and colloidal osmotic forces Genetics, Inflammation, and Stress Effect on Fluid Balance

2. 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

3. The Ins and Outs of Fluid Balance Mary Farrington MSN Student-MSN 621 April 2010

4. 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 Trancellular Drag on cylinder to see if you are right Porth (2005) p 767

5. The Goal of Human Fluid Balance • To reach euvolemia where loss and intake of fluids is balanced • Pathology that can alter fluid balance

6. Compartments Where Fluid Resides Think about these electrolytes importance in your patient assessment • Extracellular fluid compartment (ECF)surrounds the cell • Intracellular fluid compartment (ICF) contained within cell ICF Major Ion Potassium ECF Cell ECF Major Ion Sodium Chloride Cell membrane ICF Heitz (2001) p.6

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

8. Extracellular Fluids Heitz ( p.6

9. Body Fluid CompartmentsClick on Box to see if your are right. What are the major compartments for body fluids? Extracellular Intravascular Transcellular Intracellular

10. 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

11. Cell Membrane Transport Molecules and Ions depend on transport mechanisms to go from ECF to ICF Extracellular compartment Volume (ECF) Cell membrane Cell Intracellular compartment Volume (ICF) Pot Porth p 762

12. Solute Movement • Solutes move by • Diffusion • Mediated passive transport (No energy required) • Mediated active transport (Energy required) Cell Cell membrane Extracellular compartment Volume (ECF) Intracellular compartment Volume (ICF) Porth p 762

13. 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 replenishment (ECF) Permeable cell membrane (ICF) M M Cell M Equal concentration Cell Low concentration Permeable cell membrane (ICF) (ECF) Equal concentration High concentration Porth p 762

14. 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) Carrier protein glucose Low concentration Heitz p.10

15. 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 CP Semipermeable Cell membrane Cell (ECF) High concentration gradient on membrane (ICF) Porth p.75

16. Active Transport: Sodium Potassium Pump • Maintains the differences between intracellular & extracellular Na & K. (Very active in the heart) ATP (ECF) CP k Cardiac Cell k Na Na (ICF) Na http://quizlet.com/1916557/fluid-balance-flash-cards

17. Quiz :Is it A, B, or CClick on Shape to See if You Are Right Protein Carrier A concentration difference between high level of concentration and low level of concentration B Diffusion B necessary for active transport and facilitated diffusion C Concentration Gradients C particles or molecules move area of high concentration to low concentration until BALANCED A

18. Water Movement Cell membrane • Osmotic forces • Osmosis • Osmotic Pressure • Oncotic Pressure • Isotonic • Hypotonic • Hypertonic • Filtration & Hydrostatic pressure Intracellular compartment Volume (ICF) Cell Extracellular compartment Volume (ECF) Porth p 762

19. Osmosis-Passive Movement of water across semipermeable membrane from an area of lower solute concentration to higher solute concentration 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 Extracellular compartment Volume (ECF) water Intracellular compartment Volume (ICF) Cell Cell membrane Greater number of particles-Less water Fewer particles-More water Porth p.762

20. Osmosis Pressure water Hydrostatic pressure (HP) required to stop osmotic flow of water HP Extracellular compartment Volume (ECF) water water Cell Intracellular compartment Volume (ICF) Greater number of particles-Less water Semipermeable Cell membrane Fewer particles-More water Porth p 762

21. 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

22. Osmolality of Solutions • Isotonic-same osmolality as body fluids • Hypotonic-osmolality less then body fluids • Hypertonic-osmolality greater than body fluids 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. Heitz p.13

23. 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

24. 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. 30mmHg 10mmHg IF pressure -3 mm Hg Porth p 766 Picture retrieved from Dreamstime March 25,2010

25. 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 30mmHg 10mmHg Interstitial Fluid pressure -3 mm Hg Porth p.766 Picture retrieved with approval Dreamstime March 25,2010

26. Colloidal Osmotic PressureResponsible for moving fluid back to capillary with colloids. Assists in retaining fluids in plasma Click here to return to FVE 28mmHg 28mmHg IF pressure 8 mm HG Porth p 766 Picture retrieved with approval Dreamstime March 25,2010

27. Lymph SystemExcessive 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

28. Quiz :Is it A, B, or CClick on Rectangle to See if You Are Right Filtration A Pressure created by weight of fluid. Impacted by distance from heart and amount of fluid. B Hydrostatic Pressure 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 Lymphatic Drainage C A http://quizlet.com/1916557/ fluid-balance-flash-cards

29. 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) • Increased corticosteroid level Click here Porth p 778-779

30. Fluid Volume Excess Assessment and Management Porth p 778-779

31. FVE Outcomes/Interventions http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/

32. 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

33. Fluid Volume Deficit(FVD) Assessment and Management Porth p 778-779

34. FVD Outcomes/Interventions http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/

35. 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

36. Regulation of Fluid Volume Excess Increased vascular volume or increased blood pressure leading to increased atrial stretch Increasedrelease 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

37. Regulation of Fluid Volume Deficit Loss of hypotonic fluid Increased plasma osmolality Decreased plasma volume Increased thirst Decreased cardiac output Increased ADH Secretion Decreased blood pressure Decreased renal perfusion Increased reabsorption of filtered water by the kidney Decreased water and sodium filtered 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

38. Regulation of Fluid Volume Deficit-Hemorrhage 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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. • 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 answer 3. What monitoring will be important for the patient in post operative period? Click 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) Increase Consideration of preop fluid status, Surveillance of cardio respiratory status, Surveillance of urine output, goal of I=O, Daily weight. microsoft clip art

49. 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. • 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 microsoft clip art

50. 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