FLUIDS AND ELECTROLYTES

Presented by:
John Henry O. Valencia, RN, RM
Master of Arts in Nursing
Case Study:
Youre taking report on John Miller, an American who had a
colectomy 2 days ago because of a ruptured diverticulus. You learn
that his heart rate has increased over the past 24 hours, yet his
blood pressure has been gradually falling and hes had marginal
urine output (30mL/Hour). Mr. Miller weighs 4kgs. More than before
surgery and he has generalized edema.
The health care team has decided not to increase Mr. Millers
maintenance IV infusion of lactated ringers solution. The nurse from
the previous shift says not to worry: His fluid will mobilize and hell
make urine soon.
Not sure what she means by that, you head off
to check out Mr. Millers condition for yourself.
During your assessment, you find that Mr. Miller has 2+
edema, warm skin and palpable peripheral pulses. His heart
rate is 108bpm, his blood pressure is 110/60mmHg and his
urine output remains marginal at 30mL/hr. Mr. Millers
abdomen is firm and distended, with hypoactive bowel sounds.
He says his pain is well controlled due to the pain medications
that was given.
Mr. Millers edema indicates that he has enough fluid in
his body. But his vital signs and urine output seems to tell a
different tale hypovolemia. How can you reconcile these
differences?
FLUIDS 101
Fluids brings nutrition and oxygen into the cells and remove wastes.
CELLS
ICF
ECF
Fluids within cells of body [major
intracellular electrolytes:
Potassium(K+), Magnesium (Mg +2)
Fluid outside cells; [major extracellular electrolytes:
Sodium (Na+), Chloride(Cl-)]; this is where
transportation of nutrients, oxygen, and waste
products occurs
Interstitial
Intravascular Transcellular:
Fluid between most cells
Fluid within blood vessels;
also called plasma
fluids of body including
urine, digestive
secretion,
cerebrospinal, pleural,
synovial, intraocular,
gonadal, pericardial
On the Move:
(i.e. movement of solutes, solvents across different extracellular locations)
OSMOSIS
From lower concentration to higher
concentration
Normal Osmolality of ICF and ECF: 275 295
mOsm/kg
DIFFUSION
From higher concentration to lower
concentration
ACTIVE TRANSPORT
molecules move across cell membranes against
concentration gradient; requires energy, e.g. Na
K pump

FLUID PRESSURES
HYDROSTATIC PRESSURE:
pushes fluid out of vessels into tissue space;
higher to lower pressure
due to water volume in vessels; greater in
arterial end
swelling: varicose veins, fluid overload, kidney
failure & CHF

OSMOTIC / ONCOTIC PRESSURE:
pulls fluid into vessels; from weaker
concentration to stronger concentration
from plasma proteins; greater in venous end
swelling: liver problems, nephrotic syndrome
Average Value: 25mmHg
Mechanism of Regulating Body Fluids
and Electrolyte Balance
THIRST MECHANISM
Conscious desire for water
Major factor that determines
fluid intake
Initiated by the
osmoreceptors in
hypothalamus that are
stimulated by increase in
osmotic pressure of body
fluids
Also stimulated by a decrease
in the blood pressue through
the receptor of baroreceptor.

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM
An Endocrine Pathway that regulates
fluid balance (extracellular volumes
including blood plasma, lymph and
interstitial fluids) as well as arterial
vasoconstriction.

Activation of RAAS leads to increase
fluid retention and increased blood
pressure

Many drugs are available which
interrupt different steps in the
system; they lower blood pressure
and reduces stress on the heart

Hypotension / Hypovolemia
Renal Hypoperfusion
Pressure sensed by cardiac
& Arterial Baroreceptors
Circulating
Catecholamines
Activity of Sympathetic nerves
innervating afferent arteriole
Stimulation of afferent arteriole
1-adrenergic receptors
Stretch of
baroreceptors in
afferent arteriole
wall
NaCl delivery to
Macula Densa
Renin Release from JGC in the
afferent arteriole = Angiotensin II
Liver normally synthesizes
angiotensinogen at a basal
rate, releasing it into the
blood
Angiotensinogen

Angiotensin I

Angiotensin II

RENIN
ACE
Angiotensin II constricts efferent arteriole
Fraction of water filtered out
Hydrostatic Pressure in Glomerulus
Protein concentration
of blood remaining in
glomerulus
Concentrated blood
moves from glomerulus
to peritubular
cappilaries
in peritubular
cappilaries
Peritubular
hydrostatic
pressure
GLOMERULOTUBULAR BALANCE
(Intrinsic renal mechanism not unique to RAAS)
*Only part of the mechanism represented below
Aldosterone
secretion from
adrenal cortex
Activity of NHE3
transporters in the
PCT
Systematic
Arteriolar
vasoconstriction
Insertion of ENaC
in principal cells
of CD
Reabsorption of Na into
the blood, drawing H2O
into the blood by
osmosis
Reabsorption of H2O directly into the
bloodstream
Excretion of
Potassium
BP
ACE: Angiotensin
Converting Enzymes
CD: Collecting Duct
PCT: Proximal
Convuluted Tubules
NHE3: Sodium-
Hydrogen Exchanger
ENaC: Epithelial
Sodium Channel
: Oncotic Pressure

LEGEND:
PHYSIOLOGY OF RENIN-
ANGIOTENSIN-ALDOSTERONE
SYSTEM (RAAS)

Angiotensinogen Angiotensin I Angiotensin II
Sympathetic division of ANS
Reabsorption of Na
+
, Cl
-
,
water; excretion of K
+

Aldosterone
Arterial
Vasoconstrictio
n
Vasopressin (ADH)
Water Reabsorption in
the collecting Duct
Angiotensin Converting Enzyme (ACE)
Renin
Physiology of
Angiotensin Conversion
in RAAS
Atrial Natriuretic Peptides
Stored in the cells of the Atria

Counteracts the effects of RAAS
by decreasing blood pressure
and reducing intravascular
blood volume

Suppresses serum renin

Decreases aldosterone release
from the adrenal glands

Increases GFR which increases
excretion of sodium and water

Vasodilatation
(causes afferent arterial vasodilation
and relaxes mesangial cells)
(inhibits sympathetic output
from cardiovascular center)
Amount Intake = Amount Eliminated
To eliminate waste produced
by metabolism, at least 500ml
of urine must be excreted
everyday.
DISORDERS
Disorder of Water and Sodium Metabolism
Sodium is the primary cation in the extracellular fluid
sodium content determine the osmolality in ECF
while osmolality gradient across cell membrane is the
driving force of water movement so disturbance of
sodium is always accompanied with water
disturbance
BACK to Mr. Miller:
Mr. Miller is Experiencing THIRD-
SPACE FLUID SHIFTING

Please see PATHOPHYSIOLOGIC
BASIS on your handouts.