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Water forms most of the fluid part of the body. In human beings, the total body water varies from 45 to 75% of body weight. In a normal young adult male body contains 60-65% of water and 35-40% of solids. In a normal adult female, the water is 50-55% and solids are 45-50%. In females, the water is less because of more amount of subcutaneous adipose tissue. In thin persons, water content is more than in obese persons. In old age, water content is decreased due to increase in adipose tissue. The total quantity of body water in an average human being Weighing about 70 kg is about 40 litres. COMPARTMENTS OF BODY FLUIDS Total water in the body is about 40 litres. It is distributed into two major fluid compartments namely : 1. Intracellular fluid (ICF) forming 55% of the total body water (22litres). 2. Extracellular fluid (ECF) forming 45% of the total body water( 18 litres). Extracellular fluid is divided into 5 subunits:1) Interstitial fluid and lymph 2) Plasma 3) Fluid in bones
4) Fluid in dense connective tissue like cartilage 5) Transcellular fluid that includes: a. Cerebrospinal fluid b. Intraocular fluid c. Digestive juices d. Serous fluid- intra pleural fluid - Pericardial fluid - peritoneal fluid e. Synovial fluid in joints and f. Fluid in urinary tract The volume of Interstitial fluid is about 12 liters. The volume of plasma is about 2.75 liters. The volume of other subunit of extracellular is about 3.25 liters. Water moves between different compartments. COMPOSITION OF BODY FLUIDS Body fluids contains water and solids. Solids are organic and inorganic.
Organic substancesOrganic substances are glucose, amino acids, proteins, enzymes, fatty acids, lipids and hormones. Inorganic substancesInorganic substances present in body fluids are sodium, potassium, calcium, magnesium, chloride, bicarbonate, phosphate and sulfate. Extracellular fluid contains large quantity of sodium, chlorides, bicarbonate, glucose, fatty acids and oxygen. PH of extracellular fluid is 7.4 Intracellular fluid contains large quantities of potassium, magnesium, phosphates, sulfates, proteins. PH of intracellular fluid is 7.0 ELECTROLYTE Electrolyte is defined as any substance containing free ions that make the substance electrically conductive. Example- sodium, chloride, magnesium, phosphate, sulfate etc. REGULATION OF ELECTROLYTES AND FLUIDS There are four rules of regulation of fluids and electrolyte:1) All homeostatic mechanisms for fluid composition respond to changes in the ECF. - Receptors monitor the composition of plasma and CSF and triggers neural and endocrine mechanisms in response to change. - Individual cells cannot be monitored and thus ICF has no direct impact. 2) No receptors directly monitor fluid or electrolyte balance
- only plasma volume and osmotic concentration are monitored which give an direct measure of fluid or electrolyte levels. 3) water follows salt - cells cannot move water by active transport. - water will always move by osmosis and this movement Cannot be stopped. 4) The body`s content of water or electrolyte rises and loss to and from the environment. - Too much intake = high content in the body. - Too much loss= low content in the body. PRIMARY REGULATORY HORMONE a. Antidiuretic Hormone(ADH)Osmoregulators in the hypothalamus monitor the ECF and release ADH in response to high osmotic concentration( low water, high solute.) Increase in osmotic concentration causes increase in ADH levels. Primary effects of ADH:a) It stimulate water conservation at kidneys. b) It stimulate thirst. b.AldosteroneIt is released by the adrenal cortex to regulate sodiumabsorption and potassium loss in the DCT and collecting system in the kidney. Retention of sodium will result in water conservation. Aldosterone is released in response to : a) high potassium or low sodium in the ECF( e.g. renal circulation) b) activation of renin- angiotensinogen system due to a drop in blood pressure or blood volume. c) Decline in kidney filtrate osmotic concentration at the DCT. Natriuretic peptides- It is released in response to stretching of heart wall. It function to reduce thirst and block release of ADH and aldosterone resulting in diuresis.
The above diagram shows how the regulation of sodium ion levels in the extracellular fluid take place in the case of drop in the blood pressure. An increase in the blood pressure in the right atrium of the heart causes increased secretion of atrial natriuretic hormone which increases the sodium ion secretion and water loss in the form of urine. 5 . Below the diagram is showing how the electrolyte regulation takes place in the body with increased blood pressure and how the hormones maintain it to the normal. Aldosterone stimulates sodium ions and promotes water reabsorption in the kidney. there is decrease in the blood pressure leading to increased renin secretion from kidney and secretion of angiotensinogen which is converted into angiotensinogen1 and later into angiotensinogen2 which in turn stimulate aldosterone secretion from adrenal cortex. Here.
6 .CONCENTRATION OF BODY FLUIDS The concentration of body fluids is measured by three ways1) OSMOLALITY:.it determines the distribution of water among different compartments of extracellular and intracellular compartments.
eg. B) HYPERTONIC . C)HYPOTONIC.3%Nacl. When osmolality of ECF decreases water moves from ECF to ICF.0.In RBC . 7 . 0.In RBC. water moves into the cells resulting in swelling and rupture of cells. when RBC are placed inA) ISOTONIC – RBC placed in isotonic solution neither gain nor lose water because of osmotic equilibrium between inside and outside cell membrane. 3) TONICITY:It refers to relative concentration of solute particle inside a cell with respect to concentration outside the cell.9% Nacl solution and 5% glucose. ) 2) OSMOLARITY:It is expressed as the number of osmoles / litre of solution. In other words it is the concentration of osmotically active substances in the solution.It is expressed as number of particles per kg of solvent. Water movement continues until osmolality of these two fluid compartment becomes equal.water moves out of cells resulting in shrinkage of cells(crenation) eg-2%Nacl. water moves from ICF to ECF. eg. When osmolality of ECF increases.
facilitated diffussion Simple diffusion occurs through the lipid bilayer and the rate of diffusion is directly proportional to the lipid solubility.It is also known as passive transport i. No carrier protein binding. no external source of energy is required by which molecules moves from areas of high concentration to areas of low concentration. It is of two types.REGULATION OF BODY FLUIDS: The body fluids mainly regulate by the following processes: 1) Diffusion 2) osmosis 3) Filtration 4) Active transport 1) DIFFUSION. 8 .eg. Facilitated diffusion requires interacting carrier protein with the molecules. It doesn’t require energy.simple diffussion . It is also known as downhill movement.e. it is the movement of substances along the concentration or electrical gradient or both is known as diffusion.swimming in direction of water flow in river.
2) OSMOSIS.Process of movement of water caused by a concentration difference of water 9 .-It is the passive flow of the solvent.
ACTIVE TRANSPORT. 4) Mechanism of active transport. It is the movement of substances against chemical or electrical or both gradient is known as active transport. eg.When a cell membrane moves molecules or ions uphills against a concentration gradient. This complex move towards the inner surface of cell membrane.when the substance to be transported across cell membrane it combines with carrier protein of cell membrane leading to formation of protein complex. It occurs with help of carrier protein as in case of facilitated diffusion. Eg swimming in opposite direction to water flow. If more than one substance is known as antiports/ symport.sodium potassium pump. The substance is then released from 10 . Each carrier protein carry only one substance known as uniport pump.It is the movement of water and solutes from an area of high hydrostatic pressure to an area of low hydrostatic pressure. the process is known as active transport.3) FILTRATION. It is also known as uphill transport and requires energy in the form of adenosine tri phosphate.
amino acids.carrier protein and the carrier protein moves back to outer surface of cell membrane. Substances transported by active transport are in two formIonic form.glucose. It transport sodium from inside cell to outside and potassium from outside intio the cells. urea. calcium. choride. Non ionic form. potassium. sodium potassium pump for distribution of sodium and potassium across cell membrane.sodium. Eg. Diagram showing active and passive transport. ACID BASE BALANCE 11 .
To determine ph of fluid – the concentration of bicarbonate ions and carbon dioxide dissolved in fluid are measured. Acid base buffer is fastest one and it can readjust ph within seconds.is a substance that accepts hydrogen ions. c) Renal mechanism which excretes hydrogen ions and conserves the bicarbonate ions. DETERMINATION OF ACID BASE STATUS It is difficult to measure by direct method. (Donor) BASE. Indirect method can be calculated by Henderson hasselbalch equation.is a substance that liberates hydrogen ions. Renal mechanism is slower and it takes few hours to few days to bring ph back to normal. b) Respiratory mechanism which eliminates carbon dioxide.38and 7.4 and varies from 7. REGULATION OF ACID BASE BALANCE There are three different mechanism : a) Acid base buffer system which binds hydrogen ions. It is the most powerful mechanism than others.42 Maintenance of acid base status is important As even a slight change in Ph causes serious threats to physiological function. PH= PK+ LOG HCO3_ / CO2 ACID BASE BUFFER SYSTEM It is of three types:a) Bicarbonate buffer system b) Phosphate buffer system c) Protein buffer system 12 . Respiratory mechanism adjust the ph in minutes. (Acceptor) In healthy person PH of ECF=7.ACID.
4 as there is large difference between them.1 while the ph of ECF is 7.Above diagram showing the types of acid base buffer system that occur in the ICF and ECF.8 and the ph of ICF is 7. While the phosphate buffer system is comparatively more powerful as the pk value is 6. The bicarbonate buffer system is not very powerful because the pk of bicarbonate is 6. 13 .1 as there is less difference.
ACID BASE DISTURBANCES The acid base disturbances are-Respiratory Acidosis -Respiratory Alkalosis -Metabolic Acidosis -Metabolic Alkalosis The clinical manifestation. 14 . lab findings and the management is given in the table.
1. Growth and functions of cells depend upon the availability of minerals like glucose. Homeostasis is of two types positive feedback mechanism and the negative mechanism. lipids. The term homeostasis is given by the Harvard profecessor Walter b menon.SIGNIFICANCE OF BODY FLUIDS In Homeostasis:Body cells survive in the fluid medium or milieu interieur. amino acids. oxygen in proper quantities in internal environment. 16 . The maintenance of internal environment is called as HOMEOSTASIS. Term Milieu interieur given in 19th century by french physiologist Claude bernard.
minerals. hormones. 3) IN METABOLIC REACTIONS: Water inside the cells forms the medium for metabolic reaction necessary for growth and functional activities of the cells. vitamins are carried from one part to another part of body.) IN TRANSPORT MECHANISM: Water forms an important medium through which various enzymes. 4) IN TEMPERATURE REGULATION Fluid plays a vital role in maintanence of normal body temperature MEASUREMENT OF VOLUME OF BODY FLUIDS 17 .
After administration it is mixed thoroughly and sample of fluid is drawn to determine the concentration of marker substance.1824) MEASUREMENT OF INTRACELLULAR FLUID VOLUME 18 . Principle:. plasma volume and total body water.radio active 131i . sucrose. Substances used to measure plasma volume . chloride.Amt of substance excreted/ concentrationn of sustance in sample of fluid.Tritium oxide Substances used to measure Extracellular fluid – Radio active sodium. sulfate thiosulfate. Marker substances used to measure total body water are – Deuterium oxide .It is measured by Indicator dilution method or dilution method. Volume= Amt of substance injected. C is the concentration of marker substance in sample fluid. mannitol. USES OF INDICATOR DILUTION METHOD It is used to measure ECF volume.Non metabolizable saccharides like inulin. Formula to measure volume of fluid V= M/C Where V is volume of fluid compartnent M is mass or quantity of marker substances. substances whose concentration can be determined by calorimeter or radio active substances are used as marker substances. bromide. .A known quantity of substance or dye is administered into body fluid compartment. Correction factor – some amount of marker substance is lost through urine during distribution.Evan`s blue (T.
It is calculated as ICF volume= total body water.Postural hypotension . rapid.Increased temperature .Flattened neck veins .The volume intracellular fluid cannot be measured directly. heart rate .8% of body weight loss Pathophysiology – results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake Clinical manifestation:-Acute weight loss -Decrease skin turgor -Oliguria -Concentrated urine .5% of body weight loss Severe:.ECF volume MEASUREMENT OF INTERSTITIAL FLUID VOLUME It is calculated as: Interstitial fluid volume= ECF volume.Decreased central venous pressure 19 .2% of body weight loss Moderate:.plasma volume APPLIED PHYSIOLOGY FLUID VOLUME DEFICIT ( HYPOVOLEMIA) Mild:.Weak.
CHF] -Decreased OP [malnutrition.Management . nephrotic syndrome] An excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute It occurs in prolonged and excessive diuresis.An increase in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2° to: -Increased HP [pregnancy.Fluid replacement therapy & continued fluid maintenance. forcing hypotonic fluids to produce diuresis in the presence of renal impairment fluid overload from increased production of adrenal corticoid hormones (Cushing’s syndrome) 20 . Fluid Volume Excess (Hypervolemia) . end-stage liver disease.
increased weight Management --Restrict fluids to lower fluid volume -Diuretics or hypertonic saline -Continuous assessments to prevent skin breakdown Record daily weight of the patient. Electrolyte Balance: 21 . Clinical manifestations – edema. distended neck veins. increased blood pressure. tachycardia. crackles.
but this results in a high blood volume (this is why salt is bad for hypertensive patients) -Minor gains and losses of Na+ in the ECF are compensated by water in the ICF and later adjusted by hormonal activities: -ECF volume too low → renin-angiotensin system is activated to conserve water and Na+ -ECF volume too high 22 .concentrations of individual electrolytes can affect cell functions -The two most important electrolytes are sodium and potassium: 1) Sodium Balance (normal blood values: 130-145 mEq/L *) -Na+ is the dominant cation in the ECF -90% of the ECF osmotic concentration is due to sodium salts: NaCl and NaHCO3 -The total amount of Na+ in the ECF is due to a balance between Na+ uptake in the digestive system and Na+ excretion in urine and perspiration The overall sodium concentration in body fluids rarely changes because water always moves to compensate: e.g. high sodium levels in the blood will cause retention of water to maintain the same Na+ concentration.-Electrolyte balance is important because : -total electrolyte concentrations directly affect water balance .
sweating. diarrhea.in cases who cannot eat or drink.Sodium replacement . diuretics.Can be caused by a gain of sodium in excess of water or by a loss of water in excess of sodium Pathophysiology 23 .Ringer lactate solution.9%). isotonic solution(0. Hypernatremia Sodium level is greater than 145 mEq/L . etc Clinical manifestations Poor skin turgor Dry mucosa Decreased saliva production Orthostatic hypotension Nausea/abdominal cramping Altered mental status MANAGEMENT:.water restriction .→ natriuretic peptides released: block ADH and aldosterone resulting in water and Na+ loss Normal range – 135 to 145 mEq/L Hyponatremia Sodium level less than 135 mEq/L It may be caused by vomiting.
Fluid deprivation in patients who cannot perceive.45%) 24 . and cognitively impaired patients Clinical manifestations Thirst Dry. or communicate their thirst. respond to.3 to 0. very young. Mostly affects very old. swollen tongue Sticky mucous membranes Flushed skin Postural hypotension MANAGEMENT Diuretics given in sodium excess Administration of hypotonic sodium solution(0.
Potassium It is a major Intracellular electrolyte about 98% of the body’s potassium is inside the cells. excretion in urine 25 . -K+ is the dominant cation in the ICF (98% of the total body K+ is inside cells) -The concentration of K+ in the ECF depends on absorption in the GI vs.5 to 5.5 mEq/L. It Influences both skeletal and cardiac muscle activity. Normal serum potassium concentration – 3.
weak pulse 4)Orthostatic hypotension 5)Numbness (paresthesia) 26 . H+ is used for Na+ reabsorption instead of K+ at the exchange pump pH in ECF = K+ secretion 3. Changes in the K+ concentration of the ECF − K+ in ECF = K+ secretion 2. poor K intake. stress. Aldosterone levels aldosterone = Na+ reabsorption and K+ secretion Hypokalemia Causes: Diarrhea. Manifestation:1)Skeletal muscle weakness 2)Constipation 3)Irregular. diuretics. steroid administration. Changes in blood pH at low pH.-The exchange pump at the kidney tubules secrete K+ (or H+) in order to reabsorb Na+ -The rate of tubular secretion of K+ in the kidney is controlled by three factors: 1.
6)ECG changes ( ST elevation) Nursing interventions: -Encourage high K foods -Monitor ECG results -Dilute KCl – can cause -cardiac arrest occurs if given IV Administering IV Potassium -It Should be administered only after adequate urine flow has been established. Decrease in urine volume to less than 20 mL/h for 2 hours is an indication to stop the potassium infusion IV K should not be given faster than 20 mEq/h Hyperkalemia Serum Potassium greater than 5.5 mEq/L It is more dangerous than hypokalemia because cardiac arrest is frequently associated with high serum K+ levels. 27 .
Intracellular calcium is needed for 28 .Shift of potassium out of the cell as seen in acidosis Clinical manifestations: -Skeletal muscle weakness/paralysis -ECG changes -such as peaked T waves.Causes: .5 to 10mg/dL and needed for transmission of nerve impulses.Renal insufficiency . -widened QRS complexes -Heart block - Medical/Nursing Management: Monitor ECG changes – telemetry Administer Calcium solutions to neutralize the potassium Monitor muscle tone Give Kayexelate Give Insulin Calcium -More than 99% of the body’s calcium is located in the skeletal system The normal serum calcium level is 8.High potassium intake .Decreased renal potassium excretion as seen with renal failure and oliguria .
Hyperparathyroidism .Vitamin D/Calcium deficiency . It is needed for tooth and bone formation and needed for maintaining a normal heart rhythm.5 mEq/L Causes .Pancreatitis - Renal failure Clinical Manifestations .Tetany and cramps in muscles of extremities Definition – A nervous affection characterized by intermitent tonic spasms that are usually paroxysmal and involve the extremities .contraction of muscles. Hypocalcemia The Serum Calcium level less than 8. Extracellular needed for blood clotting. 29 .
Trousseau’s sign – carpal spasms Chvostek’s sign – cheek twitching Medical/Nursing management 30 .
nausea and vomiting Lethargy and confusion Constipation Cardiac Arrest (in hypercalcemic crisis.Corticosteroids drugs decreases the intestinal absorbtion of calcium..used to lower serum calcium level .useful for pts with heart disease or renal failure .Increase fluids (IV or Orally) . level 17mg/dL or higher) - Medical/Nursing Management .Calcitonin .reduces bone resorption . .increases urinary excretion of calcium and phosphorus 31 .Eliminate Calcium from diet .Encourage increased dietary intake of Calcium .Monitor neurological status Hypercalcemia>10mg/dl) - Causes: Hyperparathyroidism Prolonged immobilization Thiazide diuretics Large doses of Vitamin A and D Clinical manifestations: Muscle weakness.increases deposit of calcium and phosphorus in the bones .IV or orally Calcium Carbonate or Calcium Gluconate .
depressed ST segment.5 mg/dl. Hypomagnesemia Causes.Give Calcium Gluconate if accompanied by hypocalcemia .Thought to Normal serum magnesium level is 1. arterioles.Positive Chvostek’s and Trousseau’s sign .Renal failure . It Exerts effects on the cardiovascular system. It have a direct effect on peripheral arteries and .May occur with hypocalcemia and hypokalemia Medical/Nursing management .IV/PO Magnesium replacement. acting peripherally to produce vasodilation.(Mg< 1.Untreated diabetic ketoacidosis 32 .Neuromuscular irritability .Diarrhea Clinical manifestations .Monitor for dysphagia.Chronic Alcoholism . including Magnesium Sulfate .ECG changes with prolonged QRS. give soft foods -Measure vital signs closely -Foods high in Magnesium: Green leafy vegetables Hypermagnesemia Causes .5 to 2.5mg/dl) . and cardiac dysrhythmias .Magnesium It Helps maintain normal muscle and nerve activity.
maintanence of acid-base balance.- Excessive use of antacids and laxatives Clinical manifestations .Most likely to occur with overzealous intake or administration of simple carbohydates .High Calcium = Low Phosphate .Severe protein-calorie - malnutrition (anorexia or alcoholism) 33 . and nervous system .Phosphate levels vary inversely to calcium levels .5 to 4.Normal serum phosphorus level is 2.Mild hypotension Phosphorus .5 mg/dL .Essential for the function of muscle and red blood cells.Flushed face and skin warmth .Causes .
Increase oral intake of phosphorus rich foods Hyperphosphatemia Serum Phosphorus level greater than 4. .5 mg/dl Causes Renal failure Chemotherapy Hypoparathyroidism High phosphate intake Clinical manifestations Tetany Muscle weakness Similar to Hypocalcemia because of reciprocal relationship CONCLUSION Stabilizing ECF and ICF involves 34 .- Clinical manifestations Muscle weakness Seizures and coma Irritability Fatigue Confusion Numbness Medical/Nursing management .IV Phosphorus in severe cases.Monitor phosphorus levels .
Textbook of medical physiology.D Nutrients in drinking water – WHO 2003 Report P - 35 .1 litre/day. Electrolyte balance 3. Ph.k pandey Indian J.1.Guyton.A Regulatory Approach Macmillan. c. Fluid balance 2. 47(5) 380-387. Amy warenda czura. Hall. REFERENCES Essentials of medical physiology-Ksembulingam and sembulingam. Anaeth2003. Acid base balance so. the minimium water requirement for fluid replacement for 70 kg human in temperate zone is 3 litre /day and in tropical zone is 4. Fluer strand physiology. Fluid and Electrolyte disorders – Dr.
- 36 .
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