FLUIDS

ISOTONIC SOLUTIONS

• SAME CONCENTRATION of solutes as blood plasma

• Restore Vascular volume

• Tonicity similar to plasma

0.9 % NaCl (Sodium Chloride)

• Normal saline (NS)

• Na 154 mEq/L

• Cl 154 mEq/L

• 308 mOsm/L

0.9 % NaCl

WHAT TYPE OF SOLUTION IS USED IN THESE:

• Hypovolemic states

• Resuscitative efforts

• Shock

• Diabetic ketoacidosis

• Metabolic alkalosis

  • Increases in HCO3 caused by vomiting, hypovolemia, hypokalemia, diuretic use

• Hypercalcemia

DKA

happens when blood sugar is very high and acidic substances called ketones build up to dangerous levels in your body.

sodium, potassium, phosphates, water

The hyperglycemia-induced osmotic diuresis DEPLETES ?, ?, ?, and ?.

hypertonic

0.9% NaCl becomes ? when mixed with 5% dextrose

0.9% NaCl

What is the only compatible solution with blood products?

Lactated Ringer’s Solution

Contains multiple electrolytes in roughly the same concentration as found in plasma tonicity similar to plasma

Lactated Ringer’s Solution (HARTMANN’S SOLUTION)

• Na 130 mEq/L

• K 4 mEq/L

• Ca 3 mEq/L

• Cl 109 mEq/L

• Lactate 28 mEq/L 

• 274 mOsm/L

Lactated Ringer’s Solution

WHAT TYPE OF SOLUTION IS USED IN THESE:

• Hypovolemia

• Burns

• Fluid loss as bile or Diarrhea

• Acute blood loss

• lactic acidosis

• 7.5

• renal failure

DO NOT USE LR IN:

• ?

• pH of ?

• ?

  • Contains K and can cause hyperkalemia

D5W

• NO ELECTROLYTES, ONLY SIMPLE SUGAR

• 50 g of dextrose

D5W

WHAT TYPE OF SOLUTION IS USED IN THESE:

• Aids in renal excretion of solutes

• Hypernatremia

  • Because this solution does not contain electrolytes, it can reduce Na concentration in the blood

• Fluid loss

• Dehydration

• postoperative

  • increases, FVE

• FVD

• head injury

• resuscitation

• Peripheral circulatory

• Anuria

• Hypokalemia

DO NOT USE D5W IN:

• Excessive volumes in the early ? period (when the ADH secretion is increased due to stress reaction.)

  • ADH (decreases / increases) the blood volume, may result to ? and cardiac overload to older adults

• Solely in treatment of ? because it dilutes plasma electrolytes concentration and may cause imbalances in the ECF and ICF

• Clients with ?

  • May cause increased in ICP and cerebral edema, reduce serum sodium and increases brain water

• For fluid ? cause it can result to Hyperglycemia (50% glucose)

• Use with caution in px with renal or cardiac disease - fluid volume overload.

• ? collapse because it is an electrolyte free solution

• ?- for px with Na deficit

• ?

D5W

• isotonic on initial administration but provides free water when it is metabolized, expanding intracellular and extracellular volumes.

hypotonic

Over time, D5W without NaCl can cause water intoxication (intracellular fluid volume excess (FVE)) because the solution is ?.

T

T or F: D5W can cause water intoxication over time because water will go inside the cells, causing it to swell.

0.45% NaCl

• Half-strength saline

• Na 77 mEq/L

• Cl 77 mEq/L

• 154 mOsm/L

0.45% NaCl

• Have a lesser concentration of solutes

• Osmolality of a solute is less than that of the plasma

• Provides Na, Cl, and free water

• Promotes waste eliminations by the kidneys

• Solution becomes HYPERTONIC when mixed with 5% dextrose.

0.45% NaCl

WHAT TYPE OF SOLUTION IS USED IN THESE:

• Hypertonic dehydration

  • Losing too much water while keeping too much salt in the fluid outside your cells

• Na and Cl depletion

• Gastric fluid loss

  • suctioning, lavage, vomiting

hypotonic

0.45% NaCl is an example of what solution?

• third-space, ICP

DO NOT USE 0.45% NACL IN:

• Clients with ? fluid shifts or to clients with ↑?

  • Administer cautiously, because it can cause fluid shifts from the vascular system into cells, resulting in cardiovascular collapse and increased intracranial pressure.

HYPERTONIC SOLUTIONS

• have a greater concentration of solutes than plasma

  • A cell has less solute than the surrounding solution 

• the osmolality of a solute is more than the plasma 

3% NaCl

•  Hypertonic saline, any crystalloid solution containing more than 0.9% saline

3% NaCl

• hypertonic saline

• Na 513 mEq/L

• Cl 513 mEq/L

• 1026 mOsm/L

3% NaCl

• ↑ ECF volume, ↓ cellular swelling

  • Water will come out from the cell going to the ECF

• Removes ICF excess

• Treat hyponatremia

• Administered slowly and cautiously

  • Can cause intravascular volume overload and pulmonary edema

• No calories

5% NaCl

• Na 855 mEq/L

• Cl 855 mEq/L

• 1710 mOsm/L

5% NaCl

WHAT TYPE OF SOLUTION IS USED IN THESE:

• treat symptomatic hyponatremia

• administer slowly and cautiously

• no calories

COLLOID SOLUTIONS

• Dextran in NS or 5% of D5W

  • May be administered with NS (Na&Cl)

• Or D5W for it to become isotonic

• Plasma 

• Albumin

• Hespan (a synthetic plasma expander)

DEXTRAN

• Volume or plasma expander 

  • providing volume for the circulatory system (ECF)

• Impair coagulation

• Remains in circulatory system up to 24 h

• Treat hypovolemia in early shock

  • Rapid heartbeat, weakness, confusion, no urine output, ↓ BP, cool, clammy skin  

• Improves microcirculation 

  • By decreasing RBC aggregation or clumping

• DEXTRAN 70- HIGH MOLECULAR WEIGHT

• Higher viscosity

• It works by restoring blood plasma lost through severe bleeding. 

• Severe blood loss can decrease oxygen levels and can lead to organ failure, brain damage, coma, and possibly death

• Specifically used for shock such as that caused by bleeding or burns when blood transfusions are not quickly available

• Not a substitute for blood or blood products

H2CO2 acid, base

?& ? content influence the pH

• Chemical regulation

• Respiratory & renal regulation

Normal plasma pH is maintained by

• ? (bicarbonate-carbonic acid buffer system) 20:1

  • Adding/ removing H⁺ ions

• ?

  • Releasing & conserving CO₂

  • Retaining or excreting HCO₃

Bicarbonate buffer system

• mixture of carbonic acid (H₂CO₃) and its salt, sodium bicarbonate (NaHCO₃), potassium or magnesium bicarbonates

• this system is the only important ECF bufffer

• carbonic acid

• decreases

If strong acid is added to the bicarbonate buffer system:

• Hydrogen ions released combine with the bicarbonate ions and form ? (a weak acid)

• The pH of the solution ? only slightly

• sodium bicarbonate

• increases

If strong acid is added to the bicarbonate buffer system:

• It reacts with the carbonic acid to form ? (a weak base)

• The pH of the solution ? only slightly

Phosphate buffer system

• Nearly identical to the bicarbonate system

• Its components are:

  • Sodium salts of dihydrogen phosphate (NaH2PO4¯), a weak acid

  • Monohydrogen phosphate (Na2HPO42¯), a weak base

• This system is an effective buffer in urine and intracellular fluid

Protein buffer system

• Plasma and intracellular proteins are the body’s most plentiful and powerful buffers

• Some amino acids of proteins have:

  • Free organic acid groups (weak acids)

  • Groups that act as weak bases (e.g., amino groups)

  • Amphoteric molecules are protein molecules that can function as both a weak acid and a weak base

7.35-7.45

normal pH

80-100 mmHg

normal PaO2

35-45 mmHg

normal PaCO3

-2 to +2

normal bases excess

95-98%

normal o2 saturation

Metabolic Acidosis

• There is increased organic acids (other than carbonic acid) or decreased bicarbonate

• CAUSES

  • Anaerobic metabolism (formulation of byproduct lactic acid) = shock & cardiac arrest

  • Starvation, diabetic ketoacidosis = fatty acids accumulation

  • Kidney failure (cannot reabsorbed HCO₃)

  • Aspirin overdosage, profuse diarrhea, intestinal wound drainage (HCO₃ is lost)

Metabolic Acidosis

ASSESSMENT FINDINGS FOR ?:

• Kussmaul’s breathing (deep & rapid breathing)

• Anorexia, N & V, headache, confusion, flushing, lethargy, malaise, drowsiness, abdominal pain or discomfort, weakness

• Cardiac dysrhythmias can develop, force of cardiac contraction can be weakened

• Stupor & coma (severe cases)

• ABG: ⭣pH, ⭣HCO3 (N to ⭣PaCO2)

• Treating, replacing

• bicarbonate

MEDICAL MANAGEMENT FOR METABOLIC ACIDOSIS:

• ? the cause & ? F&E that may have been lost

• IV ? (severe cases)

Metabolic Alkalosis

• There is increased bicarbonate or decreased H⁺ ion concentrations

  • Excessive oral or parenteral use of bicarbonate-containing drugs or alkaline salts

  • Vomiting, prolonged gastric suctioning, hypokalemia, hyperaldosteronism (retention of sodium bicarbonate)

Metabolic Alkalosis

ASSESSMENT FINDINGS FOR ?:

• Anorexia, N & V, circumoral paresthesias, confusion, carpo pedal spasm, hypertonic reflexes, tetany

• ⭣ RR (compensatory effort)

• ABG: ⭡pH, ⭡HCO3 (N to ⭡ PaCO₂)

• cause

• potassium

• NaCL

MEDICAL MANAGEMENT FOR METABOLIC ALKALOSIS:

• Eliminating the ?

• Prescribing ? to correct hypokalemia

• ? if there is rapid ECF volume depletion.

Respiratory Acidosis

ASSESSMENT FINDINGS FOR ?:

• Client may breathe slowly or irregularly, or stop breathing

• Decreased expiratory volumes

• Tachycardia (dysrhythmias), Cyanosis

• Behavioral changes- mental cloudiness, confusion, disorientation, hallucinations (accumulation of CO₂)

• Tremors, muscle twitching, flushed skin, headache, weakness, stupor, coma

• ABG: ⭣pH, ⭡PaCO2 (N to ⭡HCO₃)

• individualized

• Mechanical ventilation 

• NaHCO₃

• Bronchodilators

MEDICAL MANAGEMENT FOR RESPIRATORY ALKALOSIS:

• Treatment is ? depending on the cause of imbalance

• ? (may be necessary to support respiratory function)

• IV ? if ventilation efforts do not adequately restore a balanced pH

• ?, antibiotics, airway suctioning

Respiratory Alkalosis

• Results from carbonic acid deficit

  • Anxiety, high fever, thyrotoxicosis, early salicylate (aspirin) poisoning,  mechanical ventilation

Respiratory Alkalosis

ASSESSMENT FINDINGS FOR ?:

• ⭡ RR

• Lightheadedness, numbness & tingling of the fingers & the toes, circumoral paresthesias, sweating, panic, dry mouth, convulsions (severe cases)

• ABG: ⭡pH, ⭣PaCO₂ (N to ⭣ HCO₃)

50-60%

? to ? of the body weight is water

40%

Percentage of intracellular fluids

20%

• 15%

• 5%

Percentage of extracellular fluids

• Percentage of interstitial fluids

• Percentage of intravascular fluids

Transcellular fluids

What are these fluids called?

• CSF

• Pleural

• Peritoneal

• Synovial

ECF

most solutes are found where?

11-12 L

How many liters of fluid are in the interstitial space? 

1 L

How many liters of fluid are in the transcellular fluid compartment?

3 L

How many liters of fluid are in the intravascular space?

intravascular space

At what space is the blood or serum exam taken?

interstitial, transcellular

NORMAL HEMODYNAMICS:

• mvmt of fluid from the ? space to the ? space

2,500ml/day (1500-3000 ml/day)

Average oral fluid intake in a healthy adult?

• 100

• 50

• 15

Daily fluid intake (Standard formula)

• ? ml/kg for the 1st 10 kg of wt, plus

• ? ml/kg for the next 10 kg of wt, plus

• ? ml/kg per remaining kg of wt

2500ml/day

Average fluid loss amounts to ? counterbalancing the input to maintain equilibrium

1500 ml/day

Normal urine output per day

30-50 ml/hr

Normal urine output per hour

0.5-1ml/kg/hr

Normal urine output per kg per hr

200 ml

How much fluid is lost during bowel elimination

K+, PO-4, Mg++

The major ICF é are ?, ?, and ?

Na+, HCO-3, Cl-

The major ECF é are ?, ?, and ?

OSMORECEPTORS

• Primarily, fluid volume is regulated by intake (thirst) and output (urine)

• Specialized neurons in the hypothalamus

• Highly sensitive to serum osmolality

• Triggers thirst promoting increased fluid intake

• Also sensitive to changes in BV & BP through the info relayed by baroreceptors (stretch)

Increased osmolality

osmoreceptors stimulates hypothalamus to synthesize ADH

Decreased osmolality

Serum osmolality when ADH is inhibited

700 ml

Osmoreceptors triggers thirst when ECF volume decreases by ~? (2% of body weight)

• 10%

• 90 mmHg

• RA

ADH RELEASE

• A decrease in BV by ?

• Systolic BP falls below ?

• ? is underfilled

• ADH is suppressed when BV, BP increases and RA is overfilled

Renin-Angiotensin-Aldosterone System

• Decreased ECF (Blood volume) and Decreased BP

• Triggers the release of Renin Angiotensinogen

• Release Angiotensin I - converted to Angiotensin II that acts upon the Blood vessels (Vasoconstriction) and Adrenal gland (cortex)

• ANP, BNP

• RENIN, ALDOSTERONE, ADH

NATRIURETIC PEPTIDS

• Overstretching (atrial & ventricular walls) 🡪 ? & ? are released

• ANP & BNP inhibit the release of ?, ?, and ? = ⭣Blood volume

  • “POTENT diuretic”

  • “Na-wasting”

  • (-) thirst

OSMOSIS

• Movement of water/liquid/solvent across a semipermeable membrane from a lesser concentration to a higher concentration

• SOLVENT is transported

Osmotic pressure

the power of a solution to draw water toward an area of greater concentration

Colloidal osmotic pressure

the osmotic pull exerted by plasma proteins (e.g., albumin, globulin, fibrinogen)

FILTRATION

• Movement of both solute and solvent across a semipermeable membrane from an area of higher pressure to lower pressure

• BOTH SOLUTE and SOLVENT are transported

• If HP > OP

Hydrostatic pressure

• the pressure exerted by the fluids within the closed system

• pushes water

• controls mvmt that goes out

• controlled by the BP

180 L

How much fluid from the blood is filtered by the kidney each day?

DIFFUSION

• Movement of particles, solutes, molecules from an area of higher concentration to an area of a lower concentration through a semipermeable membrane

• SOLUTE is transported

T

T or F: Wide difference in conc. has a faster rate of diffusion

F

T or F: ↑ temperature = ↓ rate of diffusion

FACILITATED DIFFUSION

• Require assistance from a carrier molecule to pass through a semipermeable membrane

• SOLUTE is transported

• Ex: insulin-glucose

ACTIVE TRANSPORT

• Movement of solute from lower concentration to higher concentration using energy (ATP)

• SOLUTE is transported

• Ex: Na-K pump

  • K is abundant is the ECF. For it to be transported, Na-K pump and ATP is needed

sodium

• maintenance of plasma and interstitial osmolarity 

• generation and transmission of action potentials

• maintenance of acid-base balance

• maintenance of electroneutrality

potassium

• regulation of intracellular osmolality

• maintenance of electrical membrane excitability

• maintenance of plasma acid-base balance

calcium

• cofactor in blood-clotting cascade

• excitable membrane stabilizer

• adds strength/density to bones and teeth

• essential element in cardiac, skeletal, and smooth muscle contraction

chloride

• maintenance of plasma acid-base balance

• maintenance of plasma electroneutrality

• formation of hydrochloric acid

magnesium

• excitable membrane stabilizer

• essential element in cardiac, skeletal, and smooth muscle contraction

• cofactor in blood-clotting cascade

• cofactor in carb metabolism

• cofactor in DNA and protein synthesis

phosphorus

• activation of B-complex vitamins

• formation of adenosine triphosphate and other high-energy substances 

• cofactor in carb, protein, and lipid metabolism

Na, Ca, Cl

?, ?, ? concentration are higher in ECF

K, Mg, PO4

?, ?, ? concentrations are higher in ICF

6-14 g

Average dietary intake of sodium is about ? to ? per day

+, -

⭡ serum Na = (+ / -) aldosterone, (+ / -) ADH & NP

+, -

↓ serum Na = (+ / -) aldosterone, (+ / -) ADH & NP