PATHOPHYSIOLOGY : FLUID BALANCE ü has less lean muscles

ü more fatty adipose tissues in the body (body

TOPIC OUTLINE fat)
1 FLUID BALANCE
2 FLUID PHYSIOLOGY GENDER
3 FLUID VOLUME OVERLOAD VS FLUID VOLUME DEFICIT
4 MANIFESTATIONS (SIGNS & SYMPTOMS) Ø In general, younger individuals has higher percentage of
body fluid than older people
FLUID BALANCE OVERVIEW Ø MEN has more lean muscle mass than fatty adipose
tissues
BODY FLUIDS
Ø MEN retain more BODY FLUID than WOMEN

Ø made up of 60-70% fluid

Ø H2O gradually decrease as we age (birth to old age)
LOCATION OF BODY FLUIDS
*due to muscle mass

LOCATION
CAUSES 1 Intracellular Fluid (ICF)
2 Extracellular Fluid (ECF)
FLUID OVERLOAD DEHYDRATION

Heart Failure not drinking enough water

Intracellular Fluid (ICF)
Renal Failure (broken
kidneys) Ø Fluid inside the cell
Ø KEY ELECTROLYTE : POTASSIUM
ü pulled from outside of the cell to inside
Ø 2/3rds or 75% of fluid inside the cell specifically in the
FACTORS THAT INFLUENCE FLUID BALANCE skeletal muscle cells
Ø Electrolyte imbalances makes so much muscle problem
FACTORS
1 Muscle
2 Body Fat Extracellular Fluid (ECF)
3 Gender
Ø Fluid inside the blood vessels, skin tissues, and spinal
MUSCLE cord (cerebrospinal fluid - CSF)
Ø 1/3rd of the body fluid
Ø muscle holds on to water TEST TIP
Ø Muscle retains more H2O
ECF
Ø skin and blood also hold the highest amount of water

6 liters of blood in the BLOOD VESSELS

(Intravascular Space)
BODY FAT
11 to 12 liters of INTERSTITIAL FLUID
Ø obese patients has less total body water than those who
are lean (thin) 1 liter in the TRANSCELLULAR SPACE (fluid between our
ü fat cells repels water cells)
Ø Obese patients has higher risk for dehydration (FVI)

DRGB 1
gg

BODY FLUIDS GAINED & LOST VIA ORGANS

BURN PATIENTS
ORGANS
1 KIDNEYS (washing machines) MOST AT RISK for fluid volume deficit
2 SKIN
3 LUNGS Loss tons of water from the blister formation on the
4 GI TRACT burnt skin

KIDNEYS

Ø washing machines of the blood LUNGS

Ø serve as the doors to your body (fluid in and out of the
body
Ø cause insensible fluid loss approx. 300 mL per day
Ø SERIOUS: if increased respiratory rate
NORMAL LAB VALUES : KIDNEYS Ø Monitor for RESPIRATORY ALKALOSIS NCLEX TIP
*Kussmaul Respirations
Daily Urine Output 1 to 2 liters
1 mL/kg/hr
240 ml in 3 hours Kussmaul Respirations

Minimum Amount of Urine per 400 - 600 mL hyperventilation

day to excrete toxins and waste

High respiratory rate

BUN AND CREATININE

Blowing off all CO2 from the body

↑ BUN & CREATININE Renal Failure

↑ ONLY BUN Dehydration

GI TRACT

Ø DIARRHEA and FISTULAS cause large fluid losses

NCLEX TIP
SKIN

Ø visible water and electrolyte losses through skin NORMAL LAB VALUES : GI TRACT
*sweating, diaphoresis
Ø CHIEF SOLUTES IN SWEAT : SODIUM, CHLORIDE & Daily Excretion 100 – 200 mL
POTASSIUM
*loss increases due to
1. Fever
FLUID PHYSIOLOGY
2. Heat Stroke
3. Thyroid Crisis
BODY FLUID KEY TERMS
Ø Every degree increase in body temperature = insensible
1 OSMOSIS
water loss increase by 10%
2 DIFFUSION
*EXAMPLE : 3 FILTRATION
8 degrees = 80% fluid loss

DRGB 2
gg

Fluid pulled out All fluid stays Suck the fluid out
DIFFUSION OSMOSIS FILTRATION from the blood inside the blood of the cell
and into the cell vessel
The MOVEMENT The MOVEMENT of The MOVEMENT of
of SOLUTES from FLUID from an area WATER occurs osmotic pressure Enough pressure Lesser pressure on
an area of of LOWER solute from an area of is greater in the on membranes the membranes
GREATER concentration to HIGH body
concentration to an area of HIGHER HYDROSTATIC
an area of LESSER solute PRESSURE to an big fat swollen Cell shape stays Shrink and skinny
concentration, concentration, with area of LOW hippo cells the same cells
leading ultimately eventual HYDROSTATIC
to EQUALIZATION EQUALIZATION of PRESSURE.
of the solute the solute FLUID VOLUME OVERLOAD VS FLUID VOLUME DEFICIT
concentrations concentrations
FLUID VOLUME OVERLOAD VS FLUID VOLUME DEFICIT
occurs through Balance and equal A passage of water
random out the plane fields and electrolytes in
movement of ions the interstitial fluid Fluid Volume Overload Fluid Volume Deficit
and molecules
Overhydration Dehydration
Ex. exchange of Where soluted go, Ex. Filtration of 180
O2 and CO2 in the fluids flow L of plasma per
Other Names : Other Names :
lungs day (kidneys)
● Fluid Volume ● Deficient Fluid
Excess Volume
● Hypervolemia ● Hypovolemia
FLUID PHYSIOLOGY ● FVO

Ø The number of osmotically active particles per kilogram

of water
Ø the concentration of the solution
*how heavy/concentrated is it?

Ø OSMOTIC PRESSURE
Ø measured in MILLIOSMOLES (mOsm)
MEMORY TRICKS
NORMAL LAB VALUES : OSMOLALITY OF BLOOD
Overhydration DRY
Osmolality of Blood 270 - 300 Overload! Dehydration
milliosmoles/kilogram Deficit of fluid
(mOsm/kg)

Isotonic Fluids Osmolarity 270 - 300 mOsm/L

FLUID VOLUME OVERLOAD

Ø MANIFESTATION : EDEMA
HYPOTONIC ISOTONIC FLUIDS HYPERTONIC
FLUIDS FLUIDS
Edema
less than 300 270 - 300 greater than 300 - the swelling of soft tissues as a result of excess fluid
mOsm/L mOsm/L mOsm/L accumulation
- Commonly seen on the lower extremities

DRGB 3
gg

MEMORY TRICKS

Hydrostatic pressure

HIGH fluid pressure

Ø MANIFESTATIONS :

EDEMA RATING

0+ No pitting edema

1+ 2 mm or less Mild
(immediate rebound of skin)

2+ 3-4 mm Moderate
(15 seconds rebound) Ø EXAMPLES :
Renal Failure
3+ 5-6 mm Moderately Severe o fail to filter the blood and excrete
(30 seconds to rebound) excess fluid in and out of the body

4+ 8 mm or deeper SEVERE!
(1-2 mins to rebound)

Heart Failure
o heart fails to pump blood forward
and backs up in the body & lungs

4 CAUSES OF EDEMA
1 Increased hydrostatic pressure TEST TIP
2 Decreased colloid osmotic pressure
3 Increased capillary permeability o MEMORY TRICK
4 Obstruction of the lymphatic system
MEMORY TRICKS
Increased hydrostatic pressure
HF - Heart Failure
Ø Increased volume
Ø High fluid pressure within the blood vessels causing fluid HF - Heavy Fluid
to be pushed out of the vascular spaces (blood vessels)
to the interstitial space = edema

DRGB 4
gg

Decreased colloid osmotic pressure

Ø Decreased fluid retention inside the blood vessels

Colloid
- serve to hold water within the vascular space
- Created by plasma proteins (albumin)

Albumin

- Do not diffuse readily across the capillary membrane

- Attract fluid into the vascular spaces Increased capillary permeability
- made in the LIVER
Ø leaky capillaries (connection between the arteries and
Ø LOW ALBUMIN (low plasma proteins)
veins)
Ø CAUSED BY : severe inflammation or tissue destruction
MEMORY TRICKS

A - Albumin
A - Attracts fluid

Ø Low albumin = fluid escapes the blood vessels and into

the body cavity (abdomen)

● EXAMPLES :
Bacteria (infection)
Burns
o Damage the capillaries leading to
Ø EXAMPLES (LOW ALBUMIN) : edema from fluid leaking out of the
Cirrhosis (liver disease) vascular spaces
o result from decreased albumin
allowing fluid to leak out of those
vessels and into 3rd spaces

Starvation
o No building blocks of protein being
consumed to produce albumin

DRGB 5
gg

PATHOPHYSIOLOGY OF MAJOR BURNS

Ø cause massive tissue damage and cellular destruction

Obstruction of the Lymphatic System

Ø Leading to: widespread systemic inflammation w/c

Lymphatic System
increases capillary permeability
*leaky blood vessels that fill up the body like a water - network of tissues, vessels and organs that work
balloon together to clean the blood and get rid of any waste the
cells make
Ø Fluids, electrolytes and other contents spill over into the
- "Drainage system"
interstitial spaces/3rd spaces - with the help of White Blood Cells (lymphocytes)
RESULT : - Clean 20 L of plasma per day
o SEVERE Low fluid volume
o Hypovolemic shock Ø problem in the back up of fluid
Þ S fluid and electrolytes go Ø CAUSES :
Cancer (tumor blockage)
into the tissues
o blocks the lymphatic system
Þ Severely low blood
pressure

Infection (big lymph nodes)

o Traffic jam as the WBC overload the
system from fighting infection
Ø INTERVENTION FOR MAJOR BURNS:

NO.1 INTERVENTION NCLEX TIP

1. IV Lactated Ringer’s (LR) solution

2. IV Normal Saline (0.9% Sodium chloride)

Isotonic solutions that increase fluid volume

inside the blood vessels, increasing BP
NOT : 5% Dextrose (glucose + water), 0.45%
normal saline (hypotonic solution)

DRGB 6
gg

FLUID VOLUME DEFICIT Urination

4 CAUSES OF FLUID VOLUME DEFICIT Ø drain fluid into and onto the body
1 Vomiting & Diarrhea
2 Hot body & Sweating
3 Severe Burns
4 Urination

Vomiting & Diarrhea

Ø from food poisoning, infection or too much alcohol

TOP 3 CAUSES OF FLUID VOLUME DEFICIT

REASONS MEMORY TRICKS

DI - Diabetes Insipidus DI think Dry Inside

Urine : 20 L

DKA - Diabetic DKA think Dry

Hot body & Sweating Ketoacidosis ● Increased urine
concentration in the
blood (hyperglycemia)
Ø Fever, Heat Stroke, Thyroid Crisis
● Caused by infection
● Manifestation :
Kussmaul respiration
(insensible fluid loss)

Diuretics - Furosemide, End in "-ide" = body dried

Hydrochlorothiazide

COMPENSATION OF FVD & DEHYDRATION

Ø Increased Thirst
Severe Burns Ø Holding on to urine (concentrated urine)
Ø Increased HR & Vasoconstriction
Ø MOST AT RISK FOR FLUID VOLUME DEFICIT try to make up for the decreased fluid through
ü due to blister formation on the skin
pumping the heart at a faster pace all around
the body and perfuse the tissues with oxygen

MANIFESTATIONS (SIGNS & SYMPTOMS)

FLUID VOLUME OVERLOAD VS FLUID VOLUME DEFICIT

DRGB 7
gg

Fluid Volume Overload Fluid Volume Deficit

Hypervolemia Hypovolemia

HIGH fluid volume LOW fluid volume

Big Bulging Body LOW & Little Body
• Increased central
BIG & Bulging Body LOW & Little Body venous pressure *PRIORITY : can kill client via
BIG fluid volume LOW fluid volume CVP Hypovolemic Shock (causing a
• Bounding pulses lot of systems to stop working)
• Big, distended neck • Decreased central
veins (Jugular Vein venous pressure
Distention – JVD) CVP
• distended veins in • Weak, thready
hands and legs pulses
• Flat, neck & hand
veins
• Tachycardia (pulse
over 100) TEST TIP

INTEGUMENTARY (SKIN) INTEGUMENTARY (SKIN)

• Periorbital edema • Sunken eyes
• Pitting edema • Dry skin (Poor turgor
(think water bed & tenting)
KEY NUMBERS : skin) • Dry mucous
● 2 -3 lbs in 1 day • Pale cool skin membranes (MM)
● 5 lbs in 7 days • Increased body
temp

➔ critical to HF NEUROMUSCULAR NEUROMUSCULAR

➔ Lead to : • ALOC – Altered • Lethargy to coma
Pulmonary Edema Level of • Weakness
Consciousness
“Mental status
changes”
Fluid Volume Overload Fluid Volume Deficit • Headache
• Weakness &
CARDIOVASCULAR CARDIOVASCULAR paresthesias
• High blood pressure • Low blood pressure
DEADLY DEADLY
• Hypertension (140 • Orthostatic
systolic) TEST TIP hypotension TEST TIP
• HTN Crisis (180 (light headed & URINE URINE
systolic) Stroke Risk dizziness upon • LOW when liquidy • HIGH when dry
- rupture small blood standing) • Decreased urine • Increased urine
vessels in the brain specific gravity specific gravity
(aneurysm) • Low 1.005 (Normal • High 1.005 (Normal
1,005 – 1.030) 1,005 – 1.030)
Low gravity = Low • High gravity = High
weight weight

DRGB 8
gg

• very dilute urine • high thick urine Hyponatremia Hypernatremia

(below 135 mEq/L) (above 145 mEq/L)
Risk for Bra in • Risk for Brain
Damage Bleeding
*Hyponatremic *most tested
encephalopathy
RENAL & URINARY RENAL & URINARY
• Increased urine • Increased urine TREATMENTS
output output initially and
• Decreased urine Decreased urine fluid balance
output (renal output (at the end) WDH
issues)
TREATMENTS

fluid balance

RESPIRATORY RESPIRATORY
• Rapid, shallow • Rapid DEEP
respiratory rate respiratory rate
• Rales (Most
crackles) – fluid in
lungs
Pulmonary Edema

GASTROINTESTINAL GASTROINTESTINAL
• Increased motility – • Decreased motility –
Diarrhea constipation
• Hepatomegaly • Diminished bowel
(enlarged liver) sounds
• Ascites (abdominal • naturally gets stuck
fluid)

LAB VALUES LAB VALUES

• Hemodilution • Hemoconcentration
• LOW when LIQUIDY • HIGH when DRY
• Decreased • Increased
Osmolality Osmolality (blood
(thickness of blood) very thick - mud)
• Decreased • Increased
Hematocrit (Hct) Hematocrit (Hct)
• Decreased Blood • Increased Blood
Urea Nitro (BUN) Urea Nitro (BUN)
• Decreased • Increased
Electrolytes Electrolytes
Low Sodium Na+ High Sodium Na+

DRGB 9