all right well welcome to adult one and fluids and volume States so one of the most important things you need to know for this class is be able to recognize two of the best dog the two best dogs on the planet you can see here pictures of gypsy and Gabby these are my fur babies uh I do have children but you won't hear me talk about that much all right um so I'm not going to read the lesson outcomes to you uh you can review these mainly the thing is you need to know how to understand where fluid goes in the body how it gets there and um well how do we manage that so um this is kind of these object outcomes kind of and how to apply that information so let's start with what you've learned so far so up to this point you've learned how to do a physical assessment you've also learned how to how to uh take Vital Signs and the significance of Vital Signs so you know prior to this time you might have been doing accounting or you might have been uh packing fruit somewhere and may not have had any idea what an spo2 was but now you have some context for what the significance of that is so heart rate respirations blood pressure those are essential items in in orth in Vital Signs and then you've also learned about orthostatic blood pressures we're going to talk about what the significance of what these numbers mean and how they relate and uh connect to and are um impacted by fluid volume status and then assessment is a consist is a key portion of that mentation capillary refill urine output um level of Consciousness how patients feel when they're immobilizing if they're able to ambulate or not how they tolerate that all of those um are important elements sry for those popups and we'll pull this all together and it is definitely has a connection to fluids and volume States when you do an assessment what you're getting at is we've taught you how to look at their skin their color temperature tgar moisture um the whether it's intact or not how it's healing uh mucous membranes how they're mentating their level of Consciousness are they oriented um how their lungs sound what their lung what their hand veins neck veins look like and uh peripheral edema and blood pressure all those things we've taught you to assess and look at so far what we've also said and you remember from your rubric there are things there that you stay say when you do your assessment that you notice are not here that's because we want you to start thinking about the things you're going to see because those changes those alterations in assessment tell you something and it all comes together to tell you something about cardiac output you may not not have thought about cardiac output but that's what the heart does to meet the metabolic demands of this organism and it depends on the context of that organism it depends on the age the size the body composition the overall health and wellness of that b individual and the presence of any kind of um medical or physical insult so cardiac output is what we're really assessing among a lot of other things but it's the one thing we're really assessing when we're looking at these aspects of the physical assessment so what is cardiac output cardiac output is basically heart rate time stroke volume every time your heart beats there's a certain volume that's ejected from The ventricle that's measured in milliliters if you do that over a period of a minute it's going to accumulate to be a liter over a minute or Le measured in liters generally 4 to 8 L per minute that's a normal cardiac output that varies a little based on the person's condition uh their health and their body H habitus and composition so heart rate is just what it sounds like you've been measuring heart rate we haven't probably haven't talked about stroke volume much but stroke volume is that volume that's in the left ventricle notice I said volume it's the volume that's in the left V ventricle when the heart contracts so you're going to see that there are three components that come together to determine what makes a cardiac cardiac output and a sufficient blood pressure we've taught you how to measure blood pressure blood pressure is an indicator of cardiac output but it is not a definitive measure of cardiac output you're going to learn more about that in adult three but in order to have a stroke volume you've got to have a volume another another and that may sound pedantic but you have to have a volume going into the ventricle in order for there to be an output in order for the organs to get what they need the necessary nutrients oxygen carbon dioxide potassium phosphorus calcium sodium all of those components have to have a transport and they move through the blood they have to have that volume in order to mobilize those compon components in their various capacities through the bloodstream so you have to have a volume that's preload that's the volume coming into the heart the heart has to be strong enough that's contractility the squeeze of those two heart muscles the right ventricle and left ventricle and then the last thing is the resistance so this is the force that's exerted back against the heart when the heart's trying to squeeze and there are times when when that resistance drops in there times when it increases and we'll talk about some scenarios where that plays out now when you think about this cardiac output this 4 to8 lers per minute it's a volume and I want you to start appreciating how that volume gets distributed because your body is going to prioritize that cardiac output based on the functioning of those organs based on demand for example Le the body knows that the brain is the essential component of who we are our identity our personality whatever you like to think of that and the Brain off the top gets 15% of cardiac output so that means that the remainder is going to be divided among the other organs now the heart you may say well the heart needs a lot of that cardiac output yes it's prioritized in distribution to it but it's V overall percentage is smaller simply because the vasculature around the heart is relatively small compared to you think of the surface area the vascular vascularity around the brain and the rest of the body so heart brain and kidneys are going to get the top cut because your body knows we've got to have those to survive if your body becomes challenged then it's going to start stealing blood flow from the gut skin muscles and other organs so I want you to see here a couple of things the heart and brain get about 20% the gut gets about 25 to 27% and with normal functioning it's going to make sense why that's important here in just a moment the kidney is going to get another 22 is% because it has an important role along with the gut in fluid management if you can start to get this uh in your head gut is fluid in kidneys fluid out yes we give fluids but when you think about normal functioning you getting through the day your gut is where you get fluid into your body and your kidney is what helps maintain the balance along with some other organ systems as well muscles get about 15 to 18% in the skin anywhere 5 to 8% so these top four are the ones I really want you to kind of lock down in your memory now let's talk numbers when you consume fluid in a day most of us consume somewhere between 2 to three liters a day unless you're one of these people that you know carries a gallon jug to the gym and that sort of thing and tries to drink um four or five lers of fluid a day six maybe so average consumption is going to be somewhere between 2 to 3,000 Ms a day 2 to three liters now you think about where you consume your fluids you consume those through the gut so all of that pretty much all of the liquid that you consume is going to go into your gut and about 200 2 2250 of that is going to be reabsorbed so we're going to process some of that and and we may lose some to uh um insensible losses or something but overall we're going to end up consuming almost reabsorbing almost all that fluid in the bowel your gut needs that liquid to mobilize Nutri nutrients through the gastrointestinal tract so that the body has time this is important has time to absorb at various stages the various nutrients electrolytes vitamins minerals carbohydrates fats and proteins that it needs in order for us to function so GI i n and majority of that two and 2 and a/4 liters is going to be reabsorbed in the early part of the large intestine that's the ilium as far as output goes notice the output on a typical day your output is pretty much going to match your input unless you've got some kind of pathology going on right now we're beginning to introduce these concepts with normal biologic function so as long as you've got normal functioning um you're going to you're going to put out about as much as you put in that's maintaining balance it's emia you're going to hear that word come back again kidneys are primarily responsible for eliminating the excess or eliminating a majority of what we need to eliminate based on what we've consumed before so you can see that here the kid kidneys are the heavy lifters about, 1500 Ms a day they're going to of this 2500 they're going to be clearing what I want you to remember is that the lungs and the skin and feces also carry a liquid component as well you don't think about feal matter being liquid until you're having diarrhea we're going to talk about that effect in just a moment but um feal material has some liquid in it so that it is malleable enough to be easily passed the skin also is responsible for evaporation and losing some moisture through the skin even when you're not sweating we still lose moisture through the skin and then the lungs just the process of inhalation and exhalation we lose some uh about 300 MLS there in a day all in all we end up with a balance what the takeaway is don't worry about the numbers what the takeaway is is G in kidneys out also lung skin and feces eliminate fluid so it's not just kidneys that's the takeaway and um these things normally balance each other out all right so let's talk about the GI tract for a minute you'll remember from your Anatomy that the GI tract has a thick mucosal layer that is highly folded and in some areas particularly in the small intestine there are a lot of V ey there's two reasons for that structure being shaped and function in the way it does and that is that the folding helps move the uh the material the ingested material helps move the ingested material through the gastrointestinal tract for it to be metabolized uh broken down and ultimately absorbed this highly folded area and this vated area provide a larger surface area so that there's more exposure to the mucosal layer in order for the essential nutrients to be absorbed so you have more optimal absorption because you've got more surface area so we've got time lots of surface area and the emulsification and liquefication of what we consume allows those nutrients to wrap around and sink into all these folds and optimize that surface area for absorption and what are we absorbing here I've got it listed for you all the things yeah we think about our cheeseburger that we ate or or our french fries or our pasta salad or whatever it might be however these are the nutrients we care about um along with fats carbohydrates and um proteins because these are the essential elements that keep us functional as you're going to see when we get into electrolytes next so what can you think of that might affect fluid volume status things you've seen encountered in life whether you've been a health care professional or not well think about celiac disease or spru these conditions are sensitivities to certain types of food that can actually cause people to have diarrhea and not process those Foods well so if they're not processing those Foods well they're not getting the nutrients out of them if it's causing diarrhea then stuff is spending less time in the gastrointestinal tract it's important because it's got to have time that emulsified uh nutrients got to have time around those mucosal layers to absorb so other conditions such as Crone disease iral bowel inflammatory bowel also colitis these not only cause things like um diarrhea and liquid stools so bear that in mind remember any type of diarrhea is more liquid than we're used to our feces being that means there's more fluid going out conditions like Crohn's irritable bowel inflammatory bowel and ulcerative colitis also change the composure of the Vas ular of the intestinal lining it take it changes the composition and the the status the function of that mucosal layer which impedes its capacity to absorb nutrients so other conditions such as her herbron bilary at treia Mal rotation Gilbert's Disease duban Johnson's syndrome cular Nar um B reection colomy colostomy ostomy by diarrhea all these conditions affect and impact the way the bowel functions which impacts the fluid that actually makes it into the tissues of our body now bowel reection colostomy colomy and ostomy anything in that class has a different effect because it decreases the time in the gut because you've decreased the amount of gut surface area and that you can't fix by decreasing infl inflammation or getting rid of an infection so bearing in mind that those are permanent alterations so we have to really watch fluid volume status in those people particularly early on in those diseases so until they've adapted their uh dietary habits to accommodate now what is the takeaway from all of that here's here it is it's right here four points if it's going in measure it if it's coming out measure it if you put a tube in it and you're putting stuff in that tube or taking stuff out of that tube measure it if it's got a hole and we put a bag on it and there's stuff coming out of it measure it so essentially if it's going into the patient or coming out of the patient you measure it that's a principle to maintain for the rest of your nursing career regardless of the situation now there will be times when it's not so necessary to measure eyes knows if a patient's going to be discharging in 2 hours 3 hours okay it's time to transition but in general as we're caring for patients as we're as you guys start thinking about putting in NG tubes putting in folies if we're putting these things in these devices in the human body we need to be making sure we're diligent about how much we're putting into it and how much is coming out so we have talked about cardiac output and we've talked about fluid conceptually as it passes through the body let's get a little more uh um tactile let's get a little more tangible in how we talk about fluid so the fluid distribution in the body roughly looks like this about 40% of it is intracellular about 20% of it is extracellular then there's another 12% that is um in structures of the body that are hard to really quantify such as the ventricles of the brain and the um cerebral spinal column and then you have plasma now I know this doesn't account for every for it do doesn't add all the way up to 100 but this gives you approximate volumes and I don't want to get into minutia because what I really want you to focus in on is I want you to notice this first of all majority of the fluid in the body is intracellular that may not be what you expect because the intracellular space when you first think about it sounds small however there are so many cells in the human body that we have small amounts of fluid packed all over the place very compactly so majority of the fluid is intracellular so that means that we need more in there and it can shift out of there and extracellular fluid is the fluid that is in the spaces between the intracellular fluid and the plasma and I'm going to show you a slide in the next presentation about extracellular and intracellular fluids so don't worry about that right now what I really want to delve into is this plasma this five 5 to 6% of the fluid that's in the body this 5 to 6% of the fluid that's in the body this is what the heart is pumping around this is the the substance of cardiac output if you will now the numbers below that speak to I know they don't match with the whole um distribution of fluid well they shouldn't because those numbers reflect the distribution of this 5 to 6% of plasma plasma is the liquid that is circulating in the body with each contraction of the heart and with passive movement of the fluid by walking ambulating and using your muscles what I want you to notice here is that 70% of that plasma is in the Venus compartment the veins and venal we're going to talk about where it sits and all in just a minute and there's some good reasons for that about 10% of that overall plasma is sitting in the arter arteries or arteriales then you've got another 10% that's around the pulmonary vascul a lot of surface area around the pulmonary vasculature so there's a lot of lung uh surface area there and then you've got about 5% in capillaries and another 5% in the heart so when you think about that distribution between the veins and arteries and remind yourself of the anatomy it begins to make sense if you remember that the arteries have a thicker wall they have a thicker Lumen and more vascular more muscular uh Lumin thicker mus mucosa uh muscular layer around the structure which means it's Tighter and it creates a pressure or resistance this this combined with the squeeze of the heart creates a pressure that we measure and refer to as blood pressure that's the resistance that's what the heart has to push against to get that fluid out to the ne in with the necessary Nutri nutrients out to the tissues the venal and veins that's a low pressure side so if you have gravity affecting a low pressure tube then that low pressure tube is going to have a greater capacity for stretch much like a water balloon is bigger at the bottom it's going to have a greater capacity for stretch and it's going to hold more of the liquid so arteria arteries hold less of the liquid and venol and veins hold more there's a benefit to that for us and you've experienced this anytime you've stood up too quickly if you're sitting in a chair and you stand up too quickly and you get Li headed that is your body experiencing a shift in card in cardiac output matching metabolic need your body goes whoa if I better sit down or I better stop or whatever what also happens immediately there are certain structures that sense those changes and respond by constricting the Venus side which immediately moves if you look at the blue distribution here it immediately moves blood extra blood into the central circulation which is why you don't necessarily pass out just because you stood up too fast so I want you to think about these things right here focus on that and then I'm going to ask you a question in a minute about blood pressure and how it's related to that these images are intended to paint a picture for you about what I just said don't worry about all the initials what I want you to see is the gray and the red if you look at the standing uh picture you can easily see that when an individual is standing you've heard people talk about I have pooling in my feet this is a simple illustration of how gravity affects the distribution of liquid in our lower extremities every day this is as a result of the planet sucking us onto it so this is normal and the body compensates for that you can also see how lying down down causes that volume to shift in closer proximity to the heart and the central circulation which can for a lot of people create a better blood pressure this picture helps you understand how we can recruit that volume back into Central circulation and create an increase in cardiac output it can also illustrate the opposite and that is if a person is sepine and we sit them up you can see how when that fluid Shi sh s by gravity into their hips waist and pelvis that their blood pressure May decrease a little bit and then when we stand them up and it shift to their feet it could cause orthostatic hypotension that's why we take those orthostatic pressures to see if the patients accommodated this so This slide right here kind of gives you a overview of where we're really going with all of these fluid and volume States there's obviously optimal this is what we referred you've heard me refer earlier to as uolia that's the optimal piece now there's also hypovolemic State and hypervolemic State and as the uh hypovolemia increases the conditions get worse in SE in severity and as the hypervolemia increases the conditions get worse in severity you can see here the conditions that tend to present with these two conditions arhythmia like tachicardia low cardiac outputs because there's low volume going in uh hypo profusion infection organ failure Etc I'm not going to read this all to you because I want you to study this and be familiar and then with hyperic States these are the fluid overload States the symptoms the manifestations are going to be different these patients are going to have edema they may have respiratory failure because of fluid backing up in the lungs they may have impaired hearing they may have hemo dilution and it the thing is that one thing that's common on both sides you'll notice organ failure organ dysfunction is common on both sides when these two get to the extremes then they can produce some similar results now this slide is just here to show you a couple of things um so what I want you to draw out of this slide is U we'll come back to the portion that has the paracin hormones and vasod dilator substances we'll talk about those Concepts later however what I want you to what I really want you to see is in this picture on the right that has the aortic Arch and the cerebral arteries you see the red dots there those are aortic Arch and cored body receptors or Barrow receptors and these are structures you have receptors throughout your body in various capacities you have proprial receptors Cho receptors Barrel receptors stretch receptors and we'll talk about some of these these little red dots they're not literally little red dots these little red dots are the signalers for the sensation when you stand up too fast and your blood pressure drops your aortic Arch recognizes it the barrel receptors sense that change in pressure in the aortic Arch The barel receptors in the kateed bodies also do it that's why your head swims they send a signal to the sympathetic nervous system that says increase cardiac output and help us not pass out and that is where fluid gets recruited from that vascular space like I was talking about before to immediately increase cardiac output and you feel better I wanted you to kind of have an idea where those structures are I don't care that you know all of the anatomy there I just want you to be familiar but you should that Anatomy is something you should know already so I don't have any problems calling that out now this last U picture on the bottom is another component we'll talk about this more when we get to regulation and that is the Rea aldosterone Angiotensin system this is imperative for you to be familiar with this is just an introduction I'm introducing it to you earlier so you early so you start wetting your whistle with this but you're going to be very familiar with how rain and aldosterone and Angiotensin respond to maintain adequate fluid volume status either by excreting or retaining fluids so those are um I'm going to show you different pictures later but that's a good one uh if you want to get familiar with it so remember we were talking earlier about fluid distribution my question to you is where is blood pressure determined where in the body is the blood pressure determined by the body not measured by us but determined by the body body you may think well it's the arm CU that's where we put the blood pressure cuff on or it's in the lower arm or it's in the heart and the truth of the matter is it's really in the lower finer smaller arterial bodies and structures of the of the human body it's really determined um adjusted I should say in the arterials there's kind of a combination of uh effects here Barrow receptors play a role just as I mentioned because we have Barrow and stretch receptors that also send signals there's not necessarily one thing there's a lot of things happening concurrently so arteriales barar receptors in the heart and cored bodies like I just showed you and then chemo receptors so chemo receptors are receptors out at the periphery and when I say periphery I'm referring to anywhere there's a cap bed that's where nutrients are exchanged when the cells in the capillary bed sense the exchange of nutrients oxygen carbon dioxide po these these Elemental nutrients I'm not even thinking about food right now I'm thinking about the elemental nutrients that Keep Us Alive um nitrogen phosphorus pottassium sodium all these things we have to have oxygen carbon dioxide the chemo receptors respond and send signals to the arterials that say hey we need to vas a diate or we need to constrict because we need more of something or we need to direct it somewhere else we need to direct it to the muscles to get away from the bear so there's really not one little spot these these different structures work concurrently to generate of blood pressure what I do want you thinking is it's at the very fin capillary arterial level and cellular level this is happening not in the vascular vascular structure levels so these things all signal the sympathetic nervous system and parasympathetic nervous system to adapt and you know this if you've ever exercised or exerted yourself ever in your lifetime when you're exerting your body says wow we need more oxygen to keep this person from having a heart attack and dying so your heart rate goes goes up and your B cardiac output goes up and your body responds when you stop that's that's the parasympathetic and then when you stop then the sympathetic the Paras sympath excuse me that's the sympathetic nervous system and then when you stop the parasympathetic nervous system says hey that's all over let's calm everything down so that is the way it e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e