Anatomy of G.U.T.

• Body Fluids
● Refers to body water & it’s dissolved substances or solutes.

• Osmolarity
● Describes the concentration of solutes or dissolved particles

• Electrolytes
● Active chemicals in the body fluids
Ag Gen
e der

Body
 “We are
approximately 2/3
water”
a. Infant – 75-80% of body weight
- greater requirement of body fluids
- poor concentrating ability of the kidney
- pre-term 90% increase

b. Male – 60% of body weight

c. Female – 55% of body weight

d. Elderly – 45% of body weight

- less metabolism
- poor skin turgor
- decrease body mass
[Link] fluid (ICF)
- fluid within the cell
- 40% of TBW = 28L
- skeletal muscle

b. Extracellular fluid (ECF)

- fluid outside the cell
- 20% of TBW = 14L
 Extracellular fluid (ECF)
b.1. Intravascular = 25% (3L of 6L is plasma)
- liquid portion of blood
b.2. Interstitial = 75% (11-12L)
- surrounds the cell
b.3. Transcellular = 1-3% (1L)
- ex. Digestive juices, water & solutes
in renal tubules & bladder, pleural fluid, joints,
eyes, lymph & CSF (secreted by epithelial cells)
⮚ maintain the body temperature, cell shape
⮚ transport nutrients, waste & gases
⮚ hydrolyzes food in the digestive system

▪ Maintains blood volume

▪ Transports system to & from the
cell

▪ Provides for internal aqeous medium for

cellular chemical function
a. Exogenous
– water either drink or ingested in solid
foods
- 2 - 3L/24h

b. Endogenous
– water is release during oxidation of
ingested foods
- ave. < 500mL/24h
• ingested foods – 750mL
• ingested liquids –
1500mL
• Cellular metabolism –
250mL

• GIT – 100-200mL
(sensible)
• Skin – 600mL
(insensible)
• Lungs – 300mL
(insensible)
• Kidney – 1500mL
Pathological losses
✔ vascular bleeding
✔ vomiting
✔ diarrhea
✔ excessive sweating
✔ GI suctioning
✔ burn
✔ patient with renal
& GIT disorders
MOVEMENT OF FLUIDS
BETWEEN
COMPARTMENTS
 Osmolality & Osmolarity

OSMOLALITY is an expression of
the
concentration of solution in terms
of 1000g
OSMOLARITY is of
anwater.
expression
of
concentration of 1000ml of
• Normal plasma
solution.
osmolality is 275-295

mOsm/kg
 • Movement of
solutes from area
of higher
concentration to
lesser
concentration
• Process that require
energy for the
movement of
substance through a
cell membrane from
area of lesser
concentration to
greater concentration
❖Major method of
transporting fluids
❖Movement of water
from an area of
lower concentration
to an area of higher
concentration
 Movement of fluids through capillaries ⇒⇒
results from blood pushing against the walls
of the capillary.
•32 mmHg ( arterioles)
•12 mm Hg ( venules)

“fluid pushing” – forces fluids & solutes

out through the capillary walls into the
interstitial fluid.
 “keeping the fluid in”
prevents too much fluid
from leaving the
capillaries

Plasma Colloid Osmotic Pressure “water magnet”

pulling force of albumin in the large CHON molecule,
IVC
attracts water & hold it
(average: 25mmHg)
inside the blood vessel
Pull or absorb fluid
from the interstitial
space
Arterial Venous
Capillary end
end
bed

Hydrostatic Hydrostatic pressure

pressure Colloid osmotic 12mmHg
32mmHg pressure
22mmHg

Filtratio
n Absorptio
n
+10 filtration -10 filtration
pressure pressure
Moving fluid into Pulling fluid into
interstitial space interstitial space

STARLING’S LAW OF THE CAPILLARIES

 Internal Regulation of
Body Water
And Electrolytes

•Thirst
• Kidney
• Hormones
- Antidiuretic
Hormones
- Aldosterone-renin
Angiotension
system
 THIRST
- major control of actual fluid
intake
- It is stimulated by ECF osmolality
- w/c
leads to drying of mucous
membranes in the mouth which in
turn stimulate the thirst center.
- thirst center is located in the
ventromedial
nucleus of the hypothalamus.
 -responsible for regulating the
volume and
osmolality of body fluids.
- It receives approximately 20% of
the
cardiac output, resulting in renal
blood flow
- GFR, ADH and the Aldosterone-
rates of about 1200ml/min.
renin-
Angiotensin system controls the
water and
● “VASOPRESSIN” , “water retainer”
● Produced by hypothalamus
● Released in response to
hyperosmolality, volume depletion,
stress
● Promotes water reabsorption in
renal tubules
● Produces vasoconstriction
 Factors & mechanism involved in
antidiuretic hormone
OSMOLALITY (ADH) production & effectIN
OSMORECEPTORS of THE
ADH
HYPOTHALAMUS

VOLUME RECEPETOR
ATRIA & GREAT VEINS
HYPOTHALAMUS ADH

BLOOD POSTERIOR PITUITARY

VOLUME GLAND
OR KIDNEY
BLOOD
PRESSURE TUBULES

NARCOTICS H2O
STRESS
ANESTHETIC
REABSORPTIO
AGENTS N
NICOTINE VASCULAR
ANTINEOPLASTIC
AGENTS
VOLUME
SURGERY & OSMOLALITY
enzyme secreted by special cells →(near glomerulus)

Causes peripheral
vasoconstriction &
stimulates production
of
✔SECRETED BY ADRENAL CORTEX
✔ACTS ON KIDNEYS TO DECREASE WATER
LOSS IN THE FORM OF URINE
✔INITIATES ACTIVE TRANSPORT OF
SODIUM FROM RENAL TUBULES
✔REDUCES NA EXCRETION,REDUCES H2O
EXCRETION
✔INCREASES POTASSIUM EXCRETION
Principles and techniques of Physical
& Laboratory Examination
• Inspection
• Palpation
• Percussion
• Auscultation
• Diagnostic test(KUB,UTZ,MRI,CTSCAN,BUN,Serum test)
• Weight,VS
 Nursing Diagnosis related to F/E
Imbalance
• Risk for fluid volume deficit
• Fluid volume deficit/excess
• High risk for injury r/t [Link]/excess
• High risk for injury r/t acid-base imbalance
• Altered urinary elimination
• Impaired integumentary integrity
 Types of IV fluids:
Isotonic = LR
PNSS (0.9%NSS)
NM
Hypertonic= D50W
D10W
D5NSS
D5LR
3%NSS

Hypotonic = D5W
D2.5W
0.45% NSS
0.3% NSS
0.2% NSS
 Fluid Volume Deficit
A. Hyperosmolarity-ECF water
deficit(exceed to 300 mOsml/L
cause: decrease water intake, increase loss
of water, injudicious use of hypertonic solution, near
drowning in salt water

SIGNS & SYMPTOMS

❖ Thirst Increase BUN,creatinine , uric acid
❖ Poor skin turgor
❖ Dry tongue Increase RBC, hct,
❖ Sunken fontanels Decrease LOC
❖ Increase temperature Muscle weakness
❖ CV symptoms
❖ Decrease urine
❖ Decrease weight
 GOAL OF CARE

1. Maintain adequate fluid volume

2. Assess: tissue dehydration, hypovolemia,
hypoxia, shrinkage of brain cells
3. Eliminate cause
4. Replace water
5. Maintain skin integrity
B. Hyposmolar Imbal.- ECF water
excess
Cause: 1. water excess – increase water intake, water retention 2* to
renal disease or brain injury, drug related cause, near drowning, surgery or
trauma
2. solute deficit – decrease Na in diet, diuretic therapy,
replacement with water only, burns
S/S: swelling of cerebral cells, pulmonary edema, flushed skin,
oliguria

SIGNS & SYMPTOMS

❖ Anorexia,nausea and vomiting
❖ Bounding pulse
❖ Lethargy,confusion,convulsion
❖ Decrease Na and hematocrit
❖ Increase urine output
❖ Sudden weight gain
 Management:

Water restriction
Eliminate the cause
Decrease Na in the diet
Diuretic therapy
• ELECTROLYTE
IMBALANCES
 SODIUM (Na)
❖ most abundant extracellular cation
❖ closely associated with chloride
❖ influenced by diet, aldosterone
135-145 mEq/L
Functions:
[Link] the ECF volume
b. Maintains plasma volume and regulates size of vascular space

c. Controls the body water distribution by maintaining the osmotic equilibrium

between the ICF and ECF
d. Helps in nerve impulse conduction to the muscles
e. Helps control muscle contractility; especially those of the heart muscle
f. Assists in maintenance of neuromuscular irritability
❖Na requirement/day = 4.5gms/day
(Luckman)
= 6.0gms/day
(Davies NCLEX)

❖ Na excretion is via sweat, urine and feces

❖ Regulation of Na
a. Aldosterone – retains Na in blood
This is controlled by rennin-angiotensin system
( increase in rennin – increase in aldosterone)
b. GIT controls the Na excretion in the presence of Na
depletion
c. Corticosteroids ( steroids ) promotes Na resorption by
kidney tubule
SOURCES
table salt, processed foods, smoked/preserved meats, corned beef,
ham, bacon, pickles, ketchup, baking products (baking powder &
soda), shellfish, alka-setlzer & cough syrups
 HYPONATREMIA

Causes:
1. Increase water intake
❖ Water intoxication
❖ Ingestion of large amounts of Water after diaphoresis
❖ Administration of Hypotonics solutions or non-electrolyte
solution Ex. D5W
2. Increase Na loss
❖ Vomiting diarrhea
❖ Salt-wasting nephritis
❖ Increase GIT drainage suction
❖ Dercrease aldosteroene ( Addison’s Disease)
❖ Diuretic Therapy
3. Decrease Na Intake
❖ Low salt diet
❖ Hypotonic Solutions via IV
 SIGNS & SYMPTOMS
1. CNS Activity
❖ Increase reflexes(Hypereflexia)
❖ Apathy, depression
❖ Headache, disorientation
❖ Confusion ( esp. in adults)
❖ Convulsion
❖ Decrease LOC(lethargy—stupor—coma)
❖ Signs of Increase ICP( If cerebral edema is present)
2. Neuromuscular activity
❖ Muscle weakness – earliest symptoms
❖ Muscle twitching
❖ Abdominal cramps
❖ Anorexia
3. Signs of decreasing blood volume
❖ BP, CR, RR, temperature
❖ Cold, clammy diaphoresis skin
❖ No thirst
❖ Decrease CVP
❖Urine output – decreased, orange
concentrated
❖Diagnostic Exams:
a. Hct – Increased
b. Hgb – Increased
c. RBC – Increased
d. Urine Specific Gravity – Increased
e. Serum Na – less than 135mEq/L
 PATHOPHYSIOLOGY
Na= below 135mEq/L

Serum Osmolarity (less than 265 mEq/L

Decrease Osmotic pressure in Blood

Attraction to H20 in blood

Increase filtration pressure Decrease blood volume

s/s of hypovolemia potential

s/s of edema formation • Hct, hb, RBC
Especially cerebral edema: •Serum CHON
•Increase ICP (projectile vomiting)
•Cold, clammy skin
•Headache, increase BP systolic
•diaphoresis
•Increase pulse pressure, dec. HR, dec. RR
•Normal diastole
•Ipsilateral pupil dilation
 NURSING MANAGEMENT

❖Diet: high sodium, water

restriction
❖Saline or LR
❖Weigh daily,monitor I&O
 HYPERNATREMIA
Na Excess in the blood ( serum Na = greater the 145mEq/L)
Causes:
1. Decrease water intake:
Ex. Impaired thirst sensation
Decreased LOC
Absence of water source
2. Increase water loss
Ex. Watery diarrheas
Excessive diuresis i.e. diabetes insipidus
Diaphoresis
Hyperventilation
3. Na Intake/Retention:
Ex. Primary Aldosteronism
Cushing Disease/Syndrome
Steroid therapy
Excessive administration of hypertonic solutions
Increase Na, CHON in diet
Renal failure
 SIGNS & SYMPTOMS
❖ Tachycardia, hypotension
❖ Dry, sticky mucus membranes
❖ Thirst, dry tongue
❖ Twitching, tremor, hyperreflexia
❖ Irritability, seizures, coma

❖ CUSHING SYNDROME
 PATHOPHYSIOLOGY
CNS Irritability
Increase Na =145mEq/L ❖Decreased reflexes
Increase Serum Osmolarity 310mEq/L ❖Apprehension
❖Agitation
Osmoreceptor cells in Hypothalamus Activated ❖Convulsion
❖Muscle twitching
❖euphoria
Shifting of Water from ISF to IVF
and ICF to ISF Thirst(1% of H2O loss)

Decrease blood volume, increase Blood volume

shrinkage of cells

[Link] vol.,CVP,& [Link] Increase BP, Increase CVP

Signs of Dehydration: ❖Hypervolemia, Potential

❖Poor skin turgor
❖Increased weight
❖Rough, dry tongue
❖(+) rales
❖Sunken eyeball
❖Edema
❖Depreseed fontanels (child 12-18 mos below)
❖Moist cough
❖Intense thirst
❖Increased HCT
 MANAGEMENT

❖Diet: low sodium (500mg –

3g/day)
❖Weigh daily, I&O
❖Loop diuretics (thiazides )
❖Desmopressin acetate
 POTASSIUM
K– most abundant intracellular cation
3.5-5 mEq/L
❖ exchanges with H ions to maintain acid-base balance
❖ alkalosis = hypoK
❖ acidosis = hyperK
❖ affected by insulin levels
FUNCTIONS
❖ muscular (esp heart) contraction
❖ neuromuscular contraction, including smooth muscles
❖ part of sodium-potassium pump
❖ Glucose uptake into the cells need K
source: dried fruits (prunes), fruits (banana,
cantaloupe, grapefruit, orange, apricots,
avocado), vegetables (spinach, broccoli,
green beans) nuts, milk, meat, coffee &
cola, salt substitutes
• RDA: 40-60 mEq/day
 Hypokalemia

serum K – less than 3.5mEq/L

Causes:
1. inc.K loss- inc. use of diuretics
Inc. use of laxative,enemas,[Link]
suction,drainage,excessive
vomiting,diarrhea,[Link]
[Link] K intake
[Link] K use by cells:
metabolic acidosis, TPN, Healing phase in Burns,
hyponatremia
 SIGNS & SYMPTOMS
• arrhythmia
• Weak, thready pulse
• ECG: depressed ST segment, prominent U
wave
• Cardiac arrest
• GIT- anorexia,N/V,paralytic ileus
• CNS- lethargy, depression, diminished deep
tendon reflexes
 SIGNS & SYMPTOMS
❖ Hyporeflexia
❖ Muscle weakness, paresthesias
❖ Leg cramps
❖ Fatigue, lethargy, coma
❖ Hypoactive bowel sounds, paralytic ileus
MANAGEMENT
IV: no more than 1mEq/10 ml
- make sure patient has voided
Oral: kalium durule (give with meals)
Diet: high potassium
Monitor drug levels of cardiac
glycosides
Protect from injury
 Nsg. Diagnosis
Alteration in C.O. deficit [Link] cardiac dysfunction potential
Impaired breathing pattern [Link] respiratory paralysis
potential
Alteration in nutrition rel. to [Link] mobility
Goal of Care
• Correct level of serum K to w/in normal
• Prevent serious [Link] cardiovascular
complication
• Improve nutritional status
• Restore physical mobility and strength
• Relief of anxiety via adequate information
 BEST TREATMENT IS PREVENTION
• Correct K loss daily. Average normal requirement for K
40mEq/L via dietary intake
• K replacement: give IV drip in of KCL sol.
● K acetate solution
● K PO4 sol.
TAKE NOTE:
• Incorporate in IVF. Never administer in concentrated
form or IV bolus or IV push. Mix with IVF thoroughly
• Usual concentration – 40mEq/L in D5W in 1L of infusion
• Concentration greater than 60 mEq/L are not
administered in peripheral veins – CAUSES PAIN and
SCLEROSIS
• For routine management: Administer at a rate NOT
FASTER than 10mEq/L per hour
• Always check for adequate urine flow before
administering. Oliguria less than 20ml/hour x 2
consecutive hours is indication for stopping KCL infusion.
Administer with caution in adults.
• Observe EKG closely where in giving KCL infusion for
potential hyperkalemia
 HYPERKALEMIA
Potassium Excess (K greater than 50 mEq/L)
• ETIOLOGY:
• Increased in K intake
[Link] [Link] KCL,,Pen G K
• Decreased excretion or loss
● Renal failure
● Addison’s
● Overuse of K-sparing diuretics
K Shift from cells to blood
● Metabolic acidosis
● Insulin deficiency
● Massive cell damage (burns, tumor lysis syndrome,
blood cell hemolysis)
● Blood transfusions
 PATHOPHYSIOLOGY
Increase K Intake Decrease K loss Shift to blood from cells

Serum K = >5.0mEq/L
Increase CNS Activity Increase GIT motility
Increase muscle activity ❖Increase bowel sounds
❖Tingling ❖ irritability
❖Hyper-reflexia ❖Diarrhea
❖numbness ❖Intestinal cramps colic
Increase cardiovascular ❖N/V
irritability ❖anorexia
Skeletal Muscle Irritability ❖Cardiac dysrythmias
❖Muscle twitching (early)
❖Cardiac arrest
❖Flaccid paralysis (late)
❖Decrease CO = signs of hypoxia
❖Increase lactic acid
❖HR= decrease(early)
❖EKG = tall T wave
= Increase QT interval
H shifts to blood
= enlarge QRS Renal Function
= heartblocks ❖Oliguria, anuria
Metabolic acidosis = Bradycardia
=pH – less 7.35
=HCO3- decrease 22mEq/L Cardiac arrest
Note: more dangerous than
HYPOKALEMIA
 SIGNS AND SYMPTOMS

• Arrhythmia or dysrhythmias
Slow cardiac rate
• ECG: narrow/peaked T wave, widened QRS, prolonged
PR interval, flattered P wave
• Twitching (early) or paralysis (late)
• GI hypermotility, diarrhea,N/V
• Drowsiness
• Oliguria
• Decrease BP
 MANAGEMENT

1. Asses : serum K levels

1. EKG changes
2. Increased GIT function : bowel sounds
2. Avoid increase in diet:
coffee,cocoa,tea,dried fruits,beans,whole
grain cereals,milk eggs,prunes,raisins,watermelon,oranges,banan
[Link] KCL thoroughly
[Link] Thiazides of loop diuretics with K sparing diuretics to prevent incr. of K
[Link] use of salt sustitutes because they contain 60mEq/L of K per teaspoon
[Link] RENAL FAILURE PATIENT,administer:
● Insulin drip- incorporate regular Insulin in D10W 1 L to promote active
transport mechanism of K back to cells. Use D10W to avoid
hypoglycemic episodes
● Kayexelate-Na exchanges with K from the blood and binds K in the GIT
 [Link]
• Potential for dec.C.O. [Link] Cardiac Dysrhytmias.
• Potential for ineffective breathing pattern [Link] [Link]
• Diarrhea [Link] incr. GIT motility
• Fluid [Link] rel. to diarrhea

GOAL OF CARE

• Restore K level within normal limits 3.5- 5.0 mEq/L

• Prevent or minimize respiratory and cardiovascular
complications
 CALCIUM
Ca – cation, most abundant in entire body
❖ 99% in bone, teeth
❖ Very little in plasma
❖ 0.8g/dL Ca for every 1 g/dL albumin increase or decrease
❖ affected by PTH, Calcitonin, albumin, Vitamin D (calcitriol)
❖ 1000-1200mg/day for adults; 1500 for elderly, pregnant, lactating
❖ 4.5-5.5 mEq/L
❖ 8.5-10.5 mg/dL – total

Functions
• skeletal & cardiac contraction
• skeletal & dental growth/density
• clotting (CF IV) – important in converting prothrombin to thrombin

• Sources: milk, yogurt, cheese, sardines, broccoli, tofu, green leafy

vegetables
 Hypocalcemia
Cause
• Inadequate calcium intake
• Excess loss of calcium- kidney dse, draining intestinal fistula
• Decreased absorption from GIT
● Insufficient vit.D
● Insufficient PTH
SIGNS & SYMPTOMS
• Decreased cardiac contractility
• Arrhythmia
• ECG: prolonged QT interval, lengthened ST segment
• Trousseau’s sign (inflate BP cuff 20mm above systole for 3 min =
carpopedal spasm)
• Chvostek’s sign (tap facial nerve anterior to the ear = ipsilateral
muscle twitching)
REGULATION OF SERUM Ca by PTH
• Increase serum Ca

Inhibits secretion of PTH

Trousseau’s sign Chvostek’s sign
 SIGNS & SYMPTOMS

• Tetany
• Hyperreflexia, seizures
• Laryngeal spasms/stridor
• Diarrhea, hyperactive bowel sounds

Related electrolyte imbalances:

Hypomagnesemia, hypokalemia,
hyperphosphatemia
 MANAGEMENT
Calcium gluconate 10% IV
Calcium chloride 10% IV
- both usually given by Dr, very slowly; venous irritant;
cardiac probs
Oral: calcium citrate, lactate, carbonate; Vit D
supplements
Diet: high calcium
WOF: tetany, seizures, laryngospasm, resp & cardiac
arrest
seizure precautions
•
 Hypercalcemia – usually from
bone resorption
Cause
• Hyperparathyroidism (eg.
adenoma)
• Metastatic cancer (bone
resorption as tumor’s ectopic PTH
effect) – eg. Multiple myeloma
• Thiazide diuretics (potentiate PTH
effect)
• Immobility
• Milk-alkali syndrome (too much
milk or antacids in eggs with
peptic ulcer)
 S/SX OF HYPERCALCEMIA
Renal Changes
❖Hypercalceuria
❖Osmotic diuresis Decrease skeletal
(polyuria,polydipsia) activity Decrease CNS
❖Renal calculi Decrease GIT ❖Muscle weakness function
activity ❖Fatigue ❖Headache
❖Anorexia ❖Decrease strength ❖Confusion
❖Constipation ❖Hypotonia ❖Disorientation
❖N/V ❖Bone pains ❖Personality
❖Abd. Pain ❖Osteoporosis Changes
❖Increase HCL ❖Memory
❖Pathologic
Impairement
fracture ❖Slurring of speech
Decrease CV activity ❖Decrease LOC
❖Increase HR ❖Coma
❖Irregular rhythm ❖Decrease deep reflexes
❖ECG: shortened QT ❖Incoordination
interval,[Link] segment ❖Acute psychotic
❖Cardiac arrest behavior
 MANAGEMENT
If parathyroid tumor = surgery
Diet: low Ca, stop taking Ca Carbonate antacids, increase oral fluids intake
MANAGEMENT:
• Hydrate (usually NaCl or Saline diuretics)
• Loop diuretics(LASIX)
• Corticosteroids—[Link] Ca
• Inorganic PO4
● Inc.PO4—[Link].
• Biphosphonates, like etidronate (Calcitonin) & alendronate (Fosamax)
• Plicamycin (Mithracin) – inhibits bone resorption
• Calcitonin – IM or intranasal

• Dialysis (severe case)

WOF: digitalis toxicity

Prevent fractures, handle gently, support joints,avoid vigorous back rub
Prevent Renal calculi formation, prevent UTI