PATHOPHYSIOLOGY Name

Chapter 4 – Part 1: Fluids and Electrolytes

I. Fluid and Electrolyte Balance

A. Distribution of Body Fluids
1. Total body water (TBW) - 60% of body weight, on average, for a normal adult male.
a. Fluid compartments
 Intracellular fluid (2/3 of total body water or about 28 L)
 Extracellular fluid (1/3 of total body water or about 14L)
o Interstitial fluid (about 11L)
o Intravascular fluid (about 3L)
o Lymph, synovial, intestinal, CSF, sweat, urine, pleural, peritoneal, pericardial, and
intraocular fluids (less than 1L)

TOTAL BODY WATER (%) IN RELATION TO BODY WEIGHT*

BODY BUILD ADULT ADULT CHILD INFANT (1 NEWBORN

MALE FEMALE (1-10 yr) mo to 1 yr) (up to 1 mo)

Normal 60 50 65 70 70-80

Lean 70 60 65-70 80

Obese 50 42 50 60

*NOTE: Total body water as a percentage of body weight.

b. Pediatrics
 At birth water is 75% to 80% of body weight.
o Infants have a high metabolic rate and greater body surface area than adults.
o Thus they have a greater fluid intake and output in relation to their body size.
 This makes them more susceptible to significant changes in body fluids than adults.
o Dehydration is a major concern.
c. Aging
 The percentage of total body weight that is fluid decreases due to:
o Increase adipose and decrease muscle mass
o Renal decline
o Diminished thirst perception
 This puts the elderly at greater risk of dehydration than younger adults.
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2. Water Movement Between the Intravascular and Interstitial Spaces (within the ECF)
 Determined by the net filtration pressure across the capillary wall.
 Net filtration = forces favoring filtration minus forces opposing filtration (Starling’s hypothesis)
o Forces favoring filtration into interstitial spaces:
 Capillary hydrostatic pressure – due to blood pressure
 Interstitial oncotic pressure – due to proteins in fluid between tissue cells (water-pulling)

o Forces favoring reabsorption into blood:

 Plasma oncotic pressure – due to plasma proteins (water pulling)
 Interstitial hydrostatic pressure – due to pressure in tissues (pushes into blood and cells)

3. Water Movement Between the Intracellular (ICF) and Extracellular (ECF) Fluid Compartments
 Caused by changes in the concentration of ECF (osmotic pressure differences).
 If ECF becomes less concentrated water flows into cells and they swell.
o Could occur if there is fluid excess or sodium deficit.
 If ECF becomes more concentrated water flows out of cells and they shrink.
o Could occur if there is fluid deficit or sodium excess.

ACTIVITY 1: For each of the following statements, decide which direction fluid would tend to move. Choices:
B = into the blood I = into the interstitial fluid C = into the cells
Lower than normal sodium levels. Low blood pressure.
Higher than normal sodium levels. Lower than normal levels of plasma proteins.
High blood pressure. Higher than normal levels of plasma proteins.

B. Alterations in Water Movement

1. Edema
 Accumulation of fluid within the interstitial spaces
 Causes
o Increase in capillary hydrostatic pressure – example: vasoconstriction
o Decrease in plasma oncotic pressure – example: liver failure & decreased plasma proteins
o Increases in capillary permeability – example: inflammation
o Lymph obstruction – example: after surgical removal of lymph nodes
2. Water Balance
 Regulated through thirst perception and ADH secretion.
 Antidiuretic hormone (ADH)
o Causes increased water reabsorption, primarily in the distal convoluted tubules of kidneys.
o Secreted when plasma volume drops or plasma concentration (osmolality) increases.
o Osmolality receptors sense increased plasma concentration and plasma volume depletion.
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C. Sodium and Chloride Balance

1. Sodium
 Primary ECF cation
 Regulates osmotic forces
 Roles - neuromuscular irritability, acid-base balance, and cellular chemical reactions and
membrane transport
2. Chloride
 Primary ECF anion
 Provides electroneutrality
 Levels vary inversely with those of bicarbonate
3. Sodium and Chloride Regulation
 Renin-angiotensin-aldosterone (RAA) system:
Trigger: A decrease in blood pressure and blood flow to the kidneys (or increased K+).
Step 1: Renin is released by juxtaglomerular cells of the kidney.
Step 2: Renin is an enzyme that converts angiotensinogen to angiotensin I (in the blood).
Step 3: Angiotensin I is converted to angiotensin II (occurs in the lungs; requires
angiotensin converting enzyme [ACE]).
Step 4: Angiotensin II causes vasoconstriction and release of aldosterone by the adrenal cortex.
Step 5: Aldosterone causes increased sodium and water retention in the kidneys.
End result: An increase in blood volume and blood pressure (and decreased K+).
 Atrial natriuretic hormone (peptide) (ANH) – has the opposite effect of aldosterone
o ANH is secreted by the atria in response to increased blood volume (stretching).
o Function: ANH decreases sodium retention so more sodium and water are excreted in the
urine. This decreases blood volume and blood pressure.

ACTIVITY 2: Match the hormones with their descriptions.

a. ADH b. aldosterone c. atrial natriuretic hormone
Causes increased retention of sodium and water when blood pressure falls.
Causes more water to be reabsorbed when the plasma becomes too concentrated.
Causes excretion of sodium and water when blood volume becomes too great.

D. Alterations in Sodium, Chloride and Water Balance

1. Isotonic Alterations
 Isotonic fluid has the same water-to-electrolyte content as normal body fluid.
 An isotonic alteration is a change in total body water in which there is a proportional change
in electrolytes and water.
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a. Isotonic fluid loss (isotonic dehydration)

o Causes - hemorrhage, mild vomiting, mild diarrhea or excessive sweating.
o Manifestations - weight loss, dryness of skin and mucous membranes, decreased skin
turgor, decreased urine output, and symptoms of hypovolemia (rapid heart rate,
flattened neck veins, and normal or decreased blood pressure, and shock).
b. Isotonic fluid excess
o Causes – excessive administration of intravenous fluids, hypersecretion of aldosterone, or
drugs such as cortisone.
o Manifestations – symptoms of hypervolemia including weight gain, decreased
hematocrit, distended neck veins, increase in BP, and edema.
2. Hypertonic Alterations
o Increased osmolality (fluid is more concentrated)
a. Hypernatremia
o Serum sodium above 147 mEq/L
o Water moves from the ICF to the ECF, causing intracellular dehydration including
shrinkage of brain cells; but there is excess extracellular fluid.
o Causes - excess administration of hypertonic IV solutions, oversecretion of aldosterone.
o Manifestations of hypernatremia
 Increased ECF causes edema and increased blood pressure.
 High sodium level causes muscular weakness and hyperactive reflexes.
 Decreased ICF causes thirst, decreased urine output, confusion, and ultimately coma.
b. Pure water deficit (hypertonic dehydration)
o Loss of water alone
 ECF becomes more concentrated, so water moves from ICF to ECF.
 Both ECF and ICF become dehydrated and hypovolemia occurs.
o Causes
 Inability to obtain water (ex. comatose patients)
 Extended hyperventilation
 Increased renal free water clearance as with decreased ADH secretion (most common cause)
o Manifestations
 Decreased ECF causes a weak pulse, postural hypotension, and tachycardia, elevated
hematocrit and elevated serum sodium level.
 Decreased ICF causes thirst, fever, decreased urine output, shrinkage of brain cells,
confusion and coma.
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3. Hypotonic Alterations
o Decreased osmolality (fluid is less concentrated)
a. Hyponatremia
o Serum sodium level below 135 mEq/L
o Sodium deficit decreases the ECF osmotic pressure, and water moves into the cells.
 Water movement causes symptoms related to hypovolemia and cellular swelling.
o Causes – inadequate intake of Na+; hypoaldosteronism; increased loss of Na+ through
diuresis, profuse sweating, or gastrointestinal losses.
o Manifestations – Increased ICF causes edema, brain cell swelling, irritability, depression,
confusion, weakness, muscle cramps, anorexia, nausea, and diarrhea.
 Pure sodium deficits cause hypotension, tachycardia, and decreased urine output.
b. Water excess
o Free water excess causes symptoms of hypervolemia and water intoxication.
o Causes – excessive administration of hypotonic intravenous solutions, drinking water to
replace isotonic fluid losses, tap water enemas, psychogenic polydipsia, renal water
retention, or increased antidiuretic hormone secretion.
o Manifestations
 Acute excesses cause swelling of brain cells, confusion and convulsions.
 Long-term water accumulation causes weakness, nausea, muscle twitching, headache,
and weight gain.
ACTIVITY 3: Place an X in the appropriate squares to indicate which fluid imbalances (on left)
are accompanied by the conditions listed in the top row (there should be a total of ten Xs).

Hypovolemia Hypervolemia Cells shrink Cells swell

Isotonic fluid loss
Isotonic fluid excess
Hypernatremia
Pure water deficit
Hyponatremia
Water excess

E. Alterations in Potassium
1. Potassium
 Major intracellular cation
 Concentration maintained by Na+/K+ pump
 Regulates intracellular electrical neutrality in relation to Na+ and H+
 Essential for transmission and conduction of nerve impulses, normal cardiac rhythms, and
skeletal and smooth muscle contraction.
 Serum levels of K+ are regulated by kidney excretion of potassium.
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Potassium Levels
 Changes in pH affect K+ balance
o Hydrogen ions accumulate in the ICF during states of acidosis.
o K+ shifts out of cells to maintain a balance of cations across the membrane.
 Aldosterone and insulin influence serum potassium levels.
o Aldosterone – is secreted in response to high K+ levels; causes increased movement of K+
into urine in exchange for Na+.
o Insulin – stimulates cellular uptake of K+.
2. Hypokalemia
 Potassium level below 3.5 mEq/L
 Potassium balance is described by changes in plasma potassium levels
 Causes – reduced intake of potassium, increased entry of potassium into body cells (as during
alkalosis), and increased loss of potassium in diarrhea or due to diuresis from the kidneys.
 Loop diuretics (like Lasix) - inhibit Na+ reabsorption in the loop of Henle, and so put an
excess demand on the exchange of K+ for Na+ in the distal tubule of the nephron, thus
resulting in K+ loss.
 Manifestations
o Membrane hyperpolarization causes a decrease in neuromuscular excitability, skeletal
muscle weakness, smooth muscle atony, and cardiac dysrhythmias.
3. Hyperkalemia
 Potassium level above 5.5 mEq/L
 Hyperkalemia is rare because of efficient renal excretion
 Caused by increased intake, shift of K+ from ICF (as during acidosis), decreased renal
excretion due to renal failure, insulin deficiency, or cell trauma
 Mild attacks
o Increased neuromuscular irritability
o Tingling of lips and fingers, restlessness, intestinal cramping, and diarrhea
 Severe attacks
o The cell is not able to repolarize, resulting in muscle weakness, loss of muscle tone,
flaccid paralysis, and even cardiac arrest.

ACTIVITY 4: Indicate whether each of the following is associated with hypokalemia (-) or hyperkalemia (+).
Acidosis. Use of loop diuretics. Renal failure.
Alkalosis. Trauma to cells. Increased neuromuscular.
Excess aldosterone. Injection of insulin. irritability.
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Chapter 4, Part 1 - ANSWER KEY TO ACTIVITIES

ACTIVITY 1: For each of the following statements, decide which direction fluid would tend to move. Choices:
B = into the blood I = into the interstitial fluid C = into the cells
C Lower than normal sodium levels. B Low blood pressure.
I Higher than normal sodium levels. I Lower than normal levels of plasma proteins.
I High blood pressure. B Higher than normal levels of plasma proteins.

ACTIVITY 2: Match the hormones with their descriptions.

a. ADH b. aldosterone c. atrial natriuretic hormone
B Causes increased retention of sodium and water when blood pressure falls.
A Causes more water to be reabsorbed when the plasma becomes too concentrated.
C Causes excretion of sodium and water when blood volume becomes too great.

ACTIVITY 3: Place an X in the appropriate squares to indicate which fluid imbalances (on left)
are accompanied by the conditions listed in the top row (there should be a total of ten Xs).

Hypovolemia Hypervolemia Cells shrink Cells swell

Isotonic fluid loss X
Isotonic fluid excess X
Hypernatremia X X
Pure water deficit X X
Hyponatremia X X
Water excess X X

ACTIVITY 4: Indicate whether each of the following is associated with hypokalemia (-) or hyperkalemia (+).
+ Acidosis. - Use of loop diuretics. + Renal failure.
- Alkalosis. + Trauma to cells. + Increased neuromuscular
- Excess aldosterone. - Injection of insulin. irritability.