Post on 16-Apr-2017
transcript
Nio Cruzada Noveno, RN, MAN, MSN
Fluids & Electrolytes
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FLUIDS and ELECTROLYTES
BODY FLUIDSFunctions of Fluids
o Body fluids:o Facilitate in the transport
[nutrients, hormones proteins, & others…]
o Aid in removal of cellular metabolic wastes
o Provide medium for cellular metabolism
o Regulate body temperatureo Provide lubrication of musculoskeletal
jointso Component in all body cavities
[parietal, pleural fluids]
Water is the principal body fluid & essential for life.
Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTESFLUIDS and ELECTROLYTES
BODY FLUIDS
ICF ECF
40% TBW 20% TBW
P IS
Distribution of Body Fluids: 50-70% of total body weight;
infant [70-80%], elderly [45-50%]
60-kg manTBW = 0.6 x 60 kg = 3.6 L
ICF = 0.4 x 60 kg = 24 L ECF =12 L
3L 9L
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FLUIDS and ELECTROLYTES
BODY FLUIDS
Factors that Dictate Body Water Requirement
1) Amount needed to give the proper osmotic concentration
2) Amount needed to replace water lost excretionNormal Routes of water gain and loss
INTAKE OUTPUTml/day ml/day
Fluid intake 1,500Food 800Metabolic water 300
TOTAL 2,600
Insensible loss 400Sweat 600Feces 100Urine 1,500
TOTAL 2,600Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS
Osmotic Pressure Gradient
Oncotic P (Colloid osmotic P)
Capillary P (Hydrostatic P)
ICF ECF
P ISFRenal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
Control of Osmotic Pressure, Volume & Electrolyte Concentration
OBLIGATORY Reabsorptiono occurs in the proximal tubuleso 178 L/day of glomerular filtrate (80%
reabsorbed)o 2 to solute reabsorptiono independent of the water requirement
FACULTATIVE Reabsorptiono occurs in the distal & collecting tubuleso independent of the active solute transporto dependent of body’s need of watero under the control of ADH Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTESFLUIDS and ELECTROLYTES
DISTURBANCES IN FLUID BALANCE
EDEMA (Dropsy)
in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2° to:
o Increased HP [pregnancy, CHF]
o Decreased OP [malnutrition, end-stage liver disease,
nephrotic syndrome]
Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
DISTURBANCES IN FLUID BALANCE
CELL OVERHYDRATION
o excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute
o occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment
o fluid overload from production of adrenal corticoid hormones [Cushing’s syndrome]
Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
DISTURBANCES IN FLUID BALANCE
CELL OVERHYDRATION
o Symptomso Weight gain & edemao Cough, moist rales, dyspnea
[fluid congestion in lungs]o CVP, bounding pulse, neck vein
engorgement [fluid excess in the vascular system]
o Bulging fontanelles Hg and Hcto Nausea & vomiting
Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
DISTURBANCES IN FLUID BALANCE
CELL OVERHYDRATION
o Managemento Restrict fluids to lower fluid volumeo Diuretics or hypertonic salineo Continuous assessments to prevent skin
breakdowno Record daily weight to assess progress of
treatment
Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
DISTURBANCES IN FLUID BALANCE
CELL DEHYDRATION (DHN)
o loss of body fluids, particularly from the extracellular fluid compartment
o water loss > water intake
o Causeso Fevero Insufficient water intakeo Diarrhea, vomitingo Excess urine output [Diabetes insipidus,
diuretics]o Excessive perspiration, burnso Hemorrhage, shock, metabolic acidosisRenal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
DISTURBANCES IN FLUID BALANCE
CELL DEHYDRATION (DHN)
o Symptomso Thirst, dry mucus membranes, sunken
eyeballso “Doughy“ abdomen, dry skin w/ poor
turgor temp, weight loss HR, RR, BPo Restlessness,irritability, disorientation,
convulsion, coma [22-30% body H20 loss]o Management
o Fluid replacement therapy & continued fluid maintenance
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FLUIDS and ELECTROLYTES
Volume Disorders 2° Alteration in Sodium Balance
Expansion Isotonic Inc N No net change Isotonic fluid
ingestion Hypertonic Inc Dec ICF ECF Sea water
ingestion Hypotonic Inc Inc ECF ICF Hypotonic IVF
Contraction Isotonic Dec N No net change Diarrhea Hypertonic Dec Dec ICF ECF Diabetes insipidus Hypotonic Dec Inc ECF ICF Addison’s dse
Volume ECF ICF Water Conditions Disorder Vol. Vol. Shift
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FLUIDS and ELECTROLYTES
ELECTROLYTES
o salts or minerals in extracellular or intracellular body fluids
o Sodium – major cation of ECF
o Potassium – major cation of ICF
o Chloride - major anion of ICF
o Protein – in ICF > ISF
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FLUIDS and ELECTROLYTES
ELECTROLYTE Composition
Electrolyte Conc Plasma (mEq/L) ISF ICF
Sodium, Na+ 142 141 10 Potassium, K+ 5 4.1 150Calcium, Ca++ 5 4.1 -Magnesium, Mg++ 3 3 40
(155)Chloride, Cl- 103 115 15Bicarbonate, HCO3
- 27 29 10Biphosphate, HPO4
- 2 2 100Sulfate, SO4
- 1 1 20Protein 16 1 60Organic foods 6 3.4 -
(155) Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
ELECTROLYTES
Functions of Electrolytes
o Contribute most of the osmotically active particles in body fluids
o Provide buffer systems for pH regulation
o Provide the proper ionic environment for normal neuromuscular irritability & tissue function
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FLUIDS and ELECTROLYTESFLUIDS and ELECTROLYTES
Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]
o Causes Na+ intake Na+ excretion [diaphoresis, GI
suctioning]o Adrenal insufficiency
o Assessmento N & V, abdominal cramps, weight losso Cold, clammy skin, skin turgoro Apprehension, HA, convulsions, focal
neurologic deficit, coma [cerebral edema]
o Fatigue, postural hypotensiono Rapid thready pulse
ELECTROLYTES
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HyponatremiaDrugs that cause decreased sodium
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Anti-convulsant:Carbamazepine
Antidiabetics:ChlorpropramideTolbutamide
Antipsychotics:FluphenazineThiozoridazineThiothixene
Antineoplastics:CyclophosphamideVincristine
Diuretics:BumetanideEthacrynic acidFurosemideThiazides
Sedatives:BarbituratesMorphine
Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
Hyponatremia [Na+ < 135 mEq/L; Normal = 135-145 mEq/L]
Managemento Provide foods high in sodiumo Administer NSS IVo Assess blood pressure frequently
[measure lying down, sitting & standing]o High sodium foods
o Celeryo Cheeses o Condimentso Processed foodso Smoked meatso Snack foods
ELECTROLYTES
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Treatment
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InterventionsMild
Water restriction if water retention problem Increase Na in foods if loss of Na
ModerateIV 0.9% NS, 0.45% NS, LR
Severe3% NS – short-term therapy in ICU setting
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FLUIDS and ELECTROLYTES
Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]
o Causeso Excessive, rapid IV adm’n of NSSo Inadequate water intakeo Kidney disease
o Assessment o Dry, sticky mucus membraneso Flushed skino Rough dry tongue, firm skin turgoro Intense thirsto Edema, oliguria to anuriao Restlessness, irritability [cerebral DHN]
ELECTROLYTES
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Hypernatremia
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Skin flushedAgitationLow-grade feverThirst
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FLUIDS and ELECTROLYTES
Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]
o Nursing Interventiono Weigh dailyo Assess degree of edema frequentlyo Measure I & Oo Assess skin frequently & institute nursing
measures to prevent breakdowno Encourage sodium-restricted diet
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]
o Causeso Renal insufficiencyo Adrenocortical insufficiencyo Cellulose damage [burns]o Infectiono Acidotic stateso Rapid infusion of IV sol’n w/ potassium-
conserving diuretics
ELECTROLYTES
Renal Disordersnionoveno@yahoo.com
HyperkalemiaDrugs that increase potassium
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ACE inhibitors
Antibiotics
Beta blockers
NSAIDs
Spironolactone
Chemotherapeutics
Renal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]
o Assessmento Thready, slow pulseo Shallow breathingo N & V, diarrhea, intestinal colico Irritabilityo Muscle weakness, flaccid
paralysiso Numbness, tinglingo Difficulty w/ phonation,
respiration
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]
o Nursing Interventionso Administer kayexalate as orderedo Administer/monitor IV infusion of
glucose & insulino Control infectiono Provide adequate calories &
carbohydrateso Discontinue IV or oral sources of K+
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]
o Causeso Renal tubule defectso Prolonged diuretic therapy o Prolonged vomiting, diarrhea, laxative
use, NG suctioning, severe diaphoresiso Anorexiao Acute alcoholismo Hyperaldosteronism, excessive steroids o Metabolic alkalosiso Administration of potassium-deficient
hyperalimentation sol’n, hypertonic glucose
o Excessive amounts of insulin
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]
o Assessmento Thready, rapid, weak pulseo Faint heart sounds BPo Skeletal muscle weakness or absent reflexeso Shallow respirationso Malaise, apathy, lethargyo Loss of orientationo Anorexia, vomiting, weight losso Gaseous intestinal distention
ELECTROLYTES
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Hypokalemia
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Skeletal muscle weaknessU-waveConstipation; ileusToxic effects of digoxinIrregular, weak pulseOrthostatic hypotensionNumbness [paresthesia]
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HypokalemiaDrugs that decrease potassium
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Adrenergics:AlbuterolEpinephrine
Antibiotics:Amphotericin BCarbenicillinGentamicin
Insulin
CisplatinCosticosteroidsDiuretics:
Furosemide Thiazides
Laxatives [excess use]
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FLUIDS and ELECTROLYTES
Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]
o Nursing Interventionso Administer K+ supplements to replace losseso Be cautious in administering drugs that are
not potassium-sparingo Monitor acid-base balanceo Monitor pulse, BP and ECGo High potassium foods
o Avocadoso Bananaso Dateso Orangeso Potatoeso Raisins
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]
o Causeso Hyperparathyroidismo Immobilityo Increased vitamin D intakeo Osteoporosis & osteomalacia [early
stages]
o Assessmento N & V, anorexia, constipationo Headache, confusiono Lethargy, stuporo Decreased muscle toneo Deep bone/flank pain
ELECTROLYTES
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HypercalcemiaDrugs that increase calcium
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Calcium-containing antacidsCalcium preparations
LithiumThiazide diuretics
Vitamin AVitamin D
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FLUIDS and ELECTROLYTES
Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]
o Nursing Interventionso Encourage mobilizationo Limit vitamin D intakeo Limit calcium intakeo Normal salineo Administer diureticso Calcitonin
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]
o Causeso Acute pancreatitiso Diarrheao Hypoparathyroidismo Lack of vitamin D in the dieto Long-term steroid therapy
o Assessmento Painful tonic muscle & facial spasmso Fatigue, dyspneao Laryngospasm, convulsionso (+) Trousseau’s and Chvostek’s signs
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]
o Nursing Interventionso Administer oral Ca lactate or IV CaCl2
or gluconateo Providing safety by padding side railso Administer dietary sources of calciumo Vitamin Do Provide quiet environmento High calcium foods
o Milko Dairy products
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L]
o Causeso Renal insufficiency, dehydrationo Excessive use of Mg-containing antacids or
laxativeso Assessment
o Lethargy, somnolence, confusiono N & Vo Muscle weakness, depressed reflexes pulse and respirations
o Nursing Interventiono Withhold Mg-cont’g drugs/foods; Ca adm’n fluid intake, unless CI
ELECTROLYTES
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FLUIDS and ELECTROLYTES
Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L]
o Causeso Low intake of Mg in the dieto Prolonged diarrhea o Massive diuresiso Hypoparathyroidism
o Assessmento Paresthesias, muscle spasmo Confusion, hallucination, convulsionso Ataxia, tremors, hyperactive deep reflexeso Flushing of the face, diaphoresis
o Nursing Interventiono Provide good dietary sources of Mg
ELECTROLYTES
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HypomagnesemiaDrugs that decrease magnesium
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Aminoglycoside:Amikacin,
gentamicin, streptomycin,
tobramycin
Amphotericin B
Cisplatin
Cyclosporine
Insulin
Laxative
Loop diuretics
Pentamidine isethionate
Renal Disordersnionoveno@yahoo.com
Hypomagnesemia
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SeizuresTetanyAnorexia & arrhythmiasRapid heart rateVomitingEmotional labilityDeep tendon reflexes increased[tremors, twitching, tetany]
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Dietary sources
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ChocolatesDry beans and peas
Green, leafy vegetablesMeatsNuts
SeafoodWhole grains
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FLUIDS and ELECTROLYTES
IV FLUID REPLACEMENT THERAPY
Indications
o Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding]
o Maintenance of daily fluid & electrolyte needs
o Correction of fluid disorders
o Correction of electrolyte disordersRenal Disordersnionoveno@yahoo.com
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FLUIDS and ELECTROLYTES
IV FLUID REPLACEMENT THERAPY
Types of Solutions
o Isotonico 0.9% sodium chloride (NSS)o Lactated Ringer’s sol’n
o Hypotonico 5% dextrose and water (D5W)o 0.45% sodium chlorideo 0.33% sodium chloride
o Hypertonico 3% NaClo Protein sol’ns
o Colloidso Salt poor albumin Plasmanate, Dextran Renal Disordersnionoveno@yahoo.com
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B U R N S
BURNS
wounds caused by excessive exposure to the following agents or causes:
Causes of Burns:
o Thermal [moist or dry heat]o Electrical o Chemical [strong acids and strong
alkali]o Radiation [UV, x-rays, radium,
sunburns]Renal Disordersnionoveno@yahoo.com
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CLASSIFICATION OF BURNS
o Superficial Partial thickness (1st degree)o Outer layer of dermiso Erythema, pain up to 48 hrso Healing 1-2 wks [sunburn]
o Deep Partial thickness (2nd degree)o Epidermis & dermiso Blisters & edema, frequently quite painfulo Healing 14-21 days
o Full thickness (3rd degree)o Epidermis, dermis, subcutaneous fato Dry, pearly white or charred in appearanceo Not painfulo Eschar must be removed; may need grafting
B U R N S
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STAGES OF BURNS
1st: Shock/Fluid Accumulation Phase
o 1st 48 hrso IVC ISCo Generalized DHN [fluid shifting]o Hypovolemia [plasma loss], BP, C.O.o Hemoconcentration, Hct [liquid blood
component ISC]o Oliguria [ renal perfusion], ADH release &
aldosteroneo HyperK, hypoNao Metabolic acidosis
B U R N S
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STAGES OF BURNS
2nd: Diuretic/Fluid Remobilization Phase
o After 48 hrso ISC IVCo Hypervolemia, o Hemodilution, Hct o Diuresis [ renal perfusion], ADH &
aldosterone secretiono HypoK, hypoNa [K moves back into the
cells, Na+ still trapped in the edema fluidso Metabolic acidosis
B U R N S
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STAGES OF BURNS
3rd: Recovery Phase
o 5th day onwardso Hypocalcemia
o Ca is lost on the exudateso Ca is utilized in the granulation tissue
formationo Negative nitrogen balance
o Due to stress response protein catabolismo Protein intake is lesser than the demand
o HypoK
B U R N S
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ASSESSMENT
1. Assess extent of body surface burnedo Greater morbidity & mortality for burns
affecting face, hands & perineumo Assess for dyspnea, stridor, hoarseness
2. Assess extent of burn injuryo Rule of nine – immediate appraisalo Lund-Browder chart – more accurateo Berkow’s method – based on client’s age &
changes that occur in proportion of head & legs to the rest of the body as one grows
B U R N S
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ASSESSMENT
B U R N S
9%
9% 9%Front=18%Back=18%
18%18%
1%Burn Evaluation
Chart
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ASSESSMENT
3. Assess depth of burno Major burns – 2nd degree over 30% of bodyo Hospitalization - eyes, face, neck, hands,
perineum, genitalia
4. Assess unique contributing factorso Age of cliento Health history
o Diabetes, preexisting ulcerso Tetanus immunization
B U R N S
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EMERGENCY MANAGEMENT
Stop the burning processo Remove patient from source of injuryo Advise client to roll on the ground if clothing
is in flame [STOP-DROP-ROLL]o Throw a blanket over the client to smother
the flameo Remove clothing only if hot or for scald burno Immerse affected part in cold water [10
min]o Irrigate copiuosly w/ large amount of
running water w/ chemical burns [except w/ phosphorus]
o Interrupt power source w/ electrical burn
B U R N S
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MANAGEMENT
o Maintenance of adequate airway
o Promoting comfort: relieve pain
o Promoting fluid-electrolyte, acid-base balance
o Preventing infection
o Maintaining adequate nutrition
o Wound care
B U R N S
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METHODS OF TREATING BURNS
o Open method or Exposure methodo Face, neck, perineum, trunko Allowing exudate to dry in 3 days
o Occlusiveo Less pain, absorption of secretion, comfort,
transportability, accelerated debridemento Aesthetic considerations
o Semi-open methodo Covering of wound w/ topical antimicrobials:
o Silver sulfadiazine 1% (Flamazine)o Silver nitrate 0.5% sol’no Mafenide acetate (sulfamylon acetate)
B U R N S
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BIOLOGIC DRESSING (Skin Graft)
o Allograft o Skin taken from other person [cadaver]
o Autograft o Same person
o Heterograft o Different specieso Xenograft
[segment of skin from animal such as pig or dog]
B U R N S
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FLUID REPLACEMENT
Types of fluids:
o Colloids o Bloodo Plasma & plasma expanders
o Electrolyteso Lactated Ringers
o Non-electrolyte o D5W
B U R N S
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FLUID REPLACEMENT
EVAN’S Formula:o C – 1ml x % burns x kg BWo E - 1ml x % burns x kg BWo Glucose 5% for insensible loss – 2,000ml
D5W
Administer sol’n 1st 24 hrs – ½ [1st 8hrs], ½ [16hrs]
BROOKE Formula: [Administer as in Evan’s]o C – 0.5ml x % burn x kg BWo E - 1.5ml x % burn x kg BWo Water – 1000ml D5W
B U R N S
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FLUID REPLACEMENT
MOORES BURN BUDGET:
o 75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1% TBSA plus 2000 D5W
HYPERTONIC RESUSCITATION Formula:
o Hypertonic salt containing 300 mEq of Na+, 100 mEq of Cl-, 200mEq lactate
o Administered to maintain urinary output of 30-40 ml/hr
B U R N S
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60Renal Disorders
ACID-BASE DISORDERSDisorder Clinical
manifestation Compensation
Respiratory acidosis
↑Paco2, ↑ or normal HCO3
-, ↓ pHKidneys eliminate H+
and retain HCO3-
Respiratory alkalosis
↓ Paco2, ↓ or normal HCO3
-, ↑ pHKidneys conserve H+ and eliminate HCO3
-
Metabolic acidosis↓ or normal Paco2,
↓HCO3-, ↓ pH
Lungs eliminate CO2 and conserve HCO3
-
Metabolic alkalosis↑ or normal Paco2,
↑HCO3-, ↑ pH
Lungs hypoventilate to ↑ Paco2, kidneys conserve H+ excrete
HCO3-
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61Renal Disorders
Causes of Acid-Base Disorders
Metabolic acidosisCauses:DKA, uremia,
starvation, diarrhea, severe infections
Manifestations:Headache, nausea
and vomitingSigns of
hyperkalemiaSeizures, coma,
hyperventilation
Nursing management:Administer sodium
bicarbonateMonitor for signs of
hyperkalemiaProvide alkaline mouthwashLubricate lips to prevent
drynessI & OInstitute seizure precautionMonitor ABG & electrolyte
losses
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62Renal Disorders
Causes of Acid-Base Disorders
Metabolic alkalosisCauses:Severe vomiting, NGT
suctioning, diuretic therapy, excessive ingestion of NaHCO3, biliary drainage
Manifestations:Nausea and vomitingSigns and symptoms
of hypokalemia
Nursing management:
Decreased respirations
Replace fluids nad electrolytes losses
I & OAssess for signs of
hypokalemiaMonitor ABG &
electrolytesnionoveno@yahoo.com
63Renal Disorders
Causes of Acid-Base Disorders
Respiratory acidosisCauses:Hypoventilation: COPD,
barbiturate or sedative overdose, acute airway obstruction, neuromuscular disorders
Manifestations:Headache, weakness, visual
disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma
Nursing management:
Semi-Fowler’s Patent airwayTurn, cough, deep-
breathAdminister fluidsO2 therapyMonitor ABG
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64Renal Disorders
Causes of Acid-Base Disorders
Respiratory alkalosisCauses: Hyperventilation,
mechanical overventilation, encephalitis
Manifestations: Numbness and tingling of
mouth and extremities Inability to concentrate Rapid respirations, dry
mouth, coma
Nursing management:
Offer reassuranceEncourage breathing
into a paper bagProvide sedation as
orderedMonitor mechanical
ventilation and ABG
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65Renal Disorders
Interpretation
UC PC FC
pH ↓ or ↑ ↓ or ↑ normal
HCO3- ↓ or ↑
normal ↓ or ↑ ↓ or ↑
Paco2↓ or ↑normal ↓ or ↑ ↓ or ↑
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Nio Cruzada Noveno, RN, MAN, MSN
Fluids & Electrolytes