hello everybody and welcome to alterations in cell function this is part three so we're going to recap what we've talked about in part one in part two and that is what are the things that cause disruptions in cell function in other words what problems can arise that will cause the reduction of atp production we've talked about how hypoxia and nutritional problems such as less glucose or vitamins that are not as available and then also the consequences of solute imbalances when we have resting membrane potential abnormalities and acid-base balance so the next thing we're going to talk about is fluid shifts and when we talk about fluid shifts we're really talking about water is water important in our body well yes it is the whole body in general is about 60 water and the amount of water in the blood is very high it's 90 percent and so water is very important and how do we as humans get water if we're healthy well we drink it which means that water has to be able to go from one space to another it needs to go from one fluid space or one compartment to another compartment to ensure that there's some kind of harmony or balance in the amount of water in the two blood spaces that we have identified the tissue space and the blood space so there has to be a balance and the movement of water is controlled by the term or by the property of osmosis and osmosis is ruled by osmolality so let's look at what those terms mean when we talk first about osmosis we maybe remember from chemistry that osmosis is the movement of water from one compartment to another semi-permeable membrane and again if we think about the movement of water from the blood space to the tissue space all of the cell membranes they're semi-permeable so there's your semi-permeable membrane and when i think of osmosis i think of water moving from an area of low to an area of high concentration in other words h2o low concentration to high concentration diffusion is an area from high to low so you've got to somehow keep that in your head and that's why i say the rule of osmosis is h2o low to high and i've set the term concentration so it is the movement of water from an area of low concentration to an area of high concentration in other words when something is more concentrated it is going to call water concentration calls or osmolality orders now what is it that i'm talking about and in the notes it says osmolality and its correlates so let's break this down because this osmolality and concentration is super important for the entire semester and so you've got to get this and so again if you're a biology major forgive me if i do this in a very simple way but i'm going to do it in a way that you have to understand it so when we talk about concentration the word concentration is almost and in our course black and white osmolality and concentration are the same thing so if you see the term osmolality you say in your head concentration and when we think about concentration or osmolality it is essentially the ratio of water to solutes in other words if there is a high concentration then there are more solutes and less water low concentration less solutes more water all right so that's confusing so let's look at this from a perspective that you know and that's juice so we all know juice you decide pick your favorite juice i've used tomato juice because it looks like blood and so we can pretend that this is blood that this tomato juice is the normal concentration the person has a normal concentration of their blood and we know that blood as well as tomato juice contains bunches of stuff it contains water and it contains tomatoes and it contains seasonings so tomato seasonings those are solutes and then water and if we wanted to make this more concentrated if we wanted to make our juice or our environment more concentrated we would have to remove water and if you removed water from our normal concentration of tomato juice if you removed water you would essentially have solutes left we would have tomatoes left okay sure you could sprinkle some spices in there too but you have solid stuff so again to make our environment more concentrated you would get rid or lose or have a loss of water what about the opposite direction if we have normal here here's our normal concentration of tomato juice if you wanted to make the environment less concentrated you would do one of two things you would either take out some tomatoes therefore this would be less concentrated it would taste more like water or you would just add a lot of water into the environment into the cup so again to make a less concentrated space or environment you would or compartment because we're talking about blood compartment you would either take solutes the solid stuff away in our case tomatoes or you would add a lot more water so that is how we can change the osmolality of an item the osmolality or the concentration in the body now clinically we can measure the solute concentration or the concentration of the blood space by drawing blood and doing a serum osmolality and so this is a laboratory value where we see that the osmolality or the serum concentration of our patient has been measured and any time the concentration is measured or a lab value is measured for a patient we see the value and we see or are given the normal range and so that's what will happen on this exam you will be given the normal range of concentration of the blood or ceramos molality as a reference for you to be able to answer the question you do not need to memorize this now again when we talk about concentration states they are certain states that follow the same principle as osmolality and therefore they're called correlates that doesn't make a lot of sense to me i do it very simply or think of it very simply like sesame street which of these things belong together which of these things are kind of the same and so when we look here if i said to you your patient has a normal concentration in their blood space i could also say your patient has a measured serum osmolality of let's say 285 or i could also say your patient is ice osmolar because that means that your patient's serum osmolality is normal i could also say that your patient is isotonic so this means normal now if i wanted to describe my patient as having a low concentration or a concentration that is less than normal i could say that the patient is hypo osmolar they have a low concentration or that their laboratory value has a concentration a measured serum osmolality that is less than 280. conversely if i wanted to say the patient has a high concentration in the blood space i could say that their measured osmolality is greater than 295 let's say it's 300 or they're in a hyper osmolar state or they have a high concentration so let's look at some other terms that we can use or a correlate that we can use to describe osmolality and concentration and that other term is known as tonicity now tonicity is a term that is interchangeable with the term salinity in other words the saltiness of a substance so the normal salinity or saltiness of the blood is measured at 0.9 percent in other words it is a value or an amount that will be given to you no need to memorize and so we can say that salinity or tonicity relates to sodium chloride in other words the combo pack we know that sodium sometimes travels on its own but sometimes it's related to tonicity and that is when it is traveling as a pair of sodium chloride so the normal concentration or the normal osmolality or the ice osmolar state of the blood tonicity of the blood is 0.9 percent so we go back to our which of these things belong together and i tell you that isotonic or normal tonicity is 0.9 percent if the tonicity of the blood is higher than normal we would say it's a hypertonic state we could say that it's hyperoz molar we could say that it's a high concentration or more concentration than usual again these things mean the same what about if it's lower so then the blood would be lower than 0.9 percent it would be hypotonic hypo osmolar and less concentrated so let's do a clinical scenario we say that normal tonicity is isotonic and we can say that a fluid that is isotonic is known as 0.9 percent or normal saline or we abbreviate it normal saline or ns if we have and hypotonic iv fluids then we know that the tonicity is lower than 0.9 percent and the only one we're going to use in this course is 0.45 and hopefully you know enough about math to know that 0.9 is less than or excuse me that 0.45 is less than 0.9 if we have a hypertonic bag of iv fluids then we're going to call that three percent because mathematically three percent is much much greater than 0.9 now i was talking about iv solutions and i know most of you are probably the individuals that watch grey's anatomy or some of these healthcare shows but i do want to make sure we're on the same page and so if an individual cannot bring in water then we can give them an iv so this is a catheter that we insert in a blood vessel and we can give them an iv solution again the three iv solutions that we talked about were the bag that was normal saline or 0.9 percent a an isos isotonic solution or the individual may need a 0.45 or a hypotonic iv solution or the individual may need a hypertonic iv solution and that would be a bag of 3 saline so if as a nurse a physician said to you please hang a bag of normal saline what do you know so when you look at all these three options a b c and d we know that the things that belong together for iv normal saline would be the bag that says 0.9 percent because that's an isotonic solution normal saline or ns is the same thing as saying an isotonic solution isotonic to normal blood is the same and so the bag that has tonicity of 0.9 all of these things mean the same thing they're correlates as we are describing or discussing the osmolality or concentration of the blood space now there are some other terms that can be used that again mean the same thing and that is osmotic pressure if i said to you what is osmotic pressure it is defined as the pressure that is exerted by all the solutes in a compartment in other words if it is normal you would say the osmotic pressure is normal but if there is a high concentration a very high concentration or a hyperosmolic state we would say that the osmotic pressure is high in other words solute suck solutes suck or draw water into that space so the space with an osmotic pressure that is elevated is going to cause water to move h2o low from an area of low concentration into an area of high concentration high osmotic pressure high osmolality high concentration low osmotic pressure low osmolality hypoosmolic osmotic low osmotic pressure now let's look at another correlate another term that means the same and that is oncotic pressure now oncotic pressure does mean the same thing but it means something that's very specific it means as it relates to protein molecules so oncotic pressure or colloidal osmotic pressure are the same pressure or the same principle as osmotic pressure but it refers specifically to protein molecules so in an example if we had a patient whose laboratory showed that he was hyper or had hyperprotinemia what would you know about this patient and you would know that he has a higher number than usual numbers of protein in his blood he has a high oncotic pressure he has a high osmotic pressure his blood is much more concentrated than normal he has a high osmolality the only thing that you don't know in a patient who has hyper protonemia or something that you wouldn't do is you wouldn't want to give him more protein you would not need to give him a bottle of albumin that is the outlier in the example so again on cardiac pressure exactly the same principle as osmotic pressure but refers specifically to the power of protein molecules because yes they also suck too so now we go back to our example which of these things belong together and if your patient needed a hypertonic solution because they're um or a hyperoz molar solution you would say that as three percent normal saline as opposed to osmolar states or low concentration would be on this range so again color coded everything on this side relates to low osmolality low oncotic pressure low concentration and everything in red is related to high so we know that fluid shifts can occur because how do you get water in your body will you have to drink it through your mouth it goes in the gut and therefore what happens first so let's say you drink a full glass of water so then the first thing you're gonna have to figure out is which way will that water shift if you drink a lot of water and it goes into the gut and then it goes into the blood space what have you done will you have added water to the blood space is that lowered or increased the concentration in the blood because you always think about what has happened first in the blood and then you say okay what is the blood more or less concentrated and so therefore the tissue space will water move from or to the tissue so let's look at this from a picture perspective because i think this is a much easier way to learn the material so let's say your patient had some kind of disease and that disease has caused the osmolality to be 305 to be valued at 305 now we know that normal hospitality is at 280 or 295. so which compartment if the blood space is measured at an osmolality of 305 which compartment is more concentrated is the blood space more concentrated or is the tissue space more concentrated and when we look at this we can see that if the blood space is measured at 305 and we always think about the effect at the blood level as changing first we know that the tissue is going to be in the normal range in other words let's say that the tissue is 295 and if the tissue is at 295 and the blood space which has had the change occurred to it first is 305 which way is water going to move and we know that water moves from an area of low h2o low to an area that is higher concentration so water is going to move from the tissue into the blood space now what effect is that going to have on the cell if the cell's water is moving out and going into the blood space what is going to happen to the cell is a cell going to shrink or is the cell going to swell and so these are questions that we're going to work through as we go through the information on serum osmolality and its effects so right now do you understand the concept of concentration do you understand that osmolality orders concentration calls that water h2o will move from an area of low concentration to high concentration if you don't then go back and re listen to this information or grab a can of orange juice and do the concentration exercise on your own do something you must understand this concept or email your instructor with questions now let's go on we've talked about the fact that a low concentration is the same thing as saying a low osmolality low tonicity low osmotic pressure low and cotton pressure and we know that water is the item or the force that is going to be shifting around in osmolality issues so what is going to cause the movement of water to change from um blood or tissue spaces and that is either one of three scenarios water is going to be either pathologically lost or pathologically gained and if our water is pathologically lost by the bloody in other words if water is lost that will cause an increased concentration of the blood space and cause the water to shift from tissue to blood if water is pathologically gained by the body or there is protein that is lost then the concentration in the blood space because we always consider the blood space first is going to go down and that will then cause the movement of water from blood to tissue always remember that whatever happens whether water is lost or gained or protein is lost that the change will occur first in the blood space and that the tissues will always be at the normal concentration it is the effect of the change in the blood space that is going to cause the change in the tissue space so let's look at some causes of a loss of water where the osmolality will go up and we know that there are different things scenarios that occur the the gray areas but we are just simply going to talk about pure water loss so how does your patient or how do you even lose water so water can be lost when there is an inability of the individual to bring in water in other words normally we have to swallow water and if an individual is too sick or too weak to get to the faucet to grab a glass of water then they will not have an inadequate amount or they will have an inadequate amount of bringing in water usually when an individual is very very sick and can't drink it is likely because they have been vomiting in other words they just can't hold anything down other instances of a loss of water is with diarrhea because whenever there is diarrhea yes you lose a lot of poop but there's a lot of water loss that occurs too there are times when individuals will have increased urination and we'll talk about those times very specifically in a minute so here's your simple diagram kind of a concept map whenever there is a disease or a problem that causes the loss of water from the body whenever there is a loss of water from the blood because we're always going to consider the blood space first that will cause the blood osmolality to go up less water concentration goes up increased blood osmolality and therefore the high concentration in the blood will cause the movement of water to move from tissue into blood and of course we have terms for this so when we do a step-by-step fix and i'm good their words are here and i'm going to show you on them on a picture again if we talk about some kind of problem that has caused diarrhea so with the scenario that i've used before that will still cause diarrhea if you eat some kind of food item that's been fixed or prepared by somebody who didn't wash their hands and you get some microbe on that food item it's going to cause diarrhea diarrhea will cause yes poop but also a whole lot of water loss there will be less water that is in the blood because that's the space we consider first so the blood when there is a loss of water from the blood space the blood will become more concentrated higher concentration hyper osmolar state will occur and then that will cause the movement of water to ensure balance or homeostasis that will cause the movement of water from tissue to blood now what is this problem or what is occurring with this problem well this problem really describes dehydration and we use that term commonly but also there is a vernacular or terms that are used for dehydration in let's see medical terminology speak and that is known as a fluid volume deficit fluid volume deficit dehydration loss of water all the same thing and because there is an increase in the concentration and the movement of water from tissue into blood what you the nurse will be able to identify in your patients so in other words these are the signs and symptoms that identify to you the nurse that your patient has a fluid volume deficit is dry mucous membranes and poor skin turgor now when we talk about mucous membranes there's several different places where there are mucous membranes but probably the most easily accessible place is in the mouth so you ask your patient to open their mouth and stick out their tongue and if it looks like the sahara desert and it's all furry and dry then you can say that your patient has dry mucous membranes now poor skin turgor there's probably several different youtube videos where you can look at skin turgor but but go ahead and do that later let's let's pretend and let's look at it on our bodies on your own body so take your arm obviously without the sleeve so be able to touch the skin and pinch some skin on your arm between your finger and your index your index finger and your thumb and then you're going to see you've kind of made a tent there and then let go and if your skin is well hydrated if the skin cells are very well hydrated then they'll snap back in other words they'll flatten out again if they are dehydrated or there is a fluid volume deficit that has caused the movement of water from tissue to blood then you will see the skin will stay tinted in other words it'll stay upright and i'll show you a picture of that in just a minute but feel free to go on youtube too in fact here is our picture so here is our baby who has this tenting or poor skin turtle right there on their belly now what other signs and symptoms might be identified in an individual with a fluid volume deficit where you're going to see sunken eyes sunken fontanelles and babies what's the fontanelle well that's the soft part that's on top of the baby's head and it should be pretty much flat or equal with the bone and if it's concave in other words it kind of dips down then that means that your baby has a sunken fontanel and your baby maybe have a fluid volume deficit decreased urinary output otherwise known as oliguria so aliguria is the term for decreased urinary output is going to be present and also a increase in the urine concentration now why is that and of course most of you could probably identify well if there's less body od if there's less water in the body overall well then the kidneys are not going to get rid of much water so the urine concentration is going to look the urine is going to look very dark now this is also part of a compensatory response and we'll talk about that in just a minute with a fluid volume deficit your patient can sometimes have a low blood pressure and they can have what's known in fancy speak as central nervous system changes in other words the brain cells that have become dehydrated because of the fluid shift from tissue into blood the brain cells are very high functioning cells they don't really like an abnormal state at all any type of abnormal state and they get very they're very persnickety very picky about their environment and whenever they become dehydrated and shrunken then the patient can show signs and symptoms of confusion restlessness um and if it's a profound state of dehydration or fluid volume deficit they can become unconscious and they can convulse now if we did lab work on an individual with signs and symptoms of fluid volume deficits such as poor skin turkey dry mucous membranes sunken eyes oliguria and low blood pressure and altered mental status or confusion we would see a high serum osmolality which which of these things belong together other terms that could be utilized would be a hyperosmolar state hypertonic state high osmotic pressure all of these terms are similar now we know that whenever an abnormal state occurs such as when a patient has a fluid volume deficit the body has a tool or a compensatory mechanism to kind of try and create a balance or harmony for that fluid volume deficit and that counter balance or compensatory mechanism is known as ras rast stands for renin angiotensin aldosterone system and it begins whenever there is a trigger it begins with the trigger and the trigger that will cause the rast system to go into effect is one of three things when the blood osmolality is high because again concentration goes up with a loss of water or there is a fluid volume deficit or a low fluid volume in the circulation or if the blood pressure is low any one or all of these three things will trigger the release of renin that's the beginning part it's not called wren an angiotensin aldosterone system for a random thing it's because renin is the first substance that is secreted by the kidney whenever these three states are occurring either one-on-one or combination now what happens when renin is in place is that renin the presence of renin will stimulate the secretion or formation of angiotensin one and then angiotensin one will become angiotensin ii so we call this a cascade of events in other words it's like when one thing happens running then angiotensin one and then angiotensin ii occurs and we know or hopefully you know that angiotensin ii is the substance that's important angiotensin ii is what then causes the changes or the compensation in the body and angiotensin ii has two important duties number one it stimulates peripheral vasoconstriction and number two it will stimulate the secretion of aldosterone from the adrenal gland now once angiotensin ii is it present again that means that peripheral vasoconstriction occurs so there's less blood that's out in the hands and feet and more in the central circulation and aldosterone al we consider is a very important substance it will cause or tell the kidneys to hold on to sodium and wherever sodium goes water will follow use follows so aldosterone is responsible for sodium retention which ultimately leads to water retention so that is why less water is removed by the kidneys in the in urine and that is why there is oligurely oliguria as a sign and symptom now once all of the states go back to normal in other words when the circulatory volume is back to normal then the wrasse is cut off or shut off and when it's high then rest is suppressed also now adh works with running angiotensin aldosterone syndrome angiotensin renin angiotensin aldosterone system ras will also get some help from the antidiuretic hormone diuretic means to pee antidiuretic means not to pee now i've kind of simple person and so i like to think of this as just a simple diagram and explanation you must understand rats not only for exam one but for almost every exam in pathophysiology and in nursing school you have to understand the rat system so i think of a speed bump as the blood flows into the kidney there's a speed bump and whenever blood slows down because of dehydration or a fluid volume deficit or because of low blood pressure then that is what triggers the release of renin which then forms angiotensin one angiotensin ii with the help of the angiotensin-converting enzyme and it is angiotensin ii that is responsible for vasoconstriction and the stimulation of the adrenals to reduce aldosterone and holding on to sodium and therefore water so i recommend that you draw the simple concept map it was a lot of words in the explanation but draw it so that you and you can have the map in front of you but draw it yourself so that it'll stay in your head and you'll remember the wrath system it's very important so let's bring all of this information together so that you can kind of get some practice as to what you can expect so a patient presents to the emergency department and they have a signs and symptoms of confusion dry mucous membranes poor skin turgor and oliguri their blood has been drawn and the cereal mal's molality is measured at 300 there's your normal range right there so what is most likely going on with this patient what would you expect the diagnosis to be and of course you would say that this individual has a fluid volume deficit but you also need to know specifically what would it might be a specific uh question asking you what diagnosis so would it be someone who has lost water gained water would it be someone who's vomiting someone with diarrhea and so on and so on so you need to know not only that this is the signs and symptoms of fluid volume deficit but the causes of a fluid volume deficit and this is your dry mucous membrane your dry furry looking tongue now let's say an individual has presented to the emergency room like we said is is like what we just said and the individual has dehydration and we know that the wrath is there with the allegurity to help this individual try and compensate for their fluid volume deficit but again the health care provider is not going to stand over them and go well your rest better get going we're going to provide volume for them or give them volume if they can't take in volume and so as nurses we give iv bag of different solutions and so if you had a patient with a fluid volume deficit and a concentration a serum osmolality of 300 what fluid will cause the blood to change in such a way as to make the fluid situation or fluid shift reversed and again i'm always going to give you what normal tonicity is so that you can decide between one of two fluid iv fluids um or iv iv bags so what are you going to give and so here are your options if you'd like to try and answer this on your own to see how well you understand the concepts then pause the recording so there are your options for our different iv solutions and when we look at this we see if the patient is in a hyper osmolar state treatment for a hyper osmolar state is always going to be the exact opposite we're going to give them a hypotonic or hypo osmolar solution and that is 0.45 hopefully you mathematically you identify that 0.9 is greater than 0.45 making this a hypotonic solution now one of the things that i do always like to talk about i know that your brain is pretty much fried with a lot of this information but i got to talk about test taking strategies so some of you may know this but if you don't i do want to point it out that let's say you were clueless you were like i've got no idea what this is i didn't have time to study osmolality i'm going to have to guess and so what you might guess is that three percent normal saline is greater than nine percent and that hypertonic is the same as three percent so therefore a and b say the same thing and if two items in a test question mean the same thing then you can delete both of them you can get rid of both of them and that leaves you with c and d as options to pick and again mathematically your odds have increased profoundly because you have a 50 50 shot of picking the right answer now there are times when test items will have stupid answers or silly answers and we know that some of you might say well i want that gin and tonic bag okay that's another story that's best left unsaid we know that to best help so let's answer the question to best begin the patient's return to osmolar homeostasis we need a hypotonic solution email your instructor if this doesn't make sense or your coach all right if you have any questions again go back through the information about a hyper osmolar state we've now completed the section on hyperosmolality states what causes them what you can expect signs and symptoms wise and now we're going to move on to a hypo osmolar state a decreased blood osmolality and this is caused in our course by two things either a pathologic water gain or protein loss again the most common mechanism is excess water or loss of solutes and so that's where we're going to stay so let's talk first about excess water so we're going to do kind of a concept map about the mechanism if you have an increase of water in the circulation it is going to dilute the blood and cause the serum osmolality to go down so if you're an arrows person you say add water so arrow up water goes up will cause the osmolality to go down and therefore in the blood space you have a lowered serum osmolality and we know that in our course the blood space is going to always be the first to change which means that the tissue space is sitting at normal and if the tissue space is normal and the blood space is low water is going to move from an area of h2o low concentration too high and that means that water will move from blood to tissue so as excess fluid is pulled into the tissue there's a specific term for that and that is known as edema now edema can be damaging to your patient because it can impair the body processes such as healing and oxygen exchange in other words again my poor artistic rendition is if the blood space is low if there is a low concentration and water is moving from blood to tissue some of it's going to sit here and some of it's going to go into the cell causing the cell to swell but what i want you to realize is if it was normal the cell should be in very close proximity to the blood vessel because all blood cells are all cells are surrounded by blood vessels and because that's how they get their food and oxygen and all things and waste products go back in and so if there's more space because that's what happens with edema when there's more space then it is much more difficult to get the required nutrients and other things into the cell and that's how the cell can actually become damaged with edema now let's talk about specific such situations where excess water is going to collect in the blood and that could be for psychotic water drinking and so you might be thinking what who does that well there are some mentally disturbed individuals that will do psychotic water drinking or there are some pledges in colleges if we're ever allowed to go back on campus the fraternities and usually it's a fraternity cause these individuals to drink a lot of water and so these individuals will come in with profound water intoxication and a low serum osmolality level if a nurse is a ding dong is having a bad day they might give too much iv fluid to their patient or or and there can be low or an out low output in other words if the kidney is not working at all and the kidney is all able to produce urine then where's the water going to go well it's going to stay in the blood space and or there can be some hormonal problems and an example of a hormonal problems that will cause the addition of water into the blood space is known as siadh s-i-a-d-h is known or is called syndrome of inappropriate anti-diuretics hormone now there's been some instructors that say well that's i in there so think of increased adh that doesn't help me i just think s i adh is too much too much adh now the possible causes of siadh of too much adh in being produced are either ectopically produced adh now what does that mean ectopic means that the adh is produced outside of where it should normally adh is is produced in the pituitary gland that's in the brain but some small cell bronchogenic cancers can cause and make adh i don't know how they do it don't know what the pathways behind that but just know that small cell bronchogenic cancer can manufacture adh and because there's no control for this manufacturing the patient's going to have an abnormally increased adh amount various drugs such as general anesthetics can cause siadh and if you think about an anesthetic causing the person to sleep well it causes the pituitary gland to go to sleep and so for whatever reason the pituitary gland when it's asleep just cranks out adh or there can be some kind of traumatic injury to the brain or a brain tumor and that will cause pressure on the pituitary gland and for whatever reason it cranks out a lot of adh again whenever there is adh that's involved you have to think to pee or not to p and when there is more adh anti-diuretic that is the term meaning not to p so when there is more adh than there is not to p and if you're not peeing if you're not urinating you're not getting rid of water and therefore that water will stay in the blood space so this will cause the addition of water or the remaining of water in the blood space and as it accumulates it will cause the osmolality to go down because antidiuretic means not to pee the individual will have oliguria so this is a different reason for the oliguria it is because the hormone is not allowing the kidney to do its job we do not pee now let's talk about another cause for a decreased serum concentration or a decreased serum osmolali and that is solute loss now there are different types of solute loss but we're only going to do one because we're in a black and white scenario where we're only going to do one problem and that problem is the loss of proteins proteins are very important in ensuring the oncotic pressure or the pressure power pressure of keeping water in a space that it's supposed to be in so when we look at our previous diagram of our tomato juice scenario we know that the concentration can go down or lessen if solutes are taken away so if there is less protein then we will say that the now blood space is now very specifically has a low oncodic pressure now you could say it has a low osmolality there is hypo osmolar state has occurred now what are some causes of hypoprotinemia and one cause is diminished protein production because the liver is responsible for producing a lot of the proteins specifically albumin the most common protein in the body and if the liver is diseased which is what occurs it with several things but one common occurrence is cirrhosis or drinking too much alcohol then the liver is not going to make proteins put a circle around this cause of hypoprotinemia students often forget this what is another cause for diminished protein in the blood and that is the inability to eat protein in other words whenever there is not food items available and this is known when it is because of protein malnutrition it is known as kwashiorkor it is a specific term for diminished protein intake plasma plasma protein loss can occur with certain kidney dysfunctions such as global nephritis so let's do a step-by-step process with that your glomerulus is essentially the filter that allows certain wasted substances to leave the urine but when there is glomerulonephritis then the the glomerulus is inflamed and it leaks it allows protein to leak into the urine and protein i've got it in yellow is like liquid gold so many of our body processes are protein based we never want to get rid of protein but when protein urea occurs then that means there is protein that is leaking out of the blood space and is now being dumped in the toilet and the patient can enter a state of hypoprotinemia when there is less protein in the blood that will cause the concentration to go down it will cause a low oncodic state a hypo osmolar state or a low oncodic pressure in comparison to its next-door neighbor the tissue the tissue remains at a normal osmolar state and this will cause the movement of water to go from an area of low concentration which happens to be the blood into the tissue so we will have the movement of water moving from blood to tissue and that will cause the individual to look very edematous because the tissues and the tissue spaces are filled with water so that is the reason for this man and this child's swollen bellies it is the movement of water from blood into the tissues in the belly say in belly space now we see also that this individual has edema or water moving from blood to tissue into the legs now the other thing that you might have noticed is that another sequela whenever the individual has a low protein state is that there is a breakdown of muscle because muscle is full of protein and as i said earlier there are so many things in our body that are protein based and the body can't do without protein so it will seek protein from another space and that is from the muscle space now this kiddo would probably have skinny little legs if he wasn't on his feet so much and therefore didn't have such swollen legs so again the sequela of hypoproteinemia is edema and nutritional problems because of the loss of muscle mass now we've talked about signs and symptoms of one sign and symptom of the edema because of a blood to tissue fluid shift let's look at the whole picture together whether it's a loss of proteins or a gain of water and regardless we're going to talk about this as being a fluid volume overload or a fluid volume excess and as tissues pull or as water from the blood states is pulled into the tissues we know that this is going to cause edema so where does this edema occur well it can occur anywhere in the skin in the belly skin in the feet skin and usually not in the arms but in the feet and legs and in the belly skin and whenever there is edema in the feet especially they're going to be puffy looking and if you touch the feet and when you push your finger in there and there's an indentation then we call that pitting edema we call that pitting edema so no matter it's water that's moved out of the blood space and is causing either edema or petting edema there can be a movement of water from blood into lung tissue this would cause pulmonary edema so you can see here this is normal and this is the state whenever water is moving into the lung tissue the lung tissue is known as alveoli and what will your patient experience if they have water that has moved from blood into the alveoli well they will cough and they will experience shortness of breath because remember the alveoli is the space where oxygen exchange occurs and oxygen can't swim through water so whenever there's water in the alveoli then this patient will have hypoxemia or a lowered blood oxygen level they will have what is known as crackles so whenever you listen to your patient's lungs with a stethoscope as a nurse the expectation is that you'll hear air moving through the lungs like this but if your patient has water in their alveoli you're gonna hear you're going to hear a crackly sound if you have long hair or you know someone with long hair grab that hair strand and then put it between your index and thumb and kind of move it back and forth and that's the sound of crackles that you would hear in the lungs if you are listening with a stethoscope now if there is a fluid volume overload and edema moving of water from blood into the tissue space it can move into the brain cells and causes swelling so not only will there be swelling of the brain cells but it will cause the same signs and symptoms as if brain cells are dehydrated patient can be restless they can be confused they can have unconsciousness they can have compulsions in other words your brain cells are very persnickety they need the perfect fluid volume state to be happy and whenever there is an overload or there is a fluid volume deficit your brain cells are not happy when they're either shrunk or swollen now we are talking about fluid volume overload and so if we did lab work when the patient had these signs and symptoms of crackles and confusion and oliguria and pitting edema we would identify a low serum osmolality which we could say is a low osmotic pressure hypo osmolar state hypotonic state and again if it was caused specifically because of protein problems we would say a low oncodic pressure or hypoprotinemia now this is kind of an important add-on note that edema can be caused by more than one factor so you might say well wait a minute i've been pregnant i had puffy feet so that is edema that's caused from a different factor for instance a hydrostatic pressure the pressure of water that is not the same as an osmotic state an osmotic state means there is a movement of water and the pressure of water in a space is off because of either a higher or low blood concentration and so that's what i want you to focus on is the osmotic oncotic states now just as with a fluid volume deficit whenever there is a fluid volume overload there is a compensatory mechanism that is triggered with a fluid volume overload and this compensatory mechanism during fluid volume overload is known as the natural peptide system or nps now what is the nps well the natural peptide natural system occurs or is triggered whenever there is a high volume and it is triggered whenever the high volume is moving through the heart so we know that whenever blood is circulating around all blood volume moves through the heart so i have a picture of a party balloon here and so i want you to go get a party balloon and when you blow up the balloon you see that the sides of that balloon stretch with air if you put a lot more air in the balloon then the sides of the balloon are going to stretch even more and that's the same thing with your heart whenever there is a lot of volume that is circulating through the heart as what's present whenever there is a hypo osmolar state and a fluid volume overload the right atrium and the left atrium and the left ventricle will detect that fluid so the atrium and the ventricles will detect that increased fluid and it will cause them to stretch when the atrium stretches the atrial naturetic peptide is made by the atrium so in other words with atrial stretch the atria will make atriometric peptide and with ventricular stretch the ventricles will make b-type natural peptide and these peptides reach the kidneys through the circulation and then they stimulate the kidneys to get rid of water to do diuresis so naturoretic means diuretic in other words it makes the individual p and once the fluid volume status goes back down to normal then the naturetic peptide system is suppressed so let's do a summary this has been a lot of information about abnormals or alterations in cell function and the production of atp and we know that fluid shifts can cause an abnormal alteration in cell metabolism or a decrease in cell function and we know that whenever there is a fluid shift problem identify for me who are the players in the fluid shift problem what players would i mention in a fluid shift problem and that is the players known as sodium sodium chloride proteins and water what about if there's a problem with acid-base imbalance what players would be mentioned in an exam question and the players with acid base imbalance are going to be ph co2 and bicarbonate what about if i was trying to lead you towards a problem with the resting membrane potential well with resting membrane potential it was all about the electrolytes the electrolytes of calcium and potassium and hyper and hypopolarization now you might be saying in your head wait a minute sodium is also in the resting membrane potential family it is and because i'm trying to keep things very simple and in the black and white mode i'm going to promise you make you a promise that sodium is going to only be in the fluid shift family so take it out of the resting membrane potential problem so that makes it a little bit easier now all you have to memorize is hypopolarization is caused by hypocalcemia and hyperkalemia hyper polarization is hypercalcemia and hypokalemia so that makes it one less thing for you to have to memorize and again if there are fluid shifts problems with your patient or acid-base imbalance with your patient or resting membrane potential with your patient what do these things have in common and all of these things can cause problems with cell function or cellular metabolism and decrease the amount of atp production i hope this recording has been helpful in your understanding of the material please contact your instructor or coach if you have any questions