Fluid and Electrolyte Imbalance PDF

FLUID AND ELECTROLYTE IMBALANCE DR. JENNIFER TAYLOR, PHD, RN, CNE NURS 201 – PATHOPHYSIOLOGY FOR NURSING PRACTICE  BODY FLUID 60% of human body is fluid:...

FLUID AND ELECTROLYTE IMBALANCE DR. JENNIFER TAYLOR, PHD, RN, CNE NURS 201 – PATHOPHYSIOLOGY FOR NURSING PRACTICE  BODY FLUID 60% of human body is fluid: Average: 42 L total body fluid (mostly water) Majority component in cells, bloodstream Solvent for body solutes/electrolytes Fluid compartments: Fluid constantly shifts between compartments ICF: Intracellular fluid (within cells) 40% total body weight, typically most stable ECF: Extracellular fluid (blood stream) 20% total body weight, IVF (intravascular fluid) ISF: Interstitial fluid (between cells, tissue) Image Credit: https://slideplayer.com/slide/ Image Credit: https://doctorlib.info/physiology/physiology-2/52.html 10873065/  BODY FLUID BALANCE, MOVEMENT Homeostasis Goal = balance/equilibrium of solute and water across Diffusion: passive membrane substance/electrolyte moves Osmosis: passive from high to low concentration water moves from high to low water concentration Semi-permeable membrane selectively limits size of solute molecules (i.e. proteins (albumin) too large)  BODY FLUID BALANCE, MOVEMENT Facilitated transport: active Active transport: active Carrier proteins carry molecules through Energy required to move substance across plasma membrane membrane against gradient Ex: glucose facilitated by carrier protein insulin; Ex: Na+/K+ pump balances K+ ICF, Na+ ECF large glucose molecule needs facilitation  BODY FLUID BALANCE, MOVEMENT Homeostasis: Hydrostatic pressure = Osmotic pressure Goal: maintain equilibrium between body fluid (water) and solutes (electrolytes, proteins) Fluid shifts when pressures create unequal balance across cell membrane Starling’s Law of Capillary Forces: osmotic & hydrostatic pressure in balance/opposition Osmotic pressure > Hydrostatic pressure, more fluid shifts to ICF (cellular swelling/edema) Hydrostatic pressure > osmotic pressure, more fluid shifts to ECF (cellular dehydration) Hydrostatic pressure: water pushes (osmosis) Water pushes into cell from vessels (high to low pressure) Force shifts fluid from ECF (vessels) to ICF (cells) HOMEOSTASIS INTERRUPTED…. Body fluid level imbalance: Fluid > or < “normal” inhibits body functions Body fluid functions: Universal biologic solvent (all chemical reactions occur in medium of water) Regulate electrolyte distribution in ECF, ICF Transport hormones, nutrients Dilute & transport toxins, waste products Transport O2 to cells, CO2 to lungs Modulate temperature shifts; absorb heat w/out changing temperature Image Credit: http://humanbiologylab.pbworks.com/w/page/50150566/ Water%20Balance%20Regulation  BODY FLUID HOMEOSTASIS Fluid Homeostasis: balance of fluid intake & output Osmolarity (solute levels in fluid) is body mechanism to monitor/assess body fluid status Mechanisms to maintain fluid homeostasis: Triggered by hypothalamus when osmolarity is high (low fluid) Thirst: conscious desire to drink (increase intake) ADH (anti-diuretic hormone): body retains fluid, reduces output Released by posterior pituitary Opposite of diuresis (excess production of urine) RAAS: renin-angiotensin-aldosterone system Image Credit: https://careclinic.io/track-water-intake/ Natriuretic peptides: excrete sodium & water  BODY FLUID HOMEOSTASIS Renin-Angiotensin-Aldosterone System (RAAS) Hypotension, hypovolemia, low cardiac output (CO) Low fluid volume, low BP -> fluid retention Low circulating fluid -> reduced renal perfusion Kidneys release renin (starts RAAS compensation) Renin converts angiotensin (from liver) to angiotensin 1 ACE (lungs) converts angiotensin 1 to angiotensin 2 (powerful vasoconstrictor), vasoconstriction increases blood pressure (BP) Triggers adrenal glands to release aldosterone (fluid retention) Aldosterone increases reabsorption of Na+, retention of Na + water Increased BP & fluid retention = return to normal blood volume  FLUID IMBALANCES: EDEMA Edema: swelling produced by increase in ISF and/or ICF ISF: can hold 10 – 30 L of additional fluid Pitting edema: exceed tissue absorption capacity, displace tissue Dependent edema = gravity related (typically LE) Nonpitting edema = firm, accumulation of plasma proteins Image Credit: https://www.mayoclinic.org/ (inflammation) diseases-conditions/edema/symptoms-causes/ syc-20366493 Etiology (cause): High hydrostatic pressure: excess fluid in bloodstream Sodium retention: Na+ triggers dehydration/thirst Ex: fluid accumulates in lungs (heart failure), fluid shift to alveoli Low osmotic pressure: low solutes to hold fluid in vessels Ex: hypoalbuminemia (low albumin) w/poor protein intake Inflammation, injury: inflammatory response increases capillary permeability, fluid shifts (swelling)  FLUID IMBALANCES: EDEMA Assessment: Symptoms determined by edema location Impaired movement, function (swelling) Increased extremity circumference Weight gain: 1 L fluid = 2.2 pounds Decreased blood flow (hypoxia) Wounds/ulcerations: skin susceptible to injury Life-threatening edema: Brain (cerebral edema), lungs (pulmonary edema), larynx (laryngeal edema) Image Credit: http://www.med-health.net/Edema-Grading.html FLUID IMBALANCES: HYPERVOLEMIA Excess fluid in body (overhydration), fluid volume overload Etiology (causes): High hydrostatic pressure (too much ECF), fluid shifts into ICF Excess sodium: increased fluid retention Ex: Heart failure – poor cardiac output stimulates RAAS, excess ECF in vessels, results in FVO Excess ADH: excess retention of fluid (lack of diuresis) Ex: SIADH - dilutional hyponatremia (fluid retained, Na+ concentration/osmolarity falls) Ex: cirrhosis of liver - stimulates ADH release, impairs blood flow through the liver & fluid accumulates (ascites) Image Credit: https://training.seer.cancer.gov/anatomy/cardiovascular/blood/ physiology.html FLUID IMBALANCES: HYPERVOLEMIA Assessment: CV: HIGH CARDIAC VOLUME (circulatory overload) Hypertension (HTN) Peripheral edema (pressure shifts fluid) Bounding pulse (vessels FULL), elevated arterial and venous pressure (HTN) Resp: dyspnea, pulmonary congestion (fluid), crackles, cough Pressure shifts fluid into lung tissue Skin: dry, shiny, stretched/“tight” w/ Image Credit: https://www.fluidacademy.org/blog-foam/item/ edema global-increased-permeability-syndrome-isicem18- ifad2018.html General: weight gain (acute) FLUID IMBALANCES: HYPOVOLEMIA Diminished fluid in body/bloodstream (dehydration), fluid volume deficit Decreased blood volume, impairs cardiac function Etiology (causes): Reduced fluid intake and/or excess fluid loss Ex: burn injuries, perspiration, diarrhea, vomiting, etc. High osmotic pressure, fluid shifts into from ICF to ECF Ex: uncontrolled diabetes mellitus (DM) – excess glucose in blood (high osmolarity), osmotic pressure draws fluid out of cells into ECF -> cellular dehydration Insufficient ADH: excess fluid loss (diuresis, excess urination) Ex: Diabetes insipidus (DI) - hypernatremia (fluid lost, Na+ retained, osmolarity rises) Complication: renal dysfunction related to decreased excretion of waste products FLUID IMBALANCES: HYPOVOLEMIA Assessment: CV: LOW CARDIAC VOLUME Hypotension (esp w/standing) Tachycardia: elev HR to compensate low BP Reduced peripheral perfusion Weak/thready pulse (vessels EMPTY), decreased arterial and venous pressure Neuro: dizzy, weak, LOC changes HA (poor cerebral blood/oxygen supply) Renal: Urine output ↓ (< 30 ml/hr) Concentration ↑ (dark yellow, high S.G.) Skin: dry skin/mucous membranes, turgor General: thirst, weight loss (acute) ELECTROLYTES Electrolytes: charged ions (cation+, anion (-)) Essential to metabolism, energy production Cell function (esp. nerve & muscle cells) Impulse conduction (action potential), muscle contraction Na+, K+ primary role in cell depolarization & repolarization Solutes: substances dissolved in ICF & ECF Protein molecules: essential body solute Maintains fluid balance, prevents shift of fluid Transports substances throughout body ELECTROLYTE BALANCE Normal Electrolyte Concentration 135 – 145 mEq/ Sodium (Na++) ECF L Potassium (K+) ICF 3.5 – 5.0 mEq/L Calcium (Ca++) ECF 8.7 – 10.5 mg/dL Chloride (Cl-) ECF 98 – 106 mEq/L Magnesium (Mg+ ICF 1.5 – 2.5 mg/dL +) Phosphate ICF 2.5 – 4.5 mg/dL Image Credit: https://www.researchgate.net/figure/onic-concentration-of- both-intracellular-and-extracellular-fluids-Image- source_fig3_309522864 ELECTROLYTE BALANCE, MOVEMENT Osmotic pressure: electrolytes/solutes (proteins) pull Pressure exerted by increased concentration of solutes Pull water from cells (diffusion) High concentration to low concentration Pressure shifts water from ICF to ECF (vessels), balance/ equalize concentration in vessels Osmolarity: solutes/liter of body fluid Number of electrolyte particles in fluid High serum osmolarity = excess electrolyte in blood Low serum osmolarity = reduced electrolyte in blood Image Credit: https://biology.stackexchange.com/questions/40883/osmolarity-vs- tonicity  ELECTROLYTE BALANCE, MOVEMENT Tonicity: Isotonic: osmotic pressure = to body fluids Osmotic pressure difference No fluid movement across membrane between two solutions Hypotonic: osmotic pressure < body fluids Ex: Intravenous (IV) fluids Low osmolarity, low solute concentration per liter Fluid/water moves into cell, cell edema (swells) Hypertonic: osmotic pressure > body fluids High osmolarity, high solute concentration per liter Fluid/water moves out of cell, cell dehydration (shrinks) Image Credit: https://2012books.lardbucket.org/books/an- Tonicity concepts essential to understanding IVF introduction-to-nutrition/s11-01-overview-of-fluid-and-electrol.html solutions SODIUM (NA+) Sodium Normal Range = 135 – 145 mEq/L Sodium 90% of ECF cations Imbalance: Hyponatremia - Serum Na++ < 135 mEq/ml Imbalance: Hypernatremia - Serum Na++ > 145 mEq/ml Primary role: fluid volume balance Elevated Na+ = fluid retention Other Na+ functions: Nerve impulse conduction Critical to muscle contraction Facilitates membrane transport (Na+/K+ pump) Image Credit: https://content.openclass.com/eps/pearson-reader/ api/item  SODIUM & BODY FLUID Wherever Sodium Goes, Water Will Follow Fluid imbalances linked to sodium imbalances Sodium (Na+) major ECF cation, regulates ECF volume Na+ levels accounts for majority of osmotic activity (body fluid/water movement) Hyponatremia: low Na+ osmolarity Low ECF concentration of Na+ shifts fluid from ECF to ICF (cellular edema) Hypernatremia: high Na+ osmolarity High ECF concentration of Na+ shifts fluid from ICF to ECF (cellular dehydration) Image Credit: https://nursekey.com/hyponatraemia-and-its-prevention/  SODIUM IMBALANCE Severe Na imbalance most dramatic impact to brain due to effect on cerebral fluid balance (or imbalance….) Image Credit: https://link.springer.com/article/10.1186/ s13049-019-0633-3 ELECTROLYTE IMBALANCE: HYPONATREMIA HYPERVOLEMIC Hyponatremia Etiology: Hypervolemic causes Fluid overload dilutes Na+: renal failure, heart failure Excess fluid most common cause of hyponatremia SIADH (Syndrome of Inappropriate ADH) Assessment: symptoms manifest < 125 mEq/ml Symptoms related to hypervolemia & hyponatremia/cell edema Neuro/MS: HA, confusion, weakness, fatigue, muscle cramps Severe (r/t cerebral edema): lethargy, seizure, coma, death CV (excess volume): HTN, bounding pulse Image Credit: https://5minuteconsult.com/ collectioncontent/1-151755/diseases-and- GI (excess volume, ascites): nausea, vomiting, diarrhea conditions/hyponatremia ELECTROLYTE IMBALANCE: HYPONATREMIA HYPOVOLEMIC Hyponatremia Etiology: Hypovolemic causes Renal loss: diuretics, renal disease (excess Na excretion) Non-renal: loss of sodium & fluid Ex: vomiting, GI suctioning, wound drainage, sweating, burns, etc. Assessment: symptoms manifest < 125 mEq/ml Symptoms related to hypovolemia & hyponatremia/cell edema Neuro/MS: HA, confusion, weakness, fatigue, muscle cramps Severe (r/t cerebral edema): lethargy, seizure, coma, death CV (hypovolemia): Tachycardia, hypoTN (low BP esp w/standing) Renal: low urine output (oliguria), azotemia (excess waste in blood) General (hypovolemia): thirst, poor skin turgor, dry mucosa Image Credit: https://www.ncbi.nlm.nih.gov/books/  ELECTROLYTE IMBALANCE: HYPERNATREMIA HYPOVOLEMIC Hypernatremia Etiology: Hypovolemic causes Excess fluid loss most common cause (fluid lost, Na left behind) Fever, watery diarrhea, tachypnea, etc. Decreased water intake (esp w/elderly) DI: Na+ retention, excretion of excess dilute urine Assessment: symptoms manifest > 155 mEq/ml Symptoms r/t cellular dehydration (Excess Na ECF pulls water from ICF) Neuro: restless, irritable, muscle twitching/spasms Severe (r/t cerebral dehydration): lethargy, seizure, coma, death CV (hypovolemia): Tachycardia, hypoTN General (hypovolemia): thirst, fever Image Credit: https://slideplayer.com/slide/ 10431894/ ELECTROLYTE IMBALANCE: HYPERNATREMIA HYPERVOLEMIC Hypernatremia Etiology: Hypervolemic causes Hyperaldosteronism – increase tubular reabsorption Excess salt intake, Antacids with sodium bicarbs Assessment: symptoms manifest > 155 mEq/ml Symptoms r/t cellular dehydration (Excess Na ECF pulls water from ICF) Neuro: restless, irritable, muscle twitching/spasms, severe (r/t cerebral dehydration): seizure, coma, death CV (hypervolemia): Tachycardia, hyperTN, bounding pulse Resp (hypervolemia): dyspnea, pulmonary congestion Image Credit: https://emcrit.org/wp-content/uploads/ General (hypervolemia): weight gain 2016/11/Hypernatremia-in-Critically-Ill-Pts.pdf  POTASSIUM (K+) Potassium Normal Range = 3.5 – 5 mEq/L Primary cation in ICF (cell is “OK”), 2% in plasma (ECF) Hypokalemia - Serum K+ < 3.5 mEq/ml Hyperkalemia - Serum K+ > 5 mEq/ml Primary role: Maintain action potentials K+ gradient stimulus for action potential initiation (electrical excitability)Image Credit: https:// www.differencebetween.com/ difference-between- K out, Na in = cell depolarization (cardiac rhythms, muscle contraction) depolarization-and-vs- repolarization/ Other functions: Acid-base balance: hydrogen, K+ shifts b/t ICF & ECF to maintain pH Potassium Regulation: nephrons (kidney), aldosterone triggers K+ excretion POTASSIUM & PH Intracellular pH Buffer: H+ and K+ ion exchange, shift between ICF and ECF to buffer pH Alkalosis (high pH): H+ moves out of Acidosis (low pH): H+ moves into cell, cell, K+ into cell (hypokalemia) K+ moves out (hyperkalemia) Image Credit: http://notezonnursing.blogspot.com/2011/05/some-fluidelectrolyte-balance- ELECTROLYTE IMBALANCE: HYPOKALEMIA Etiology: Excess K+ excretion (renal) Medication side effects (diuretics most common cause) Severe GI loss: vomiting, diarrhea Inadequate intake of K+ Ex: NPO status, bariatric surgery Image Credit: https://study.com/academy/lesson/what-is-hypokalemia- definition-causes-symptoms-treatment.html Alkalosis: ECF K+ shifts into ICF, H+ ions shift out Assessment: Decreases cell excitability, action potential CV: hypoTN (low BP esp w/standing), cardiac arrythmias Prolonged PR interval (delayed conduction atria to ventricles) Flattened T wave (decreased repolarization/action potential) Neuro/MS: muscle fatigue, weakness, leg cramps, poor reflexes General: anorexia, n/v (decreased peristalsis) Image Credit: https://www.nclexquiz.com/blog/ecg-ekg-changes-hypokalemia- hyperkalemia/  ELECTROLYTE IMBALANCE: HYPERKALEMIA Etiology: Excess K+ retention/decreased K+ excretion (renal) Renal failure (most common) Massive injury/burn (releases K+ from damaged cells) Acidosis: ICF K+ shifts into ECF, H+ ions shift into cell Assessment: increases excitability, action potential Image Credit: https://study.com/academy/lesson/what-is-hypokalemia- definition-causes-symptoms-treatment.html Decreases excitability threshold (fires too quick) Levels > 7.0 mEq/L significant, Levels > 8.5 mEq/L fatal CV: Ventricular dysrhythmias (v-fib, cardiac arrest) Peaked T wave (excess repolarization) Wide QRS interval (impaired ventricular conduction) Neuro/MS (early): numbness tingling, muscle cramps, confusion Image Credit: https://www.nclexquiz.com/blog/ecg-ekg-changes-hypokalemia- hyperkalemia/  CALCIUM (CA++) Calcium Normal Range = 8.7 – 10 mg/dL 99% of Ca+ bound in bones, teeth (primary mineral) 1% in circulation, ECF (measure serum levels) Hypocalcemia - Serum Ca++ < 8.7 mg/dL Hypercalcemia - Serum Ca++ > 10 mg/dL Serum (free) calcium functions: Neuro: nerve impulse conduction/excitability, muscle contraction Blood clotting factor Image Credit: https://ascientificcuriosity.wordpress.com/ Regulation of Calcium: parathyroid hormone (PTH) health-and-nutrition/calcium-got-plants/ Decreased serum calcium concentration stimulates PTH, mobilizes calcium in bones to stabilize serum calcium ELECTROLYTE IMBALANCE: HYPOCALCEMIA Etiology: Insufficient supply of calcium (most common) Chvostek’s sign: facial Inadequate calcium or Vitamin D intake nerve twitch w/light tap to facial nerve Hypoparathyroidism: inability to get Ca from bone Increased excretion of calcium Renal disease, diarrhea, wound drainage Assessment: Increased neural excitability (fire more easily) Neuro: muscle twitch/cramps, tetany (contraction), hyperreflexia, paresthesia (numbness, tingling) CV: HypoTN, arrhythmias Resp: dyspnea, laryngospasm Trousseau’s sign: carpopedal spasm w/blood flow occlusion (Ca++ concentration produces spasm) ELECTROLYTE IMBALANCE: HYPERCALCEMIA Etiology: Increased calcium from bone Metastatic Cancer (most common cause): Ca++ released from bone destroyed by cancer Immobility: increased Ca from bone loss Hyperparathyroidism: excess PTH increases Ca from bone Excessive calcium or Vitamin D intake Assessment: Decreased neural excitability (less able to fire) Neuro: muscle weakness, hyporeflexia/ataxia (flaccid/limp), paresthesia (numbness, tingling) CV: HyperTN, arrhythmias “Bones, Stones, Groans, Image Credit: Moans” https://www.slideshare.net/ MS: osteopenia (bone loss), bone pain, pathologic Fx DrLalaShouravDas/ GI: constipation, anorexia, n/v, cramps, hypoactive BS hypercalcemia-82719827 PHOSPHORUS Phosphorus Normal Range = 2.5 – 4.5 mg/dL ICF anion (14% in cells), 85% of phosphorus in bones Hypophosphatemia, Serum Phosphorus < 2.5 mg/dL Hyperphosphatemia, Serum Phosphorus > 4.5 mg/dL Roles of Phosphorus: Formation of teeth and bones, red blood cells Essential to carb, protein, lipid metabolism, ATP creation Building block of nucleic acids (RNA & DNA) Regulate acid-base as buffer Regulation of Phosphorus: Image Credit: https://sites.google.com/site/ faiqyosefchem10hp2/role-of-phosphorus-in-the-body? Renal: Phosphate excretion depends on serum phosphate concentrations tmpl=%2Fsystem%2Fapp%2Ftemplates%2Fprint%2 F&showPrintDialog=1 PTH: elevated PTH reduces phosphate retention (inverse relationship) Reciprocal to calcium regulation to prevent Ca++ phosphate crystals  HYPOPHOSPHATEMIA & HYPERPHOSPHATEMIA Hypophosphatemia Hyperphosphatemia Serum Phosphorus < 2.5 mg/dL Serum Phosphorus > 4.5 mg/dL Etiology Decreased intestinal absorption Renal failure (reduced secretion) (diarrhea, prolonged antacids, low Vit D) Rhabdomyolysis (rapid production) Malnutrition, alcoholism Increased renal loss, alkalosis Assessment Decrease energy, deficiency in ATP S/S related to complementary calcium Neuro: tremors, paresthesia, weakness, deficit hyporelexia, confusion, stupor, coma Neuro: Paresthesia, tetany MS: weak, joint stiffness, bone pain CV: Hypotension, arrhythmias Blood: Hemolytic anemia (hemolysis), impaired WBC & platelet function MAGNESIUM Magnesium Normal Range = 1.5 – 2.5 mg/dL ICF cation, majority stored in bone (60%) Hypomagnesemia – serum magnesium < 1.5 mg/dL Image Credit: http:// drleonardcoldwell.com/why- Hypermagnesemia – serum magnesium > 2.5 mg/dL magnesium-is-the-most-essential- mineral-your-body-isnt-getting-enough- Roles of Magnesium: of/ Essential for absorption of Calcium & Vitamin D (necessary for PTH function) Co-factor in enzymatic reactions (over 300, esp carb & protein metabolism) Facilitates ATP production (powers Na-K pump) Transmits electrical impulse across nerves/muscle via K+ & Na+ channels Regulation of Magnesium: Renal, GI system balance through selective absorption, excretion PTH stimulates magnesium reabsorption (triggered by Ca++ levels)  HYPOMAGNESEMIA & HYPERMAGNESEMIA Hypomagnesemia Hypermagnesemia Serum Magnesium < 1.5 mg/dL Serum Magnesium > 2.5 mg/dL Increased excretion/loss of magnesium (GI Decreased excretion of magnesium (renal loss, renal disease) disease, kidney injury, untreated DKA) Etiology Insufficient supply of magnesium VERY rare; kidneys very effective at (malnutrition, malabsorption, alcohol abuse) regulating high magnesium VERY SIMILAR TO HYPOCALCEMIA S/S related to neuromuscular and CV (hypomagnesemia common cause d/t PTH) function Neuro: hyperreflexia, tremors, nystagmus Neuro: hyporeflexia, muscle weakness, Assessmen (eye twitch), irritability, anxiety, mood changes drowsiness t Positive Chvostek & Trousseau signs CV: HypoTN, tachycardia shifting to CV: tachycardia, HyperTN, cardiac bradycardia, prolonged PR, widened/ dysrhythmias delayed QRS, peaked T Bone (chronic hypoMg): osteoporosis  CHLORIDE Chloride Normal Range = 98 – 106 mEq/L ECF anion, majority stored in bone (60%) Hypochloremia – serum chloride < 98 mEq/L Hyperchloremia – serum chloride > 106 mEq/L Roles of Chloride: Essential for regulation of fluid (BP), pH balance Supports nerve impulse conduction, muscle contraction Facilitates absorption of nutrients Bound to Na+, tend to fluctuate similarly Regulation of Chloride: Renal balances through selective absorption, excretion Image Credit: https://www.eufic.org/en/vitamins-and-minerals/article/ chloride-foods-functions-how-much-do-you-need-more  HYPOCHLOREMIA & HYPERCHLOREMIA Hypochloremia Hyperchloremia Serum Chloride < 98 mEq/L Serum Chloride > 106 mEq/L Increased excretion/loss of chloride (GI loss, VERY rare renal disease, excess sweating) Dehydration: medications (diuretics), heat pH imbalance: Chronic respiratory acidosis, exposure, decreased fluid intake Etiology metabolic alkalosis Decreased excretion of chloride (renal Rare – typically only impacts critical care/ disease) ICU Typically occurs w/Hyponatremia Typically occurs w/Hypernatremia No direct symptoms Fluid retention: HTN, edema Assessmen Symptoms reflect associated imbalances of CV: impaired conduction, irregular HR t other electrolyte disorders or cause Neuro: weakness, confusion REFERENCES Mosby’s Dictionary of Medical, Nursing & Health Professions. (2009). (8th Ed.). St. Louis, MO: Mosby Elsevier. Capriotti, T. (2024). Davis Advantage for pathophysiology: Introductory concepts and clinical perspectives (3rd Ed.). FA Davis: Philadelphia, PA.