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Pathophysiology Week Two

by: Shina Patel

Pathophysiology Week Two NUTH2003

Shina Patel

GPA 3.6

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Chapter Two Notes contain detailed, in-depth notes on Fluid, Electrolytes, and Acid Base Balance. Also includes common disease processes linked to the topics.
Professor Homsey
Class Notes
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This 8 page Class Notes was uploaded by Shina Patel on Friday July 29, 2016. The Class Notes belongs to NUTH2003 at Seton Hall University taught by Professor Homsey in Fall 2016. Since its upload, it has received 6 views. For similar materials see Pathophysiology in Nursing and Health Sciences at Seton Hall University.


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Date Created: 07/29/16
Pathophysiology Chapter 2: Fluids, Electrolytes, and Acid-Base Balance Week Two Fluid Imbalance Review of Concepts and Processes  Water is a major component of the body and is found both within and outside of the cells. (Intracellular, Extracellular, Interstitial Fluid).  Water is essential to maintain homeostasis.  Water carries nutrients into cells and removes wastes, transports enzymes, and moves blood cells around the body. Also facilitates movements: joints and lungs. Fluid Compartments  About 60% of the human body is made up of water and in an infant 70%  Female bodies have less water than males because they have a higher amount of fatty tissue.  Elderly and obese also have a lower amount of water in their body.  Fluid is distributed between the intracellular compartment (ICF) and extracellular compartment (ECF).  Intravascular Fluid: Blood  Interstitial Fluid: Fluid between cells.  Cerebrospinal Fluid  Transcellular fluid: Present in various secretions, such as those in the pericardial (heart) cavity or the synovial cavity of the joints.  Adult male: 4% of weight is blood, 15% of weight is interstitial fluid, 1% transcellular fluid.  A large volume of water is present in the digestive secretions entering the stomach and small intestine, and this fluid is reabsorbed in the colon, making up a very efficient water-recycling system. Movement of Water  Amount of water leaving the body should equate to the amount of water entering the body. Fluid is lost through urine, feces, and insensible losses (perspiration). Fluid enters the body through liquids and solid foods.  Control of fluid balance is maintained by: 1. Thirst mechanism: hypothalamus, osmoreceptor cells 2. Hormone: antidiuretic hormone (ADH) -> controls amount of fluid leaving body in urine 3. Aldosterone: determines reabsorption of sodium ions and water from kidney tubules 4. Hormone: Atrial natriuretic peptide (ANP): made and released in the heart, reduces workload on the heart by regulating fluid, sodium, and potassium levels.  Moves freely between compartments due to osmosis and filtration depending on the hydrostatic and osmotic pressures within the compartments.  Hydrostatic pressure is viewed as the “push force”. Osmotic pressure is the “pull force” where proteins and electrolytes contribute the osmotic pressure of a fluid.  Major factor in the movement of water through cell membrane is the difference between the osmotic pressure and interstitial fluids.  Ex: if an erythrocyte is placed in a hypotonic solution (low osmosis), water may enter the cell, causing it to swell and malfunction. Fluid Excess- Edema  Fluid excess occurs in the extracellular compartment and may be referred to as isotonic/ iso-osmolar, hypotonic/ hyper-osmolar, or hypertonic/hyper- osmolar depending on the cause.  Edema refers to an excessive amount of fluid in the interstitial compartment, which causes swelling or enlargement of tissue. Edema can be graded from a +1 to +4.  Buttocks, ankles, feet.  Prolonged edema interferes with venous return, arterial circulation, and cell function in the affected area  Four general causes of edema: 1. Increased capillary hydrostatic pressure 2. Loss of proteins, particularly, albumin. 3. Obstruction of the lymphatic circulation. 4. Increased capillary permeability.  Effects of Edema 1. A local area of swelling may be visible and may be very pale or red in color. 2. Pitting edema occurs in the presence of excess interstitial fluid. A depression remains 3. People who have generalized edema May gain body weight 4. Functional impairment due to edema may occur, for ex, when it restricts range of movement of joints. 5. Pain may occur if edema exerts pressure on the nerves locally. 6. Arterial circulation may be impaired 7. Dental related issues: Dentures may not fit well. 8. Possible formation of skin ulcers. Fluid Deficit- Dehydration  Insufficient body fluid resulting from inadequate intake of excessive loss of fluids or a combination of the two.  Losses are more common and affect the extracellular compartment first.  Fluid loss is often measured by a change in body weight 1. Mild deficit: decrease in 2% of body weight 2. Moderate deficit: decrease in 5% of body weight 3. Severe deficit: decrease in 8% of body weight.  More serious problem for infants and elderly.  Water loss accompanied by protein loss and electrolyte loss  Isotonic dehydration: proportionate loss of fluid and electrolytes  Hypotonic: Loss of more electrolytes than water.  Hypertonic dehydration: Loss of more water than electrolytes.  Causes of dehydration:] 1. Vomiting and diarrhea 2. Excessive sweating 3. Diabetic Ketoacidosis 4. Insufficient water intake 5. Use of a concentrated formula in attempt to provide more nutrition to infant  Effects of Dehydration: 1. Dry mucous membranes in the mouth 2. Decreased skin turgor 3. Lower BP, weak pulse, fatigue 4. Increased hematocrit 5. Decreased mental function, confusion, loss of consciousness 6. Increased thirst 7. Increasing heart rate 8. Constricting the cutaneous blood vessels leading to pale and cool skin. 9. Producing less urine and concentrating the urine. Third-Spacing Fluid Deficit and Fluid Excess  Situation which fluid shifts out of the blood into a body cavity or tissue where is it no longer available as circulating fluid. Example: Peritonitis.  Lab tests such as hematocrit and electrolyte concentration will indicate 3 rd spacing. Electrolyte Imbalances Sodium Imbalance  Sodium is the primary cation (positively charged ions) in the extracellular fluid.  Diffusion of sodium occurs b/w the vascular and interstitial fluids.  Sodium transport across the cell membrane is controlled by the sodium potassium pump.  Sodium is actively secreted into mucus and other body secretions. It exists in the body primarily as salts such as sodium bicarbonate and sodium chloride.  Lost in the form of sweat, urine, and fees.  Sodium levels controlled by kidneys  Sodium is important in mantainance of extracellular fluid volume through its effect on osmotic pressure because it makes up about 90% of the solute in extracellular fluid.  Hyponatremia: Refers to a serum sodium concentration below 3.8 to 5 mmol per liter.  Causes of Hyponatremia: Losses from excessive sweating, vomiting, or diarrhea. Use of certain diuretic drugs combined with low salt diets. Hormonal imbalances such as insufficient Aldosterone and excess ADH secretion. Early chronic renal failure and excessive water intake.  Effects of Hyponatremia: Impaired nerve conduction, decreased osmotic pressure resulting in low BP, swelling of brain cells causing confusion, headache, seizures, and weakness.  Hypernatremia: Excessive sodium level in the blood and ECF.  Causes of Hypernatremia: Insufficient ADH which leads to large volume of dilute urine, loss of thirst mechanism, Watery diarrhea, and prolonged periods of rapid respiration.  Effects of Hypernatremia: Weakness, agitation, firm fatty tissues, increased thirst, dry mouth, rough mucous membranes, and decreased urine output because ADH is secreted. Potassium Imbalance Review of Potassium  Potassium is a major intracellular cation and so its serum levels are low compared to sodium. (3.5 to 5 mmol per liter).  Ingested through foods: bananas, citrus fruits, lentils, etc and output through urine.  Hormone: Insulin also promotes movement of potassium into cells.  Potassium levels are also influenced by the acid base balance. Acidosis shifts potassium out of cells and alkalosis shifts potassium into cells.  Abnormal potassium levels have an effect on the contractions of cardiac muscle causing changed in ECG readings.  Hypoalkemia: Serum level of potassium is less than 2 mmol per liter.  Causes of hypoalkemia: excessive levels from the body due to diarrhea, diuresis associated with certain diuretic drugs, presence of excessive aldosterone or glucocorticoids in the body, decreased dietary intake, and treatment of diabetic ketoacidosis with insulin.  Effects of Hypoalkemia: Cardiac dysrhythmias. Interference with neuromuscular function. Paresthesias such as “pins and needles”, Decreased digestive tract motility. Respiratory muscles become weak, and renal function is impaired leading failure to concentration the urine.  Hyperalkemia: Serum level of potassium is greater than 2.6 mmol per liter  Causes of Hyperalkemia: Renal failure, deficit of aldosterone, “potassium sparing” diuretic drugs, leakage of intracellular potassium into extracellular fluids, and displacement of potassium from cells by prolonged or severe acidosis.  Effects of Hyperalkemia: ECG shows cardiac dysrhythmias. Muscle weakness is common. Fatigue, nausea, and paresthesias. Calcium Imbalance Review of Calcium  Calcium is an important extracellular cation. It is ingested through milk products. Stored in bones, Excreted through urine/feces  Calcium balance is controlled by PTH and calcitonin, but also influenced by vitamin D and phosphate ions.  Low blood calcium levels stimulate secretion of PTH hormone which leads to calcium absorption.  Calcium has many important functions: provides structural strength, stability of nerve membranes, muscle contractions, many metabolic processes and enzyme reactions.  HYPOCALCEMIA Serum calcium level is below 2.2 mmol per liter.  CAUSES OF HYPOCALCEMIA Hypoparathyroidism, malabsorption syndrome, deficient serum albumin, increased serum pH- resulting in alkalosis.  EFFECTS OF HYPOCALCEMIA Increase permeability/excitability of nerve membranes, Heart contractions become weak.  Skeletal muscle spasms result from the increased irritability of the nerves associated with nerve fibers. Hypercalcemia  Serum calcium level is greater than 2.5 mmol per liter.  CAUSES OF HYPERCALCEMIA Uncontrolled releases of calcium from the bones due to neoplasms, Hyperparathyroidism, Immobility which may lead to demineralization, Increased intake of calcium and milk-alkali syndrome, associated with increased milk and antacid intake.  EFFECTS OF HYPERCALCEMIA Depression of neuromuscular activity, interfere with function of ADH in the kidneys, Cardiac contractions increase in strength, and decreased bone density. Other Electrolytes Magnesium  Intracellular ion that has a normal serum level of 0,7 to 1.1 mmol per liter. About 50% of total body magnesium to stored in bone. Found in green vegetables.  Magnesium balances are rare  HYPOMAGNESEMIA Results from malabsorption or malnutrition, often associated with chronic alcoholism. May also occur with diabetic ketoacidosis, hyperparathyroidism, and hyperaloderonism. Low serum magnesium levels leads to neuromuscular hyperirritability, with tremors or chorea, insomnia, personality disorder.  HYPERMAGNESEMIA Occurs with renal failure. Excess magnesium depresses neuromuscular function leading to decreased reflexes , lethargy, and cardiac arrhythmias. Phosphate  Phosphate ions are located primarily in the bone but circulate in both the intracellular and extracellular fluids.  Serum level is normally .85 to 1.45 mmol per liter.  Phosphate is important for: bone/tooth mineralization, metabolic processes, part of cell membrane, phosphate buffer system  HYPOPHOSPHATEMIA Low serum phosphate levels may result from malabsorption syndromes, diarrhea, and excessive use of antacids. Neurologic function is impaired, tremors, weak reflexes, confusion, paresthesias, stupor. Effects: blood cells functions less efficiently oxygen transport decreases, and clotting, and phagocytosis.  HYPERPHOSPATEMIA High serum phosphate levels often results from renal failure. Tissue damage or cancer chemotherapy may cause the release of intracellular phosphate. Chloride  Major extracellular anion with a normal serum level of 98 to 106 mmol per liter.  Chloride tends to follow sodium ions.  Low serum chloride levels to high serum bicarbonate or alkalosis. This is referred to as chloride shift.  HYPOCHLOREMIA Low serum chloride is associated with alkalosis in the early stages of vomiting when hydrochloric acid is lost from the stomach. Excessive perspiration associated with fever or strenuous labor on a hot day can lead to loss of sodium chloride resulting in hyponatremia and hypochloremia, and ultimately dehydration.  HYPERCHLOREMIA Excess chloride ion may develop with excessive intake of sodium chloride, orally or intravenously leading to weight gain and edema. Acid-Base Imbalance Review of Concepts and Processes  Acid base balance is essential to homeostasis.  Normal serum pH range is 7.35 to 7.45  Death usually results if the serum pH is below 6.8 or above 7.8  A pH less than 7.35 depresses the central nervous system & decreases cell enzyme function. Control of Serum pH  Three mechanisms control or compensate for pH: 1. The buffer pairs circulating in the blood respond to pH changed immediately. 2. Respiratory system can alter carbon dioxide levels in the body by changing the respiratory rate. 3. Kidneys can modify the excretion rate of acids and the production and absorption of bicarbonate ion.  The kidneys are slow to compensate for a change in pH but are the most effective mechanism. Buffer System  A buffer is a combination of a weak acid and it alkaline salt.  Body has 4 major buffer pairs: 1. Sodium bicarbonate-carbonic acid buffer 2. The phosphate system 3. Hemoglobin system 4. Protein System The Bicarbonate-Carbonic Acid Buffer System and Maintenance of Serum pH  Composed of carbonic acid and bicarbonate ion (base).  Respiratory system and kidneys  Normal range: 7.35 to 7.45  Ratio of bicarbonate ion to carbonic acid must be 20:1 !!! Respiratory System  When serum carbon dioxide or hydrogen ion levels increase, chemoreceptors stimulate the respiratory control center to increase the respiratory rate, thus removing more C02 from the body. Renal System  Kidneys can also reduce the acid content of the body by exchanging hydrogen for sodium ions under the influence of aldosterone.  Urine pH may range from 4.5 to 8.0 as the kidneys compensate.  Arterial blood gasses, base excess, anion gap can be used to determine acid base balance. Acid Base Imbalance  Table 2.8  Alkalosis refers to an increase in serum pH or decreased hydrogen ions. It may be respiratory alkalosis if increased respirations cause a decrease in C02.  Imbalances may be acute or chronic. Compensation  Cause of the imbalance determines the first change in the ratio. Respiratory disorders are always represented by an initial change in carbon dioxide.  The compensation is assessed by the subsequent change in the second part of the ratio.  Ex: if a patient has respiratory acidosis, the lungs can not compensate but they kidneys can.  As long as the ratio of 20:1 is maintained and the serum levels are normal, compensation is achieved. Decompensation  If the kidneys and lungs cannot compensate properly, the ratio changes, and serum pH moves out of the normal range which affects cell metabolism and function. Acidosis  Respiratory acidosis, increase in carbon dioxide levels may occur when: 1. Conditions such as pneumonia, airway obstruction, or chest injuries take place 2. Chronic respiratory acidosis is common with people with COPD.  Metabolic Acidosis is associated with a decrease in serum bicarbonate resulting from: 1. Excessive loss of bicarbonate ions: diarrhea and loss of bicarbonate 2. Increased utilization of serum bicarbonate to buffer increased acids, when large amounts of acids are produces in the body because the buffer bicarbonate binds with such acids that can be removed by the kidneys 3. Renal disease or failure 4. Decompensated metabolic acidosis  Effects of Acidosis: 1. Nervous system function is impaired 2. Headache, lethargy, weakness, and confusion develop. 3. Compensations are deep, rapid breathing and secretion of urine with low pH. Alkalosis  Does not occur as frequently as acidosis.  Results from hyperventilation usually caused by anxiety, high fever, or an overdose of Aspirin.  Breathing back in exhaled air “Breathing into brown bag”  Metabolic acidosis, in which there is an increase in serum bicarbonate ion, commonly follows loss of hydrochloric acid from the stomach either in the early stages of vomiting or with drainage from the stomach.  Effects of Alkalosis: 1. Irritability of nervous system 2. Restlessness 3. Muscle twitching 4. Tingling 5. Numbness of fingers, seizures, coma Treatment of Imbalances  Deficits can be removed by adding fluids or the particular electrolyte to the body fluids.  Add electrolytes, such as sodium, in accordance to how much water is being added  Addition of bicarbonate to the blood will reverse acidosis  Diet may be modified to maintain better electrolyte balance.  Other factors such as respiratory or kidney disorders and hormonal imbalances can have dramatic effects on the fluid/ electrolyte balance.


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