Fluid & Electrolytes + Liver Flashcards

1
Q

define osmolality

A

solute particles per Kg of solvent

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2
Q

define osmolarity

A

solute particles per L of solvent

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3
Q

What is the distribution of fluid in the body

A

1/3 extracellular

2/3 intracellular

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4
Q

What ions are intracellular

A

K+
Mg2+
HPO4-
Proteins

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5
Q

what ions are extracellular

A

Na+
HCO3-
Cl-
Ca+

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6
Q

What is extracellular fluid divided into

A

1/3 vascular

2/3 interstitial

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7
Q

What are the 3 forces that regulate fluid movmement

A

osmosis
hydrostatic pressure
oncotic pressure

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8
Q

define osmosis

A

movement of H20 from an area of high concentration to an area of low concentration

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9
Q

define hydrostatic pressure

A

force of the blood as it pushes on the capillary walls

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10
Q

T or F hydrostatic pushes small proteins out of the capillaries into the interstitial space

A

T

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11
Q

define oncotic pressure

A

pulls fluid from the surrounding tissues back into the capillaries

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12
Q

What drives filtration

A

hydrostatic fluid

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13
Q

what drives reabsorption

A

oncotic fluid

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14
Q

what are the two forces that regulate solute movmemnt

A

diffusion

active transport

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15
Q

what is diffusion

A

movement of solute particles from an area of high concentration to low concentration

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16
Q

Is energy required for diffusion

A

no

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17
Q

What is active transport

A

solutes moving against contentration gradient
from [low] to [high]
requires ATP

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18
Q

What 3 things play a part in production of ATP and proper fn of the sodium/potassium pump

A

magnesium
phosphate
thiamine

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19
Q

What is ADH

A

antidiuretic hormone aka vasopressin

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20
Q

how does ADH work

A

stimulates water reabsorption
opens small channels in collecting duct
water moves through these channels from [low] (collecting duct) to [high] (blood)

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21
Q

What is ADH release triggered by

A

osmotic sensors
baroreceptors
RAA system

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22
Q

Where are the osmotic sensors that trigger ADH release? how do they work

A

hypothalamus

reacts to the concentration of solutes in your blood

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23
Q

Where are the baroreceptors that trigger ADH release? how do they work?

A

Lt atrium, carotid artery and aortic arch –> react to decreased arterial pressure

rt atrium and vena cavas react to less volume returning to the heart

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24
Q

What organ is essential in regulating fluid volume

A

kidneys

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25
what triggers the RAA system (3)
decreased BP in the glomerulus SNS stimulation of the kidneys decrease in Na+ concentration in the distal tubule
26
How is angiotensin 2 released
kidneys secrete renin angiotensinogen from liver converts renin to angiotensin 1 ACE from the lungs converts angiotensin 1 to angiotensin 2
27
what does angiotensin 2 do? What does this mean for preload and afterload?
arterial vasoconstrictor (inc afterload) stimulates ADH from posterior pituitary (inc preload and afterload (vasopressin)) stimulates aldosterone release (inc preload) stimulates SNS activity (inc preload, afterload and contractility)
28
Where is aldosterone produced
adrenal cortex
29
What does aldosterone do
triggers reabsorption of Na+ (and H20) from nephron collecting duct back to bloodstream
30
is aldosterone reabsorption passive?
no, active transport requires ATP
31
What ion does aldosterone cause to be excreted in urine
K+
32
Which hormone causes the movement of both fluids and solutes
aldosterone | Sodium and water
33
What is aldosterone release triggered by (2)
stress response of the hypothalamus RAA system
34
what are two stress hormones
cortisol aldosterone
35
where do thiazide diuretics work
distal tubule
36
what are 2 examples of thiazide diuretics
HCTZ | metolazone
37
Where do loop diuretics work
ascending portion of the loop of Henle and distal renal tubule
38
What is an example of a loop diuretic
lasix
39
what do both thiazide and loop diuretics do
decrease Na+ & Cl- reabsorption - loss of Na+ & H20 also causes hypokalemia loss of hydrogen ions chloride is excreted/bicarb is retained
40
What type of relationship do chloride and bicarb have
inverse
41
what acid-base imbalance can diuretics cause? why? what type of diuretic more commonly causes this?
metabolic alkalosis cause chloride to be excreted and since bicarb has an inverse relationship with chloride it is retained loop diuretics
42
What type of diuretics cause loss of bicarb, sodium, ater and potassium
carbonic anhydrase inhibitors (acetazolamide)
43
how do potassium sparing diuretics work? what is an example of one?
inhibits aldosterone - decreased sodium reabsorption thereby preventing potassium secretion spironolactone
44
what can spironolactone cause
hyperkalemia
45
What peptides are released in response to myocardial stretch? what do they cause?
ANP & BNP vasodilation loss of Na+ & H20 inhibits the SNS and RAA
46
What do ANP AND BNP result in
increased urine output decreased blood volume - decreased preload does not impact osmolality
47
What do ANP and BNP affect solute and solvent
move both fluids and solutes in proportion to each other
48
What triggers ANP release? where is it secreted?
mainly secreted in atrium triggered by hypernatremia and myocardial stretch
49
where is BNP secreted? How is BNP release triggered?
secreted by the ventricles | triggered by myocardial stretch
50
What is tonicity
ability of a solution to make water move in and out of cells
51
What are the three different types of fluid
isotonic - same osmolality btw plasma and cells hypotonic - lower osmolality in plasma then cells hypertonic - higher osmolality in plasma then cells
52
what is the term for balanced/normal amt of fluid volume
euvolemic
53
what is the term given for too much fluid volume
hypervolemic
54
what is the term given for too little fluid volume
hypovolemic
55
What is the term for ratio of RBC to total volume of blood in a sample
hematocrit
56
What can hematocrit tell us
is an indicator of concentration - good for trending low Hct = more dilute high hct = more concentrated
57
In acidosis what happens in the blood regarding hydrogen and potassium
there are too many hydrogen ions in the blood so hydrogen begins to move into the cells and potassium moves out
58
what happens with hydrogen and potassium in alkalosis
not enough hydrogen ions in the blood so hydrogen moves out | potassium moves in
59
what hormone is responsible for telling cells to take in glucose
insulin
60
when moves into the cell with glucose
potassium
61
What is required to move potassium into a cell
magnesium, thiamine and phosphate to operate K+/Na+ pump
62
what moves out of a cell as glucose and potassium move in
Na+
63
How many forms of serum calcium are there? what are they?
2 | ionized & bound
64
what is the difference between ionized calcium and bound calcium
ionized calcium - free/active | bound - bound mostly to albumin but some other proteins
65
which one of the calcium forms is most responsible for calcium related functions
ionized
66
What do calcium and hydrogen compete for binding sites on
albumin
67
What happens to calcium in acidosis
greater number of hydrogen ions competing with calcium for binding sites on albumin the amount of bound calcium falls and ionized calcium goes up
68
What happens to bound calcium and ionized calcium in acidosis? alkalosis?
acidosis: bound goes down, ionized up to compete with H+ ions alkalosis: bound goes up, ionized go down
69
what should you consider when replacing albumin
ionized calcium level
70
what are 3 causes of metabolic acidosis
lactic acidosis renal dysfunction loss of bicarbonate
71
Below what acidotic pH level do we begin to get concerned? why?
7.2 | vasoactive drugs do not work as well
72
What is a primary electrolyte in the extracellular fluid
sodium
73
what is the normal range for sodium
135-145
74
What are the 4 main functions of Na+
ECF osmolality/tonicity fluid balance cellular depolarization - part of action potential
75
What are the 3 ways in which Na+ is regulated
retained or excreted by kidneys influenced by aldosterone and ANP moved by Na+/k+ pump
76
What is the cardinal rule for Na+
always followed by water
77
What are the two main causes of hyponatremia? what is the main one
dilutional (main) | low intake
78
what are three things that can cause dilutional hyponatremia
heart failure SIADH excess free H2O
79
What are 4 clinical manifestations of hyponatremia
H2O moves into cell causing them to lyse CNS effects - confusion, irritability, seizures low serum osmolality HA, muscle weakness
80
below what sodium level do you see seizures and delirium
Na+ <110
81
how do you treat hyponatremia
fluid restriction increase H2O administer hypertonic NaCl (3%)
82
What are 2 causes of hypernatremia
water deficit loss of hypotonic solutes - diarrhea - GI losses - diuresis - DI
83
What are clinical manifestations of hypernatremia (5)
cells shrivel as H20 moves out CNS symptoms - twitching, seizures, coma thirst high serum osmolality fever, flushed skin
84
What is the treatment for hypernatremia
slowly replace H20 as needed with IV D5W or free water in enteral feeds limit Na+ intake treat underlying cause
85
What is the primary electrolyte in intracellular fluid
K+
86
what is the normal range for K+? what about in cardiac?
3.5-5 | 4-5
87
What are the 3 functions of K+
essential for nerve impulse conduction muscle contraction acid/base balance ICF osmolality
88
How is potassium regulated
balance in body mainly controlled by dietary intake and kidneys Na+/K+ pump and diffusion influenced by acid-base balance: H+ and K+ move in and out of cells opposite of each other in response to serum pH changse
89
What are 4 causes of Hypokalemia
inadequate intake GI losses Diuresis Shift into cells due to alkalosis or movement of glucose/insulin
90
What are 3 clinical manifestations of hypokalemia
flattened T waves dysrhythmias skeletal muscle weakness
91
How do you treat hypokalemia (4)
replacement of lost (as opposed to displaced) K- correction of acid-base balance ensure adequate nutrition reconsider meds such as diuretics that are contributing to loss
92
What are 4 causes of hyperkalemia
high intake renal dysfunction shifts out of cells d/t acidosis cell injury/death release K+
93
what are 4 manifestations of hyperkalemia
ECG changes - peaked T waves bradycardia and blocks skeletal muscle weakness cramps, nausea
94
Treatment for hyperkalemia
resolve acid/base imbalance promote removal with diuretics K-binding resins (kayexalate) dialysis stabilize cell membrane by ensuring adequate Ca2+ shift by administering d50 followed by insulin
95
What is the distribution of phosphate
80% found in bones 20% in ICF (tiny bit in ECF)
96
what is the normal range for phosphate
0.9-1.4
97
What are the 3 functions of phosphate
cell membrane structure FORMATION OF ATP AND 2,3 DPG WHICH IS USED IN BINDING OF O2 TO HGB co-factor in intracellular enzyme reactions
98
where is phosphate absorbed
GI tract
99
what does phosphate compete with for absorption
Ca2+
100
What type of relationship do PO4 and Ca2+ have? what are they regulated by
inverse relationship - regulated by the parathyroid hormone
101
What happens to phosphate when calcium increases
decreases
102
which acid/base balance problem causes phosphate to move into cells
alkalosis
103
when insulin moves glucose into the cells what goes in with it
K+ | PO4-
104
what are 3 causes of hypercalcemia
cancer, especially bone mets renal dysfunction Ca2+ is excreted by the kidneys hyperparathyroidism (increases Ca2+ release from bones and increases absorption)
105
What are 4 clinical manifestations for hypercalcemia
decreased cell membrane excitability CNS: fatigue, confusion, depression Neuromuscular: muscle weakness, hyporeflexia CVS: dysrhythmias, shortened QT, short ST
106
What is the treatment for hypercalcemia (5)
correct PO4 levels (inverse relationship) ensure adequate fluid volume to support urine output correct acid-base imbalances diuretics dialysis
107
What is the normal range for chloride
100-112 mmol/L
108
what are 2 functions for chloride
along with Na+ helps regulate serum osmolality helps maintain acid/base balance
109
what are 3 ways chloride is regulated
ingested (NaCl) reabsorbed or excreted by the kidneys as required to maintain acid/base balance inverse relationship with bicarbonate HCO3-
110
what does chloride have an inverse relationship with
bicarbonate
111
What are some causes of hypochloremia (4)
sodium deficit excess HCO3- GI losses - vomiting/suctioning/diarrhea increased renal losses (diuretics)
112
what are clinical manifestations of hypochloremia in CNS
overexcitability cramps, twitching, agitation seizures, coma (severe)
113
what can hypochloremia cause in CVS
dysrhythmias
114
what acid/base imbalance makes us concerned about hypochloremia
alkalosis including low Na+ or K+
115
what is the treatment for hypochloremia
correct underlying cause such as acid/base imbalance ensure adequate hydrationm
116
what are 3 causes of hyperchloremia
sodium excess (large and rapid infusions of NS) bicarbonate deficit acidosis
117
what are 4 clinical manifestations of hyperchloremia
signs of metabolic acidosis (tachypnea, lethargy, weakness) dysrhythmias, decreased CO decreased LOC/coma role in acid/base balance will also affect Na+ and K+ levels
118
what is normal osmolarity of plasma
290 mOsm/L
119
where is hydrostatic pressure the greatest
arterial end of capillary system | aortas
120
where can hydrostatic pressure build up and cause problems
pulmonary vascular system --> fluid backs up into pulmonary system causing pulmonary edema
121
where in the vascular system is oncotic pressure the greatest
venous end of capillary system
122
what solute in our blood is most responsible for maintaining oncotic pressure
albumin
123
where is the best example of diffusion in the body
gas exchange in the lungs
124
how does the sodium-potassium pump work
active transport
125
what does the Na+/K+ pump need to work
ATP!
126
which hormone causes just water to be reabsorbed back into the bloodstream from the nephrons collecting duct
ADH
127
which hormones are released as a consequence of the RAA system
aldosterone and ADH
128
what hormone in the collecting ducts in the nephron to retain sodium and water and excrete potassium
aldosterone
129
what does adding fluid to a solution do to its concentration
decrease its osmolarity
130
prior to intervention, a rapidly bleeding patient is experiencing which of the following
isotonic hypovolemia
131
what would a rapidly bleeding patients hematocrit be
normal
132
you administered lasix and your patient produces 2L of fluid in the following 3 hours. what changes would you expect to see in their hematocrit
increased hematocrit
133
what state would a patient who was over-rescuitated with plasmalyte and NS be experiencing
isotonic hypervolemia
134
what state can SIADH cause
hypotonic hypervolemia
135
an elderly person with communication challenges in long term care is at risk for experiencing what state
hypertonic hypovolemia
136
which volume and concentration state is induced to treat cerebral vasospasm
isotonic hypervolemia
137
what medication is given for cerebral vasospasm
nimlodopine Ca2+ channel blocker that works on smooth muscle
138
what happens when you have blood in the brain regarding CSF
blocks reuptake causing hydrocephalus
139
receives blood flow from how many sources
2 25% hepatic artery - directly from the blood 75% - portal vein nutrient rich blood from gut, stomach, spleen and pancreas is oxygen poor
140
what two organs dont go through the liver
legs and kidneys
141
does blood flow through liver in capillaries
no sinusoids
142
what are the major functional cells of the liver
hepatocyte
143
what liver cells conjugate bilirubin
hepatocytes
144
what do hepatocytes do
perform metabolic, secretory and ednocrine fn | conjugate bilirubin
145
what cells make up 70% of bodies macrophages
Kupffer cells in liver
146
What do Kupffer cells do
make up 70% of bodies macrophages produce cytokines (triggered by endotoxins) filter bacteria and endotoxins destroy worn RBC, WBC, and bactera
147
where are kupffer cells found
in the lining of the sinusoids of the liver
148
what are 6 fn of the liver
carbohydrate, protein and lipid metabolism synthesis of clotting factors bile production filtration of "old" red blood cells storage of vitamins and minerals detoxification, bacteria removal and cell clean-up
149
What are 3 processes of carbohydrate metabolism in the liver
glycogenesis - converts glucose to glycogen glycogenolysis - breaks down glycogen back to glucose gluconeogeneis - converting non-carbohydrate things such as amino acids and proteins into glucose
150
what does the liver do with amino acids
converts them to glucose or lipids
151
What organ syntehsizes amino acids
liver
152
what 3 plasma protein are formed in the liver
``` albumin (60^ of plasma proteins) globulins (immune function) clotting factors (fibrinogen, prothrombin and factors V, VII, IX and X) ```
153
what hormone does the liver inactivate
GROWTH HORMONE
154
What blood vessel does blood flow out of the liver
hepatic vein
155
what does the liver do with excess carbs and proteins
converts them into fatty acid and triglycerides which are sent out for storage in adipose tissue
156
What does the liver create cholesterol out of
fatty acids
157
what does the liver do with trigylcerides
oxidizes them to produce energy
158
what happens in gluconeogenesis
fats are converted to glycogen and stored for energy
159
The liver stores what vimtamins
A, D, E and K (fat soluble) | vitamin B12
160
what minerals are stored in the liver
iron and copper
161
Where does the body store a back up supply of blood
in the sinusoids of the liver
162
what hormones does the liver inactivate (6_
aldosterone, cortisol, epinephrine | growth hormone, glucagon, glucocorticoids
163
what do kupffer cells do
detoxification of drugs and toxins | removes bacteria, antigens and byproducts of coagulation
164
Where in the body is lactate cleared
liver
165
what creates ammonia
created in the gut and cells during the breakdown of protein
166
How is ammonia removed from the body
the liver converts ammonia to water soluble urea
167
4 ways in which the liver can be acutely injured
Tylenol OD shock states viral infection budd chiari syndrome
168
what are two chronic causes of liver injury
EtOH and non alcohol liver disease | chronic viral hepatitis (B, C)
169
why does liver failure cause decreased LOC
unable to convert ammonia to H20 soluble urea which crosses BBB affecting astroctyes causing creation of osmotically active substances causing cerebral edema accumulation of medications and their metabolites
170
why does liver failure cause bleeding
unable to creat clotting factors portal HTN causes the formation of variceis unable to store vitamin K
171
why does liver failure cause edema,a sites, leaking wound sites
unable to create albumin causing decreased oncotic pressure (unable to pull fluid) backflow of blood from damaged liver
172
why does liver failure cause jaundice
unable to conjugate bilirubin and excrete it so you have excess bilirubin
173
why does liver failure lead to increased chance of infection
unable to produce globulins which are important in immune function unable to produce cytokines poor nutrition large portion of marcophages are found in the liver bacteria can pass through a damaged liver without being broken down
174
why does portal HTN occur in liver failure
liver becomes cirrhosed and blood is unable to flow through it
175
why does hypoglycemia occur in liver failure
unable to perform glycogenolysis and gluconeogenesis impaired carbohydrate metabolism
176
What are LFTs
AST, ALT, Albumin, PT/INR, alk phos, GGT, bilirubin, ammonia, platelets
177
What is AST? where is it found? is it specific for the liver?
asparate aminotransferase found in the liver, heart, skeletal muscle, pancrease and kidneys low specificity to the liver
178
What enzyme found in hepatocytes is most specific to the liver
ALT
179
Does decreasing ALT/AST mean that your pts liver is improving
not necessarily, could mean that your pateints liver injury has progressed to the point they have few functioning hepatocytes
180
What does albumin tell us
chronic liver failure indicator as albumin has a long half life of 20 days
181
what is a good indicator of chronic liver injury
albumin
182
is albumin specific
no a decrease could be liver, could be leaking out such as sepsis or trauma or could be malnourished
183
What is a very sensitive indicator of liver dysfunction that is often the first to be affected
PTT and INR since the liver synthesizes so many clotting factors
184
is alk phos able to tell us liver function on its own?
no need GGT as well
185
what is alk phos? where is it commonly found? | what is is most specific for on its own
alkaline phosphatase found in may tissues mostly bone and liver most specific for bone disease
186
what is GGT? what does it do? where is it found? Where is it most concentrated?
gammaglutamyl transferase assists amino acids across membranes liver, kidney, pancreas, heart and brain most concetnrated in biliary ductules that carry bile to the bile ducts so very sensitvie but non specific indicator or hepatobiliary disease
187
if you have a high alk phos and GGT what does this mean
liver porblem
188
if you have a high alk phos and normal ggt what does this mean
bone problem
189
Why do we check platelet levels in our LFTs
liver produces thrombopoietin which tells the bone marrow to increase platelet production
190
What is refeeding syndrome
potential fatal shift in fluid and electrolytes that occurs when re-introducing malnourished patients to any form of nutrition
191
what time frame does re-feeding syndrome occur in
12-72 hours after refeeding is initaited
192
how long can refeeding syndrome continue for
2-7 days
193
what are three things that occur during times of malnourishment
body maintains glucose levels from glycogen stores (about a days worth) then switches to gluconeogenesis which uses fats and amino acids from protein catabolism for energy intracellular electrolytes (K, Mg, and PO4) and calcium from the bones are depleted from within the cells water, vitamin and mineral depletion occurs as well
194
what occurs when we start refeeding malnourished patients
carbs are used for metabolism blood glucose increases insulin released moves glucose, K+, PO4- into cells using thiamine sodium potassium pump kicks in and uses magnesium sodium moves out of the cell d/t Na+/K+ pump which leads to edema and fluid overload
195
what specifically causes edema to occur in refeeding syndrome
sodium moving out of the cell as K+ moves in
196
what is the main electrolyte imbalance that is a hallmark sign of refeeding syndrome
hypophosphatasemia
197
What are 5 signs of refeeding syndrome
``` hypophosphatemia abnormalities in fluid balance vitamin deficiency e.g. vitamin B1 (thiamine) hypomagnesaemia hypokalemia ```
198
what can the electrolyte and fluid balance abnormalities in refeeding syndrome cause
cardiac, respiratory and neuromuscular consequences
199
how do we start feeding pts suspected of refeeding syndrome
slowly
200
what should we monitor for refeeding syndrome
blood work closely and replacement of electrolytes
201
What is thiamine absolutely necessary for
ATP
202
what are three things that occur with low thiamine
muscle weakness Wernicke syndrome HF