Fluid and Electrolyte

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Fluid and Electrolyte Imbalances: 

1 Fluid and Electrolyte Imbalances

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2

Body Fluid Compartments: 

3 Body Fluid Compartments 2/3 (65%) of TBW is intracellular (ICF) 1/3 extracellular water 25 % interstitial fluid (ISF) 5- 8 % in plasma (IVF intravascular fluid) 1- 2 % in transcellular fluids – CSF, intraocular fluids, serous membranes, and in GI, respiratory and urinary tracts (third space)

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6 Fluid compartments are separated by membranes that are freely permeable to water. Movement of fluids due to: hydrostatic pressure osmotic pressure\ Capillary filtration (hydrostatic) pressure Capillary colloid osmotic pressure Interstitial hydrostatic pressure Tissue colloid osmotic pressure

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7

Balance: 

8 Balance Fluid and electrolyte homeostasis is maintained in the body Neutral balance: input = output Positive balance: input > output Negative balance: input < output

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Solutes – dissolved particles: 

11 Solutes – dissolved particles Electrolytes – charged particles Cations – positively charged ions Na+, K+ , Ca++, H+ Anions – negatively charged ions Cl-, HCO3- , PO43- Non-electrolytes - Uncharged Proteins, urea, glucose, O2, CO2

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12 Body fluids are: Electrically neutral Osmotically maintained Specific number of particles per volume of fluid

Homeostasis maintained by:: 

13 Homeostasis maintained by: Ion transport Water movement Kidney function

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14 MW (Molecular Weight) = sum of the weights of atoms in a molecule mEq (milliequivalents) = MW (in mg)/ valence mOsm (milliosmoles) = number of particles in a solution

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15 Tonicity Isotonic Hypertonic Hypotonic

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16

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17 Cell in a hypertonic solution

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18 Cell in a hypotonic solution

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19 Movement of body fluids “ Where sodium goes, water follows.” Diffusion – movement of particles down a concentration gradient. Osmosis – diffusion of water across a selectively permeable membrane Active transport – movement of particles up a concentration gradient ; requires energy

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20 ICF to ECF – osmolality changes in ICF not rapid IVF → ISF → IVF happens constantly due to changes in fluid pressures and osmotic forces at the arterial and venous ends of capillaries

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21

Regulation of body water: 

22 Regulation of body water ADH – antidiuretic hormone + thirst Decreased amount of water in body Increased amount of Na+ in the body Increased blood osmolality Decreased circulating blood volume Stimulate osmoreceptors in hypothalamus ADH released from posterior pituitary Increased thirst

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23

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24 Result: increased water consumption increased water conservation Increased water in body, increased volume and decreased Na+ concentration

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25 Dysfunction or trauma can cause: Decreased amount of water in body Increased amount of Na+ in the body Increased blood osmolality Decreased circulating blood volume

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26 Edema is the accumulation of fluid within the interstitial spaces. Causes: increased hydrostatic pressure lowered plasma osmotic pressure increased capillary membrane permeability lymphatic channel obstruction

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27 Hydrostatic pressure increases due to: Venous obstruction: thrombophlebitis (inflammation of veins) hepatic obstruction tight clothing on extremities prolonged standing Salt or water retention congestive heart failure renal failure

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28 Decreased plasma osmotic pressure: ↓ plasma albumin (liver disease or protein malnutrition) plasma proteins lost in : glomerular diseases of kidney hemorrhage, burns, open wounds and cirrhosis of liver

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29 Increased capillary permeability: Inflammation immune responses Lymphatic channels blocked: surgical removal infection involving lymphatics lymphedema

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30 Fluid accumulation: increases distance for diffusion may impair blood flow = slower healing increased risk of infection pressure sores over bony prominences Psychological effects

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31 Edema of specific organs can be life threatening (larynx, brain, lung) Water is trapped, unavailable for metabolic processes. Can result in dehydration and shock. (severe burns)

Electrolyte balance: 

32 Electrolyte balance Na + (Sodium) 90 % of total ECF cations 136 -145 mEq / L Pairs with Cl- , HCO3- to neutralize charge Low in ICF Most important ion in regulating water balance Important in nerve and muscle function

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33

Regulation of Sodium: 

34 Regulation of Sodium Renal tubule reabsorption affected by hormones: Aldosterone Renin/angiotensin Atrial Natriuretic Peptide (ANP)

Potassium: 

35 Potassium Major intracellular cation ICF conc. = 150- 160 mEq/ L Resting membrane potential Regulates fluid, ion balance inside cell pH balance

Regulation of Potassium: 

36 Regulation of Potassium Through kidney Aldosterone Insulin

Isotonic alterations in water balance: 

37 Isotonic alterations in water balance Occur when TBW changes are accompanied by = changes in electrolytes Loses plasma or ECF Isotonic fluid loss ↓ECF volume, weight loss, dry skin and mucous membranes, ↓ urine output, and hypovolemia ( rapid heart rate, flattened neck veins, and normal or ↓ B.P. – shock)

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38 Isotonic fluid excess Excess IV fluids Hypersecretion of aldosterone Effect of drugs – cortisone Get hypervolemia – weight gain, decreased hematocrit, diluted plasma proteins, distended neck veins, ↑ B.P. Can lead to edema (↑ capillary hydrostatic pressure) pulmonary edema and heart failure

Electrolyte imbalances: Sodium: 

39 Electrolyte imbalances: Sodium Hypernatremia (high levels of sodium) Plasma Na+ > 145 mEq / L Due to ↑ Na + or ↓ water Water moves from ICF → ECF Cells dehydrate

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40

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41 Hypernatremia Due to: Hypertonic IV soln. Oversecretion of aldosterone Loss of pure water Long term sweating with chronic fever Respiratory infection → water vapor loss Diabetes – polyuria Insufficient intake of water (hypodipsia)

Clinical manifestations of Hypernatremia: 

42 Clinical manifestations of Hypernatremia Thirst Lethargy Neurological dysfunction due to dehydration of brain cells Decreased vascular volume

Treatment of Hypernatremia: 

43 Treatment of Hypernatremia Lower serum Na+ Isotonic salt-free IV fluid Oral solutions preferable

Hyponatremia: 

44 Hyponatremia Overall decrease in Na+ in ECF Two types: depletional and dilutional Depletional Hyponatremia Na+ loss: diuretics, chronic vomiting Chronic diarrhea Decreased aldosterone Decreased Na+ intake

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45 Dilutional Hyponatremia: Renal dysfunction with ↑ intake of hypotonic fluids Excessive sweating→ increased thirst → intake of excessive amounts of pure water Syndrome of Inappropriate ADH (SIADH) or oliguric renal failure, severe congestive heart failure, cirrhosis all lead to: Impaired renal excretion of water Hyperglycemia – attracts water

Clinical manifestations of Hyponatremia: 

46 Clinical manifestations of Hyponatremia Neurological symptoms Lethargy, headache, confusion, apprehension, depressed reflexes, seizures and coma Muscle symptoms Cramps, weakness, fatigue Gastrointestinal symptoms Nausea, vomiting, abdominal cramps, and diarrhea Tx – limit water intake or discontinue meds

Hypokalemia: 

47 Hypokalemia Serum K+ < 3.5 mEq /L Beware if diabetic Insulin gets K+ into cell Ketoacidosis – H+ replaces K+, which is lost in urine β – adrenergic drugs or epinephrine

Causes of Hypokalemia: 

48 Causes of Hypokalemia Decreased intake of K+ Increased K+ loss Chronic diuretics Acid/base imbalance Trauma and stress Increased aldosterone Redistribution between ICF and ECF

Clinical manifestations of Hypokalemia: 

49 Clinical manifestations of Hypokalemia Neuromuscular disorders Weakness, flaccid paralysis, respiratory arrest, constipation Dysrhythmias, appearance of U wave Postural hypotension Cardiac arrest Others – table 6-5 Treatment- Increase K+ intake, but slowly, preferably by foods

Hyperkalemia: 

50 Hyperkalemia Serum K+ > 5.5 mEq / L Check for renal disease Massive cellular trauma Insulin deficiency Addison’s disease Potassium sparing diuretics Decreased blood pH Exercise causes K+ to move out of cells

Clinical manifestations of Hyperkalemia: 

51 Clinical manifestations of Hyperkalemia Early – hyperactive muscles , paresthesia Late - Muscle weakness, flaccid paralysis Change in ECG pattern Dysrhythmias Bradycardia , heart block, cardiac arrest

Treatment of Hyperkalemia: 

52 Treatment of Hyperkalemia If time, decrease intake and increase renal excretion Insulin + glucose Bicarbonate Ca++ counters effect on heart

Calcium Imbalances: 

53 Calcium Imbalances Most in ECF Regulated by: Parathyroid hormone ↑Blood Ca++ by stimulating osteoclasts ↑GI absorption and renal retention Calcitonin from the thyroid gland Promotes bone formation ↑ renal excretion

Hypercalcemia: 

54 Hypercalcemia Results from: Hyperparathyroidism Hypothyroid states Renal disease Excessive intake of vitamin D Milk-alkali syndrome Certain drugs Malignant tumors – hypercalcemia of malignancy Tumor products promote bone breakdown Tumor growth in bone causing Ca++ release

Hypercalcemia: 

55 Hypercalcemia Usually also see hypophosphatemia Effects: Many nonspecific – fatigue, weakness, lethargy Increases formation of kidney stones and pancreatic stones Muscle cramps Bradycardia, cardiac arrest Pain GI activity also common Nausea, abdominal cramps Diarrhea / constipation Metastatic calcification

Hypocalcemia: 

56 Hypocalcemia Hyperactive neuromuscular reflexes and tetany differentiate it from hypercalcemia Convulsions in severe cases Caused by: Renal failure Lack of vitamin D Suppression of parathyroid function Hypersecretion of calcitonin Malabsorption states Abnormal intestinal acidity and acid/ base bal. Widespread infection or peritoneal inflammation

Hypocalcemia: 

Hypocalcemia 57