FLUIDS AND ELECTROLYTES AVERAGE INPUT

Preliminaries… - 1200 ml/day - H2O

- 1100 ml/day - “hidden” H2O in foods
In CKD, there’s an alteration in regulation of K and - 300 ml/day - water oxidation
metabolic acidosis occurs
AVERAGE OUTPUT
Common Medications - 1500 ml/day - urine
-sodium bicarbonate, calcium bicarbonate. Calcium + - 1000 ml/day - skin and lungs
Vitamin D - 100 ml/day - GI tract (feces)

-kidneys activate vitamin D (activated form - In chronic renal failure (CRF)...

cholecalciferol/calciferol)
↑Uric Acid - Arthritis | Purine Metabolism (Diet: limit
-renal osteodystrophy - ↓ absorption of calcium intake of beans, salmons, sardines, seafoods)
↑Ammonia - protein metabolism (ammonia is regulated
Hormone via liver)
↑Creatinine - muscle metabolism
ADH, Aldosterone (Adrenal Gland) ↑Urea - protein metabolism
↪plays a role in sodium and potassium
↓ ↓ Liver cirrhosis - accumulation of ammonia resulting to
reabsorption excretion ↓excretion by the liver (maglisod ang liver to excrete
↓ excessive ammonia)
maintains fluid balance
Most reliable urine test indicator: Creatinine
*Dilutional Hyponatremia - water dilutes Na R: It is not affected by other factors

IV - Contains more Na than IC | IC - Contains more BODY FLUID COMPARTMENTS

K than IV Plasma | Interstitial | Intracellular

GFR - 80 - 120 cc/min Distribution: 25% fluid

Oliguria - ↓ 30 cc/hr 33% extracellular
Total Body Fluid 8% plasma
*monitor I&O = reflects internal circulation 66% intracellular
*Anesthesia - relaxes smooth muscle of bladder
3 Factors affecting Body Fluids
FLUIDS
- Blood 1. Gender
- Urine (Cardiac output (6-7L/min) → 25 % goes Females: 45% solids, 55% fluids
to the kidneys | ↓ GFR means ↓ CO Males: 40% solids, 60% fluids
- Saliva
- Serum Albumin 2. Age - as person ages, thirst mechanism
- Bile decreases
- Hormones 3. Body Fats - Fats (hydrophobic) do not absorb
- Cerebrospinal Fluid fluid.

SOURCES OF BODY FLUIDS *Female has more body fat than male = male has more
- Fluid taken orally fluid than female
- Food ingested
Fluid Compartments
2 Barriers
- Capillary wall (Blood vessel wall) - semi permeable
- Cell membrane
Calcium - located Intra and Extra
↑ Calcium in IVC - Calcification (Hardening of BV)
*Calcification of Coronary artery → ↓Pumping →
Cardiac Arrest
*IV - 6L plasma fluid (Blood Volume)
↪3L plasma, 3L Blood Cells
*IS - 11 - 12 L
*Transcellular - 1L
↪CSF, Synovial Fluid
MOVEMENT
1st Phase: Blood Plasma moves around the body and
nutrients and fluids are picked up from lungs and the
GIT
2nd phase: ISF and its component move between
blood capillaries and cells
3rd phase: Fluids and its components move back from
cells to IS to IV compartment. IVF flows to the kidneys
where there would be excretion of metabolic waste
products in the form of URINE
IV Types (Commercial lang)
Hypotonic Solutions - contains less sodium
-used to hydrate patients (water enters cells)
-solute concentration outside the cell is lower
compared to inside
Ex: 0.45% NaCL, 0.33% NaCL, 0.225% NaCL, 2.5%
Dextrose in Water
-complication: cellular swelling
Hypertonic Solutions - contains more sodium
-water leaves cells
-solute concentration outside the cell (IV) is higher
compared to inside
Ex. Dextrose 10% in water (D10W), Dextrose 20% in
water (D20W), Dextrose 30% in water (D30W)
Complication: Cellular Dehydration
Isotonic Solutions - contents have the same
component with blood
-no net movement between compartments
-used to treat fluid volume deficit, hypotension
Ex. 0.9% NaCL (PNSS), Dextrose 5% in water (D5W),
Dextrose 5% in Lactated Ringers (D5LR)
*3rd Space Fluid Shifting
-ascites - accumulation of fluid in peritoneal cavity
-pleural effusion - fluid in pleural cavity
-caused by severe hypoalbuminemia
Oliguria - water goes to third space → IV volume
deficit → ↓ kidney perfusion → ↓ Urine Output
Edema - ↓IV fluid volume → ↓albumin → ↓ oncotic
pressure → shifting of fluid from IVC to Interstitial
Space
ELECTROLYTES
- Active chemicals that carry + (cation) and -
(anion) charges
NORMAL VALUES
Cation
Sodium (Na) - 135 - 145 mEq/L
Potassium (K) - 3.5 - 5.5 mEq/L
Calcium (Ca) - 8.5 - 10.6 mg/dL
Ionized Ca - 4.5 - 5.5 mg/dL
Magnesium (Mg) - 1.5 - 2.5 mEq/L
Anion
-Bicarbonate (HCO3) - 24 - 30 mEq/L
-Chloride (Cl) - 95 - 105 mEq/L
-Phosphate (PO4) - 2.8 - 4.5 mg/dL
ROLES
1. Calcium - muscle contraction, nerve signaling, blood
clotting, cell division, and forming/maintaining bones
and teeth
-maintained by parathyroid gland
(PTH - Calcium, Calcitonin - PO4)
*Kidneys = activates Vitamin D → cholecalciferol →
calcium absorption
2. Sodium - fluid balance, muscle contractions, nerve
signaling
3. Magnesium - muscle contractions. Proper heart
rhythm, nerve functioning
4. Potassium - keep BP stable, heart contractions,
muscle functions
↑K intake → ↑Na Excretion → ↓IV fluid volume → ↓BP
↑K intake → ↓Tension within IV → ↓BP
(if there’s increased tension, ↑Pressure in IVC →
vasospasm → ↑BP)
5. Chloride - maintains fluid balance
Renin-Angiotensin-Aldosterone-System (RAAS)
↓Blood Volume, ↓BP → Juxtaglomerular Apparatus
(located in the nephrons) releases renin → renin
circulates → liver produces angiotensinogen → renin
converts angiotensinogen to angiotensin I →
angiotensin I circulates → lungs produce Angiotensin
Converting Enzyme (ACE) → ACE converts
angiotensin I to angiotensin II (vasoconstrictor) →
Angiotensin II stimulates adrenal cortex to produce
aldosterone → Na absorption, K excretion = ↑BP
Colloids
-macromolecules of protein that are primarily located
within plasma
-holds water within BV
-blood
HOMEOSTASIS
- balance of fluids, electrolytes, and bases
- body is equipped with compensatory mechanisms
- ↓BV - thirst center (hypothalamus) secretes
vasopressin (ADH - antidiuretic hormone) → prevents
water excretion → water retention → hyponatremia
(dilute)
- ↑ADH (in cases like SIADH - Syndrome of
Inappropriate Antidiuretic Hormone) → Fluid Volume
Overload
- ↓ ADH (in cases like Diabetes Insipidus) → ↑water
excretion → large volume of water excreted → ↑UO
Starling’s Law of Capillary Forces identifies Hydrostatic
Pressure and Osmotic Pressure
Hydrostatic Pressure - water force in ECF pushing
outward
Osmotic Pressure - solute force pulling inward
Water I&O
Minimum intake - 1100 ml/day
Normal output - 500 ml/24 hrs
ORGANS INVOLVED IN MAINTAINING
HOMEOSTASIS
1. Kidneys
-releases erythropoietin (used in production of RBC -
target organ: bone marrow)
-hormones help kidneys
*ADH - acts on renal tubules
*Aldosterone - Na reabsorption and K excretion
In hypernatremia, adrenal cortex decreases production
of aldosterone → ↓Na reabsorption
In hyperkalemia, adrenal cortex increases production
of aldosterone → ↑ K excretion
2. Heart
-cardiac output necessary for kidney’s functioning
(urine formation)
3. Blood vessel
- vasodilation and vasoconstriction (affects delivery of
blood and electrolytes)
4. Lungs
- remove 300 ml of water through exhalation
- loss is profound for patient with hyperventilation
- regulation of acid-base balance through excretion of
CO2
Respiratory Acidosis/Alkalosis - lungs affected, kidneys
compensate
Metabolic Acidosis/Alkalosis - kidneys affected, lungs
compensate
5. GI tract
-8L/24 hrs of fluid circulate in GIT
-Small intestine - common site for absorption
FACTORS AFFECTING FLUIDS & ELECTROLYTES
1. Climate - ↑temp → sweat production → ↓Fluid
Volume
2. Diet - ↓ diet affects electrolyte levels
3. Stress (cortisol, mineralocorticoid - steroids)
-stimulation of SNS → release of cortisol → ↑glucose
metabolism → availability of glucose in the brain
*Patients with DM should not be given steroids unless
ordered
4. Illness
↓ kidney perfusion
Hyperaldosteronism
↪↑ Na, ↓K excretion = water retention

6. Hypothalamus 5. Trauma
-regulator of water intake
-manufactures ADH Burns → BV and cellular destruction → release of K
from cells → ↑K in blood stream → hyperkalemia
ADH → renal tubules → ↑Na reabsorption → ↑water
retention Burns - albumin leakage from IV to IS → ↓oncotic
pressure → edema
-thirst center (promotes intake of water)
6. Surgical Procedures
7. Pituitary gland
- stores ADH -Anesthesia: relaxes muscles | effect on smooth
muscles in urinary bladder → urinary retention →
8. Adrenal Gland electrolyte imbalances
-adrenal cortex secretes aldosterone

9. Parathyroid gland
-manufactures parathyroid hormone

In hypocalcemia, PTG secretes PTH (hypercalcemic)

→ facilitates osteoclasts activity → breaks down bone
tissue → calcium going to bloodstream

In hypercalcemia, PTG secretes calcitonin

(hypocalcemic) → brings calcium back to the bones
FLUID VOLUME IMBALANCES
1. Isotonic Imbalance - water and electrolytes lost in
equal proportions
2. Osmolar Imbalance - loss or gain of H2O only
LABORATORY TESTS
1. Urine Specific Gravity (1.010 - 1.020)
- ↑ Fluid volume → diluted urine → ↓ urine
specific gravity
- ↓ Fluid volume - concentrated urine → ↑ urine
specific gravity
2. Hematocrit (men: 39 - 49%, women: 35-45%)
- ↑ Fluid in blood → dilution of blood cells → ↓
hematocrit level
- ↓ Fluid in blood → hemoconcentration - ↑
hematocrit level
- ↑ RBC → polycythemia vera
3. Serum Osmolality (285 - 295 mOsm/kg)
- Concentration of particles dissolved in blood
- ↓ fluid volume → ↑ serum osmolality
- ↑ fluid volume → ↓ serum osmality
4. Urine Osmolality (50 - 1200 mOsm/kg)
- Measures concentration of particles dissolved
in urine
5. Serum Albumin
- Hypoalbuminemia = edema
HYPOVOLEMIA
- fluid volume deficit
- loss of ECF volume exceeds intake of fluid
- water and electrolytes lost in same proportion
ETIOLOGY
1. Abnormal Fluid loss
- vomiting, diarrhea, GI suctioning and sweating
*Diaphoresis in patients with Hypoglycemia
2. Decreased intake - nausea
3. Third-space fluid shifts
edema formation in burns, ascites with liver dysfunction
*Patients with liver cirrhosis →metabolizes albumin - ↓
albumin production → edema
4. Adrenal insufficiency
↓ aldosterone → ↓reabsorption of Na → ↓FV
5. Diabetes Insipidus
- ↓ ADH production → ↓absorption of fluid → H2O
excretion → Fluid Volume Deficit
6. Osmotic Diuresis
CLINICAL MANIFESTATIONS
1. Acute weight loss
2. ↓skin turgor
3. Oliguria - ↓Kidney perfusion - ↓GFR → UO
-kidneys try to conserve water
HYPOCALCEMIA
- low calcium content in the blood
- Calcium plays an important role for muscle
contraction, nerve function, blood clotting, and bone
health
ETIOLOGY
1. Removal of parathyroid glands
- No parathyroid = loss of PTH
PTH is responsible for simulating calcium release from
the bones, reabsorption of calcium in the kidneys, and
conversion of vitamin D into active form (Calcitriol)
wherein a protein is produced that mimics
PTH leading to increased serum calcium
levels.
● Vitamin D Supplements - increased
intestinal calcium absorption yet reduced
calcium excretion.
● Granulomatous Diseases - calcitriol
production is increased, resulting in an
increased calcium absorption.
● Genetic Factors - less sensitivity to calcium
levels would cause PTH secretion to
become abnormal
● Immobility - weight-bearing effect reduces
and can lead to bone destruction

2. Hyperphosphatemia CLINICAL MANIFESTATION

- Calcium and Phosphorus are inversely proportional, 1. Muscular weakness
and the increased amount of phosphorus causes 2. Fatigue
calcium ions to bind into it 3. Hyporeflexia
4. Slowed GI motility
3. Malnutrition/Vitamin D deficiency 5. Nausea and vomiting
- Lack of Vitamin D intake and calcium containing food 6. Constipation
- Vitamin D is responsible for absorption of calcium in 7. Lethargy
the intestines to bring it to the bloodstream 8. Confusion
9. Cardiac dysrhythmia
4. Kidney Failure 10. Flank Pain
- Related to hyperphosphatemia

5. Pancreatitis
- inflammation causes glucagon release = increased
secretion of calcitonin
Calcitonin is suppresses osteoclast activity, which
prevents the breaking down of bones to release
calcium to the bloodstream

CLINICAL MANIFESTATIONS

1. Positive Trousseau and Chovstek’s Sign

- Trousseau: when inflating a blood pressure cuff on
the arm leads to carpal spasm
- Chovstek: tapping the facial nerve causes facial
muscle twitching

2.

Hypercalcemia
Etiologic factors
● Primary hyperparathyroidism - Excess
production of PTH increases serum calcium
levels.
● Cancer - May stimulate
malignancy-associated hypercalcemia,