Fluidsandelectrolytes

FLUIDS FLUIDS AND AND

ELECTROLYTESELECTROLYTES

OBJECTIVESOBJECTIVESAfter this lecture/discussion, the learner should be able to:After this lecture/discussion, the learner should be able to:

1.1. Describe the mechanisms that maintain fluid, electrolyte Describe the mechanisms that maintain fluid, electrolyte and and acid-base balance.acid-base balance.

2.2. Compare the mechanisms and effects of fluid deficit and Compare the mechanisms and effects of fluid deficit and excess.excess.3.3. Discuss the mechanisms and effects of deficits and excess.Discuss the mechanisms and effects of deficits and excess.4.4. Describe the mechanisms that maintain acid-base balance.Describe the mechanisms that maintain acid-base balance.5.5. Differentiate between metabolic and respiratory acidosis and Differentiate between metabolic and respiratory acidosis and alkalosis.alkalosis.6.6. Apply the pathophysiologic principles of acid-base balance to Apply the pathophysiologic principles of acid-base balance to the the interpretation of ABG measurements.interpretation of ABG measurements.7.7. Analyze the components of ABGs to identify the type of acid-base Analyze the components of ABGs to identify the type of acid-base balance.balance.8.8. Describe the causes and effects of each type of acid-base Describe the causes and effects of each type of acid-base balance.balance.9.9. Use ABG findings in formulating the care of the patient with an Use ABG findings in formulating the care of the patient with an

acid-base imbalance.acid-base imbalance.10.10. Describe the management of patients with a fluid, electrolyte, or Describe the management of patients with a fluid, electrolyte, or

acid-base imbalance.acid-base imbalance.

HOW IMPORTANT IS WATER?HOW IMPORTANT IS WATER?

• Between 50% and 60% of the human Between 50% and 60% of the human body by weight is waterbody by weight is water

• Water provides a medium for Water provides a medium for transporting nutrients to cells and wastes transporting nutrients to cells and wastes from cells and for transporting from cells and for transporting substances such as hormones, enzymes, substances such as hormones, enzymes, blood platelets, and red and white blood blood platelets, and red and white blood cellscells

• Water facilitates cellular metabolism and Water facilitates cellular metabolism and proper cellular chemical functioningproper cellular chemical functioning

• Water acts as a solvent for electrolytes Water acts as a solvent for electrolytes and nonelectrolytesand nonelectrolytes

• Helps maintain normal body temperatureHelps maintain normal body temperature

• Facilitates digestion and promotes Facilitates digestion and promotes eliminationelimination

• Acts as a tissue lubricantActs as a tissue lubricant

VARIATIONS IN FLUID CONTENTVARIATIONS IN FLUID CONTENT

BODY FATBODY FATBecause fat cells contain little Because fat cells contain little water and lean tissue is rich in water and lean tissue is rich in water, the more obese the water, the more obese the person, the smaller the person, the smaller the percentage of total body water percentage of total body water compared with body weight.compared with body weight.

This is also true between sexes This is also true between sexes because females tend to have because females tend to have proportionally more body fat proportionally more body fat than males.than males.

There is also an increase in fat There is also an increase in fat cells in older peoplecells in older people

VARIATIONS IN FLUID CONTENTVARIATIONS IN FLUID CONTENT

AGEAGE

AVENUES BY WHICH WATER AVENUES BY WHICH WATER ENTERS AND LEAVES THE BODYENTERS AND LEAVES THE BODY

↓Blood volume or ↓BP

Volume receptor

Atria and great veins

Hypothalamus

↓

Posterior pituitary gland

Osmoreceptors in hypothalamus

↑Osmolarity

↑ADH Kidney tubules

↑H2O reabsorption

↑vascular volume and ↓osmolarity

Narcotics, Stress, Anesthetic agents, Heat, Nicotine, Antineoplastic

agents, Surgery

ANTIDIURETIC HORMONE REGULATION MECHANISMSANTIDIURETIC HORMONE REGULATION MECHANISMS

Juxtaglomerular cells-kidney

↓Serum Sodium ↓Blood volume

Angiotensin I

Kidney tubulesAngiotensin II

Adrenal Cortex

↑Sodium resorption

(H2O resorbed with sodium); ↑ Blood volume

Angiotensinogen in plasma

RENIN

Angiotensin-Angiotensin-converting converting

enzymeenzyme

ALDOSTERONE

Intestine, sweat glands, Salivary

glands

Via vasoconstriction of arterial smooth muscle

ALDOSTERONE-RENIN-ANGIOTENSIN SYSTEMALDOSTERONE-RENIN-ANGIOTENSIN SYSTEM

FLUID BALANCEFLUID BALANCE• The desirable amount of fluid intake and loss in adults ranges from

1500 to 3500 mL each 24 hours. Ave= 2500 mL• Normally INTAKE = OUTPUT

FLUID IMBALANCEFLUID IMBALANCE• Changes in ECF volume = alterations in sodium balance• Change in sodium/water ratio = either hypoosmolarity or

hyperosmolarity• Fluid excess or deficit = loss of fluid balance• As with all clinical problems, the same pathophysiologic change is

not of equal significance to all people• For example, consider two persons who have the same viral

syndrome with associated nausea and vomiting

FLUID DEFICIT/HYPOVOLEMIAFLUID DEFICIT/HYPOVOLEMIA• May occur as a result of:May occur as a result of:

– Reduced fluid intakeReduced fluid intake– Loss of body fluidsLoss of body fluids– Sequestration (compartmentalizing) of body fluidsSequestration (compartmentalizing) of body fluids

Pathophysiology and Clinical ManifestationsPathophysiology and Clinical Manifestations

DECREASED FLUID VOLUMEDECREASED FLUID VOLUME

Stimulation of thirst Stimulation of thirst center in hypothalamuscenter in hypothalamus

Person complains of thirstPerson complains of thirst

↑ ↑ ADH SecretionADH Secretion

↑ ↑ Water resorptionWater resorption

↓ ↓ Urine OutputUrine Output

Renin-Angiotensin-Renin-Angiotensin-Aldosterone System Aldosterone System

ActivationActivation

↑ ↑ Sodium and Sodium and Water ResorptionWater Resorption

↑ ↑ Urine specific gravity except Urine specific gravity except with osmotic diuresiswith osmotic diuresis

Pathophysiology and Clinical ManifestationsPathophysiology and Clinical ManifestationsUNTREATED FLUID VOLUME DEFICITUNTREATED FLUID VOLUME DEFICIT

Depletion of fluids availableDepletion of fluids available

↑ ↑ BODY TEMPERATUREBODY TEMPERATURE

Dry mucous membranesDry mucous membranes

Difficulty with speechDifficulty with speech

Cells become unable to continue Cells become unable to continue providing water to replace ECF providing water to replace ECF

losseslosses

Signs of circulatory collapse Signs of circulatory collapse

↓↓ blood pressureblood pressure

↑ ↑ heart rateheart rate

↑ ↑ respiratory raterespiratory rate

Restlessness and ApprehensionRestlessness and Apprehension

Collaborative Care ManagementCollaborative Care ManagementIdentification of vulnerable patients and risk factors:Identification of vulnerable patients and risk factors:

* Compromised mental state * Compromised mental state * Physical limitations * Physical limitations * Disease states * Disease states * Limited access to adequate food and fluids* Limited access to adequate food and fluids

Development of a plan of careDevelopment of a plan of care

Family members should Family members should be educated about the be educated about the

importance of fluid and importance of fluid and nutrition intakenutrition intake

Collaboration with the Collaboration with the nurse, patient, family nurse, patient, family members, and other members, and other

health care providers health care providers for continued for continued

assessment and assessment and treatment of problemstreatment of problems

Ongoing assessment and Ongoing assessment and detailed action plan of detailed action plan of

fluid and serum fluid and serum electrolyte balance. electrolyte balance.

Factors such as Factors such as medications (particularly medications (particularly

diuretics), diuretics), hyperventilation, fever, hyperventilation, fever,

burns, diarrhea, and burns, diarrhea, and diabetes with diabetes with

appropriate referralappropriate referral

Collaborative Care Key PointsCollaborative Care Key Points• 1 Liter of water = 1 kg of water by weight1 Liter of water = 1 kg of water by weight• Fluid replacement are calculated according to this ratio plus 1.5 L to Fluid replacement are calculated according to this ratio plus 1.5 L to

fulfill the current daily needsfulfill the current daily needs• For example, JUAN, a one-year-old, lost 1 kg of water from diarrhea as For example, JUAN, a one-year-old, lost 1 kg of water from diarrhea as

weighed from his diaper over the last 24 hours. Therefore, since 1 weighed from his diaper over the last 24 hours. Therefore, since 1 kg=1 L, fluid replacement therapy for him will involve 1 L of fluids + kg=1 L, fluid replacement therapy for him will involve 1 L of fluids + 1500 L.1500 L.

• Oral fluid resuscitation is preferable but if the patient is unable to Oral fluid resuscitation is preferable but if the patient is unable to tolerate fluids, IV Therapy may be orderedtolerate fluids, IV Therapy may be ordered

• Vital signs should be assessed regularlyVital signs should be assessed regularly• Postural hypotension is common for postural persons with fluid Postural hypotension is common for postural persons with fluid

volume deficit. How do we assess this?volume deficit. How do we assess this?• For example, in the care of LOIDA, a 31 year old with severe DHN, you For example, in the care of LOIDA, a 31 year old with severe DHN, you

take her blood pressure (130/80) and pulse (75) while she’s lying take her blood pressure (130/80) and pulse (75) while she’s lying down. Then you ask her to sit at the edge of bed. When you take her down. Then you ask her to sit at the edge of bed. When you take her blood pressure again, you get 115/80 and when you take her pulse, blood pressure again, you get 115/80 and when you take her pulse, you get 80. This is consistent with intravascular volume depletion.you get 80. This is consistent with intravascular volume depletion.

• Daily weighing is also useful to monitor fluid and electrolyte balanceDaily weighing is also useful to monitor fluid and electrolyte balance• Laboratory results should be reviewed for various fluid and electrolyte Laboratory results should be reviewed for various fluid and electrolyte

disturbances so that appropriate adjustments to therapy can be disturbances so that appropriate adjustments to therapy can be initiatedinitiated

FLUID EXCESS/HYPERVOLEMIAFLUID EXCESS/HYPERVOLEMIAPsychiatric Psychiatric

Disorders, SIADH, Disorders, SIADH, Certain head injuriesCertain head injuries

Dietary Sodium Dietary Sodium IndiscretionIndiscretion

Renal and endocrine Renal and endocrine disturbances, disturbances,

malignancies, adenomasmalignancies, adenomas

OverhydrationOverhydrationExcessive Sodium Excessive Sodium

IntakeIntake

Failure of renal or Failure of renal or hormonal regulatory hormonal regulatory

functionsfunctions

FLUID VOLUME EXCESS/HYPERVOLEMIAFLUID VOLUME EXCESS/HYPERVOLEMIA

• Since ECF becomes hypoosmolar, fluid moves into the cells to equalize Since ECF becomes hypoosmolar, fluid moves into the cells to equalize the concentration on both sides of the cell membranethe concentration on both sides of the cell membrane

• Thus there, is an increase in intracellular fluidThus there, is an increase in intracellular fluid• The brain cells are particularly sensitive to the increase of intracellular The brain cells are particularly sensitive to the increase of intracellular

water, the most common signs of hypoosmolar overhydration are water, the most common signs of hypoosmolar overhydration are changes in mental status. Confusion, ataxia, and convulsions may also changes in mental status. Confusion, ataxia, and convulsions may also occur.occur.

• Other clinical manifestations include: hyperventilation, sudden weight Other clinical manifestations include: hyperventilation, sudden weight gain, warm, moist skin, increased ICP: slow bounding pulse with an gain, warm, moist skin, increased ICP: slow bounding pulse with an increase in systolic and decrease in diastolic pressue and peripheral increase in systolic and decrease in diastolic pressue and peripheral edema, usually not markededema, usually not marked

WHAT DO ELECTROLYTES DO?WHAT DO ELECTROLYTES DO?

• Controls and regulates volume of body fluidsControls and regulates volume of body fluids

• Its concentration is the major determinant of ECF volumeIts concentration is the major determinant of ECF volume

• Is the chief electrolyte of ECFIs the chief electrolyte of ECF

• Influence ICF VolumeInfluence ICF Volume

•Participates in the generation and transmission of nerve impulsesParticipates in the generation and transmission of nerve impulses

• Is an essential electrolyte in the sodium-potassium pumpIs an essential electrolyte in the sodium-potassium pump

• RDA: not known precisely. 500 mgRDA: not known precisely. 500 mg

• Eliminated primarily by the kidneys, smaller in feces and perspirationEliminated primarily by the kidneys, smaller in feces and perspiration

• Salt intake affects sodium concentrationsSalt intake affects sodium concentrations

• Sodium is conserved through reabsorption in the kidneys, a process Sodium is conserved through reabsorption in the kidneys, a process stimulated by aldosteronestimulated by aldosterone

• Normal value: 135-145 mEq/LNormal value: 135-145 mEq/L

HYPONATREMIAHYPONATREMIA• Refers to the serum sodium concentration less than 135 mEq/L• Common with thiazide diuretic use, but may also be seen with

loop and potassium-sparing diuretics as well• Occurs with marked sodium restriction, vomiting and diarrhea,

SIADH, etc. The etiology may be mulfactorial• May also occur postop due to temporary alteration in

hypothalamic function, loss of GI fluids by vomiting or suction, or hydration with nonelectrolyte solutions

• Postoperative hyponatremia is a more serious complication in premenopausal women. The reasons behind this is unknown

• Therefore monitoring serum levels is critical and careful assessment for symptoms of hyponatremia is important for all postoperative patients

PATHOPHYSIOLOGY OF HYPONATREMIAPATHOPHYSIOLOGY OF HYPONATREMIASodium loss from the intravascular compartmentSodium loss from the intravascular compartment

Diffusion of water into the interstitial spacesDiffusion of water into the interstitial spaces

Sodium in the interstitial space is dilutedSodium in the interstitial space is diluted

Decreased osmolarity of ECFDecreased osmolarity of ECF

Water moves into the cell as a result of sodium lossWater moves into the cell as a result of sodium loss

Water moves into the cell as a result of sodium lossWater moves into the cell as a result of sodium loss

Extracellular compartment is depleted of waterExtracellular compartment is depleted of water

CLINICAL SYMPTOMSCLINICAL SYMPTOMS

CLINICAL MANIFESTATIONS OF HYPONATREMIACLINICAL MANIFESTATIONS OF HYPONATREMIA

Muscle Weakness

APATHY

Postural hypotensio

nNausea and

Abdominal Cramps

Weight Loss

In severe hyponatremia: mental confusion, delirium, shock and comaIn severe hyponatremia: mental confusion, delirium, shock and coma

COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT• General goal: correct sodium imbalance and restore normal fluid and General goal: correct sodium imbalance and restore normal fluid and

electrolyte homeostasiselectrolyte homeostasis• Recognition of people at risk for hyponatremia is essential for its Recognition of people at risk for hyponatremia is essential for its

prevention: athletes, persons working in hot environmentsprevention: athletes, persons working in hot environments• Salt is always replaced along with waterSalt is always replaced along with water• Management includes educating vulnerable people to recognize signs Management includes educating vulnerable people to recognize signs

and symptoms of sodium depletion and maintaining sufficient sodium and symptoms of sodium depletion and maintaining sufficient sodium and water intake to replace skin and insensible fluid lossand water intake to replace skin and insensible fluid loss

• Generally, an increased sodium and water intake provides adequate Generally, an increased sodium and water intake provides adequate treatmenttreatment

• Education as the importance of sodium and fluid balance and the Education as the importance of sodium and fluid balance and the rationale for prescription medications to ensure compliancerationale for prescription medications to ensure compliance

• Daily weight. MIODaily weight. MIO• Monitoring of sodium levels to determine extent of replacementMonitoring of sodium levels to determine extent of replacement• Generally, PNSS or PLRS is prescribedGenerally, PNSS or PLRS is prescribed• Too rapid restoration of sodium balance, hypertonic sodium solutions Too rapid restoration of sodium balance, hypertonic sodium solutions

may provoke brain injury may provoke brain injury

HYPERNATREMIAHYPERNATREMIA

• A serum sodium level above 145 mEq/L is termed hypernatremiaA serum sodium level above 145 mEq/L is termed hypernatremia• May occur as a result of fluid deficit or sodium excessMay occur as a result of fluid deficit or sodium excess• Frequently occurs with fluid imbalanceFrequently occurs with fluid imbalance• Develops when an excess of sodium occurs without a proportional Develops when an excess of sodium occurs without a proportional

increase in body fluid or when water loss occurs without increase in body fluid or when water loss occurs without proportional loss of sodiumproportional loss of sodium

• Risk Factors: excess dietary or parenteral sodium intake, watery Risk Factors: excess dietary or parenteral sodium intake, watery diarrhea, diabetes insipidus, damage to thirst center, too young, too diarrhea, diabetes insipidus, damage to thirst center, too young, too old, those with physical or mental status compromise, and people old, those with physical or mental status compromise, and people with hypothalamic dysfunctionwith hypothalamic dysfunction

PATHOPHYSIOLOGY OF HYPERNATREMIAPATHOPHYSIOLOGY OF HYPERNATREMIAIncreased Sodium concentration in ECFIncreased Sodium concentration in ECF

Osmolarity risesOsmolarity rises

Water leaves the cell by osmosis and enters Water leaves the cell by osmosis and enters the the extracellular compartmentsthe the extracellular compartments

Dilution of fluids in ECFDilution of fluids in ECF Cells are water depletedCells are water depleted

Suppression of aldosterone Suppression of aldosterone secretionsecretion

Sodium is exreted in the Sodium is exreted in the urineurine

CLINICAL SYMPTOMSCLINICAL SYMPTOMS

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS

Dry, sticky Dry, sticky mucous mucous

membranesmembranes

Firm, rubbery Firm, rubbery tissue turgortissue turgor

Manic Manic excitementexcitement

TachycardiaTachycardiaDEATHDEATH

COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT• Recognition of risk factors: bedridden and debilitated patients, Recognition of risk factors: bedridden and debilitated patients,

diabetes insipidus, fluid deprivation, the elderly and the very diabetes insipidus, fluid deprivation, the elderly and the very youngyoung

• A careful and accurate record of MIO permits quick recognition A careful and accurate record of MIO permits quick recognition of negative fluid balanceof negative fluid balance

• People with kidney failure, CHF, or increased aldosterone People with kidney failure, CHF, or increased aldosterone production may require dietary sodium intake restrictionproduction may require dietary sodium intake restriction

• Usually, osmolar balance can be restored with oral fluids. If Usually, osmolar balance can be restored with oral fluids. If not, the parenteral route may be necessarynot, the parenteral route may be necessary

• Fluid resuscitation must be undertaken with particular caution Fluid resuscitation must be undertaken with particular caution in patients with compromised cardiac or renal functionin patients with compromised cardiac or renal function

• The nurse should closely monitor the patient’s response to The nurse should closely monitor the patient’s response to fluids and be alert to symptoms of fluid overloadfluids and be alert to symptoms of fluid overload

• Major cation of the ICF. Chief regulator of cellular enzyme activity and Major cation of the ICF. Chief regulator of cellular enzyme activity and cellular water content cellular water content

• The more K, the less Na. The less K, the more NaThe more K, the less Na. The less K, the more Na

• Plays a vital role in such processes such as transmission of electrical Plays a vital role in such processes such as transmission of electrical impulses, particularly in nerve, heart, skeletal, intestinal and lung tissue; impulses, particularly in nerve, heart, skeletal, intestinal and lung tissue; CHON and CHO metabolism; and cellular building; and maintenance of CHON and CHO metabolism; and cellular building; and maintenance of cellular metabolism and excitationcellular metabolism and excitation

• Assists in regulation of acid-base balance by cellular exchange with HAssists in regulation of acid-base balance by cellular exchange with H

• RDA: not known precisely. 50-100 mEqRDA: not known precisely. 50-100 mEq

• Sources: bananas, peaches, kiwi, figs, dates, apricots, oranges, Sources: bananas, peaches, kiwi, figs, dates, apricots, oranges, prunes, melons, raisins, broccoli, and potatoes, meat, dairy productsprunes, melons, raisins, broccoli, and potatoes, meat, dairy products

• Excreted primarily by the kidneys. No effective conserving mechanismExcreted primarily by the kidneys. No effective conserving mechanism

• Conserved by sodium pump and kidneys when levels are lowConserved by sodium pump and kidneys when levels are low

• Aldosterone triggers K excretion in urineAldosterone triggers K excretion in urine

• Normal value: 3.5 – 5 mEq/LNormal value: 3.5 – 5 mEq/L

CAUSES AND EFFECTS OF HYPOKALEMIACAUSES AND EFFECTS OF HYPOKALEMIA• Known as a low level of serum potassium, less than 3.5 mEq/L Known as a low level of serum potassium, less than 3.5 mEq/L

Decreased IntakeDecreased Intake

↓ Food and Fluids as in starvation

Failure to replace GI losses

Increased LossIncreased Loss

↑ ↑ AldosteroneAldosteroneGastrointestinal lossesGastrointestinal losses

Potassium-losing diureticsPotassium-losing diureticsLoss from cells as in trauma, Loss from cells as in trauma,

burnsburns

Shift of Potassium Shift of Potassium into Cellsinto Cells

(No change in total (No change in total body potassium)body potassium)

HYPOKALEMIAHYPOKALEMIA

GI TractGI Tract

Anorexia

N&V

Abdominal distention

CNSCNS

Lethargy, Diminished

deep-tendon reflexes,

Confusion, Mental

depression

MusclesMuscles

Weakness, Flaccid paralysis,

Weakness of respiratory muscles,

Respiratory arrest

CV SystemCV System

Decrease in standing BP,

Dysrhythmias, ECG changes,

Myocardial damage, Cardiac

arrest

KidneysKidneys

↓Capacity to concentrate waste, water loss, thirst,

kidney damage

PATHOPHYSIOLOGY OF HYPOKALEMIAPATHOPHYSIOLOGY OF HYPOKALEMIA

= Action Potential= Action Potential

Nerve and Muscle ActivityNerve and Muscle Activity

Low Low Extracellular Extracellular

K+K+

Increase in Increase in resting resting

membrane membrane potentialpotential

The cell The cell becomes becomes

less less excitableexcitable

Sodium is retained in the body through resorption by Sodium is retained in the body through resorption by the kidney tubulesthe kidney tubules

Potassium is excretedPotassium is excreted

Aldosterone is secretedAldosterone is secreted

Use of certain diuretics such as thiazides and furosemide, and Use of certain diuretics such as thiazides and furosemide, and corticosteroidscorticosteroids

Increased urinary outputIncreased urinary output

Loss of potassium in urineLoss of potassium in urine

COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT• Being alert to the conditions that cause potassium depletion such as

vomiting, diarrhea and diuretics, by monitoring the patient for early warning signs

• No more than 3 enemas without consulting a physician• Education about the importance of adequate dietary intake of

potassium • In severe hypokalemia, a patient may die unless potassium is

administered promptly• The safest way to administer K is orally. When K is given IV, the rate

of flow must be monitored closely and should be diluted. Should not exceed 20 mEq/hr

• If PO, taken with at least ½ glass of water• Cardiac monitoring is useful• Potassium sparing diuretics such as triamterene, spironolactone, etc• Symptoms of K depletion: muscle weakness, anorexia, nausea and

vomiting = appropriate referral

CAUSES AND EFFECTS OF HYPERKALEMIACAUSES AND EFFECTS OF HYPERKALEMIA• Serum potassium level greater than 5.5 mEq/LSerum potassium level greater than 5.5 mEq/L

Excess IntakeExcess Intake

Dietary intake of excess of kidney’s ability to

excrete; Excess parenteral administration

Decreased LossDecreased Loss

Potassium-sparing diuretics; Potassium-sparing diuretics; Renal failure; Adrenal Renal failure; Adrenal

insufficiencyinsufficiency

Shift of Potassium Shift of Potassium out of the Cellsout of the Cells

Extensive injuries, Extensive injuries, crushing injuries, crushing injuries,

metabolic acidosismetabolic acidosis

HYPERKALEMIAHYPERKALEMIA

GI TractGI Tract

N&V

Diarrhea, Colic

CNSCNS

Numbness, paresthesias

MusclesMuscles

Early: irritability

Late: weakness leading to flaccid

paralysis

CV SystemCV System

Conduction disturbance, ventricular fibrillation,

Cardiac Arrest

KidneysKidneys

Oliguria leading to

anuria

COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT• Patients at risk should be identified: impaired renal function to Patients at risk should be identified: impaired renal function to

avoid OTC, esp. NSAIDS which provoke hyperkalemia; and salt avoid OTC, esp. NSAIDS which provoke hyperkalemia; and salt substitutes that are high in potassiumsubstitutes that are high in potassium

• Severity guides therapySeverity guides therapy– Mild: Withholding provoking agent (i.e., K supp)Mild: Withholding provoking agent (i.e., K supp)– Severe (>6 mEq/L: cation-exchange resin such as Kayexalate Severe (>6 mEq/L: cation-exchange resin such as Kayexalate

(act by exchanging the cations in the resin for the potassium (act by exchanging the cations in the resin for the potassium in the intestine in the intestine potassium is then excreted in the stool; potassium is then excreted in the stool; Continuous cardiac monitoringContinuous cardiac monitoring

• Bowel function must be maintained if Kayexelate therapy is to Bowel function must be maintained if Kayexelate therapy is to be effectivebe effective

• Potassium-wasting diuretics may be prescribed to promote Potassium-wasting diuretics may be prescribed to promote further potassium loss. Dialysis for patients with renal failure to further potassium loss. Dialysis for patients with renal failure to eliminate excess potassiumeliminate excess potassium

• Intravenous Ca Gluconate may be prescribed to counteract the Intravenous Ca Gluconate may be prescribed to counteract the cardiac effects of hyperkalemiacardiac effects of hyperkalemia

• Insulin infusions and IV NaCO3 may be used to promote Insulin infusions and IV NaCO3 may be used to promote intracellular uptake of Kintracellular uptake of K

• Most abundant electrolyte in the body. 99% in bones and teethMost abundant electrolyte in the body. 99% in bones and teeth

• Close link between calcium and phosphorus. High PO4, Low CaClose link between calcium and phosphorus. High PO4, Low Ca

• Necessary for nerve impulse transmission and blood clotting and is Necessary for nerve impulse transmission and blood clotting and is also a catalyst for muscle contraction and other cellular activitiesalso a catalyst for muscle contraction and other cellular activities

• Needed for Vitamin B12 absorption and useNeeded for Vitamin B12 absorption and use

• Necessary for strong bones and teeth and thickness and strength of Necessary for strong bones and teeth and thickness and strength of cell membranescell membranes

• RDA: 1g for adults. Higher for children and pregnant and lactating RDA: 1g for adults. Higher for children and pregnant and lactating women according to body weight, older people, esp. post-menopausal women according to body weight, older people, esp. post-menopausal

• Found in milk, cheese, and dried beans; some in meat and vegetablesFound in milk, cheese, and dried beans; some in meat and vegetables

• Use is stimulated by Vitamin D. Excreted in urine, feces, bile, digestive Use is stimulated by Vitamin D. Excreted in urine, feces, bile, digestive secretions, and perspirationsecretions, and perspiration

• Dec. serum calcium = PTH hormone release = calcium reabsorptionDec. serum calcium = PTH hormone release = calcium reabsorption

• Normal value 8.5 – 10.5 mg/dlNormal value 8.5 – 10.5 mg/dl

CAUSES AND EFFECTS OF HYPOCALCEMIACAUSES AND EFFECTS OF HYPOCALCEMIADecreased Decreased Ionized CaIonized Ca

Large tranfusion with citrated blood

Excess LossExcess Loss

Kidney DiseaseKidney DiseaseDraining fistulaDraining fistula

Decrease in GI Tract Decrease in GI Tract and Bone Absorptionand Bone Absorption

↑↑MagnesiumMagnesium

↑↑CalcitoninCalcitonin

↓Vitamin D↓Parathyroid Hormone

HYPOCALCEMIAHYPOCALCEMIA

BonesBonesOsteoporosis

leading to Fractures

CNSCNS

Tingling

↓ convulsions

OtherOther

Abnormal deposits

of calcium in body tissues

MusclesMuscles

Muscle spasm

↓

Tetany

Cardiovascular Cardiovascular SystemSystem

Dysrhythmias

↓

Cardiac arrest

Inadequate Inadequate IntakeIntake

Dietary DeficitDietary Deficit

PATHOPHYSIOLOGY OF HYPOCALCEMIAPATHOPHYSIOLOGY OF HYPOCALCEMIA•Calcium ions are thought to line the pores of cell membranes, especially neurons

•Calcium and Sodium repel each other

•When serum calcium levels are low, this blocking effect is minimized

•When Sodium moves more easily into the cell, depolarization takes place more easily

•This results in increased excitability of the nervous system leading to muscle spasm, tingling sensations, and if severe, convulsions and tetany

•Skeletal, smooth, and cardiac muscle functions are all affected by overstimulation

Sodium Calcium

CLINICAL MANIFESTATIONS OF HYPOCALCEMIACLINICAL MANIFESTATIONS OF HYPOCALCEMIA

COMPLAINT OF NUMBNESS AND TINGLING OF EARS, NOSE, COMPLAINT OF NUMBNESS AND TINGLING OF EARS, NOSE, FINGERTIPS OR TOESFINGERTIPS OR TOES

TREATMENTTREATMENT

PAINFUL MUSCULAR SPASMS (TETANY) PAINFUL MUSCULAR SPASMS (TETANY) ESPECIALLY OF FEET AND HANDS ESPECIALLY OF FEET AND HANDS

(CARPOPEDAL SPASMS), MUSCLE TWITCHING (CARPOPEDAL SPASMS), MUSCLE TWITCHING AND CONVULSIONS MAY FOLLOWAND CONVULSIONS MAY FOLLOW

TESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCYTESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCY

COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT• Identify risk factors: Inadequate calcium intake, excess calcium loss, Identify risk factors: Inadequate calcium intake, excess calcium loss,

Vitamin D deficiency, patients with poor dietsVitamin D deficiency, patients with poor diets• Education about the importance of adequate calcium and Vitamin D Education about the importance of adequate calcium and Vitamin D

intakeintake• Patients undergoing thyroid, parathyroid, and radical neck surgery are Patients undergoing thyroid, parathyroid, and radical neck surgery are

particularly vulnerable to hypocalcemia secondary to parathyroid particularly vulnerable to hypocalcemia secondary to parathyroid hormone deficithormone deficit

• Monitoring of serum calcium levels and correction of deficitsMonitoring of serum calcium levels and correction of deficits• Citrate is added to store blood to prevent coagulation. Citrate is added to store blood to prevent coagulation. • Citrate + Transfusion = Citrate+CalciumCitrate + Transfusion = Citrate+Calcium• Normally, Liver + Citrate = Quick metabolismNormally, Liver + Citrate = Quick metabolism• Preexisting calcium deficit/hepatic dysfunction/large amounts of BT Preexisting calcium deficit/hepatic dysfunction/large amounts of BT

very rapidly = hypocalcemiavery rapidly = hypocalcemia• With acute hypocalcemia, Ca Gluconate is used + Continuous cardiac With acute hypocalcemia, Ca Gluconate is used + Continuous cardiac

monitoringmonitoring• Mild Hypocalcemia: High calcium diet or oral calcium saltsMild Hypocalcemia: High calcium diet or oral calcium salts• If PTH or Vit D Deficiency is the cause: aluminum hydroxide gel is If PTH or Vit D Deficiency is the cause: aluminum hydroxide gel is

used because when serum phosphate level rises, calcium level fallsused because when serum phosphate level rises, calcium level falls• Complication: Bone demineralizationComplication: Bone demineralization• Therefore, careful ambulation should be encouraged to minimize bone Therefore, careful ambulation should be encouraged to minimize bone

resorptionresorption

HYPERCALCEMIA: Serum concentration > 10mg/dLHYPERCALCEMIA: Serum concentration > 10mg/dLCauses and EffectsCauses and Effects

Loss from bonesLoss from bones

Immobilization, Carcinoma with bone metastases, Multiple

myeloma

Excess IntakeExcess Intake

↑ ↑ Calcium diet (esp. milk)Calcium diet (esp. milk)Antacids containing calciumAntacids containing calcium

Increase in factors Increase in factors Causing Mobilization Causing Mobilization

from bonefrom bone

↑↑PTH, ↑PTH, ↑ Vitamin D, steroid therapy

HYPERCALCEMIAHYPERCALCEMIA

KidneysKidneys

Stones

↓

Kidney Damage

CNSCNS

↓Deep-tendon reflexes

↓

Lethargy

↓

Coma

BonesBones

Bone pain

↓

Osteoporosis

↓

Fractures

MusclesMuscles

Muscle fatigue, hypotonia

↓

↓ GI motility

CV SystemCV System

Depressed activity

↓

Dysrhythmias

↓

Cardiac Arrest

HOW IT HAPPENSHOW IT HAPPENSHYPERCALCEMIAHYPERCALCEMIA

DEPRESSED NERVE DEPRESSED NERVE AND MUSCLE AND MUSCLE

ACTIVITYACTIVITY

DEEP TENDON DEEP TENDON REFLEXES MAY BE REFLEXES MAY BE

DECREASED OR DECREASED OR ABSENTABSENT

MYOCARDIAL MYOCARDIAL FUNCTION IS FUNCTION IS

ALTEREDALTERED

CLINICAL MANIFESTATIONS OF HYPERCALCEMIACLINICAL MANIFESTATIONS OF HYPERCALCEMIA

Decreased GI Decreased GI MotilityMotility

Cardiac DysrhythmiasCardiac Dysrhythmias

ConstipationConstipation

NauseaNausea

Mental status changes: Mental status changes: lethargy, confusion, lethargy, confusion,

memory lossmemory loss

CLINICAL MANIFESTATIONS OF HYPERCALCEMIACLINICAL MANIFESTATIONS OF HYPERCALCEMIA

ImmobilizationImmobilization Bone Bone DemineralizationDemineralization

Calcium Calcium accumulates in accumulates in

the ECF and the ECF and passes through passes through

the kidneysthe kidneys

Ca PrecipitationCa PrecipitationCalcium StonesCalcium Stones

COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT

• Mild hypercalcemia: hydration and education about avoiding foods high in calcium or medications that promote calcium elevation

• Ambulation as appropriate; weight-bearing exercises as tolerated• Trapeze, resistance devices• Marked hypercalcemia: prevention of pathologic fractures,

individualized plan of care• Prevention of renal calculi: encourage oral fluids to prevent

concentrated urine: 3000 to 4000 mL/day unless contraindicated• Acid-ash fruit juices: cranberry juice and prune juice• Severe hypercalcemia: medical emergency: continuous cardiac

monitoring, hydration, IV furosemide, Calcitonin and/or plicamycin (mithramycin), q2 serum and urinary electrolytes

• Mostly found within body cells: heart, bone, nerve, and muscle tissuesMostly found within body cells: heart, bone, nerve, and muscle tissues

• Second most important cation in the ICF, 2Second most important cation in the ICF, 2ndnd to K+ to K+

• Functions: Metabolism of CHO and CHON, protein and DNA synthesis, Functions: Metabolism of CHO and CHON, protein and DNA synthesis, DNA and RNA transcription, and translation of RNA, maintains normal DNA and RNA transcription, and translation of RNA, maintains normal intracellular levels of potassium, helps maintain electric activity in intracellular levels of potassium, helps maintain electric activity in nervous tissue membranes and muscle membranesnervous tissue membranes and muscle membranes

• RDA: about 18-30 mEq; children require larger amountsRDA: about 18-30 mEq; children require larger amounts

• Sources: vegetables, nuts, fish, whole grains, peas, and beansSources: vegetables, nuts, fish, whole grains, peas, and beans

• Absorbed in the intestines and excreted by the kidneysAbsorbed in the intestines and excreted by the kidneys

• Plasma concentrations of magnesium range from 1.5 – 2.5 mEq/L, with Plasma concentrations of magnesium range from 1.5 – 2.5 mEq/L, with about one third of that amount bound to plasma proteinsabout one third of that amount bound to plasma proteins

HYPOMAGNESEMIA: Serum level < 1.5 mEq/LHYPOMAGNESEMIA: Serum level < 1.5 mEq/L• Usually coexists with hypokalemia and les often with hypocalcemia

Decreased IntakeDecreased Intake

Prolonged malnutrition, Starvation

Impaired absorption from GI TractImpaired absorption from GI Tract

Malabsorption syndrome, Alcohol Withdrawal Malabsorption syndrome, Alcohol Withdrawal Syndrome, Hypercalcemia, Diarrhea, Syndrome, Hypercalcemia, Diarrhea,

Draining gastrointestinal fistulaDraining gastrointestinal fistula

Excessive Excessive ExcretionExcretion

↑↑Aldosterone, Aldosterone, Conditions Conditions

causing large causing large losses of urinelosses of urine

HYPOMAGNESEMIAHYPOMAGNESEMIA

Mental ChangesMental Changes

Agitation, Depression, Confusion

CNSCNS

Convulsions, Paresthesias, Tremor, Ataxia

MusclesMuscles

Cramps, Spasticity, Tetany

CV SystemCV System

Tachycardia, Hypotension, Dysrhythmias

HYPOKALEMIAHYPOKALEMIA

PATHOPHYSIOLOGY OF HYPOMAGNESEMIAPATHOPHYSIOLOGY OF HYPOMAGNESEMIA

Low serum magnesium levelLow serum magnesium level

Increased acetylcholine releaseIncreased acetylcholine release

Increased neuromuscular irritabilityIncreased neuromuscular irritability

Increased sensitivity to acetylcholine at the myoneural junctionIncreased sensitivity to acetylcholine at the myoneural junction

Diminished threshold of Diminished threshold of excitation for the motor excitation for the motor

nervenerve

Enhancement of myofibril Enhancement of myofibril contractioncontraction


High Serum CalciumHigh Serum Calcium

Increased acetylcholine releaseIncreased acetylcholine release

Increased neuromuscular irritabilityIncreased neuromuscular irritability

Increased sensitivity to acetylcholine at the myoneural junctionIncreased sensitivity to acetylcholine at the myoneural junction

Diminished threshold of Diminished threshold of excitation for the motor excitation for the motor

nervenerve

Enhancement of myofibril Enhancement of myofibril contractioncontraction

High Serum CalciumHigh Serum CalciumExcretion of MagnesiumExcretion of Magnesium

By the GI tractBy the GI tract


MAGNESIUMMAGNESIUM

INHIBITS TRANSPORT OF PTHINHIBITS TRANSPORT OF PTH

DECREASE IN THE AMOUNT OF CALCIUM BEING RELEASED DECREASE IN THE AMOUNT OF CALCIUM BEING RELEASED FROM THE BONEFROM THE BONE

POSSIBLE CALCIUM DEFICITPOSSIBLE CALCIUM DEFICIT

CLINICAL MANIFESTATIONS OF HYPOMAGNESEMIACLINICAL MANIFESTATIONS OF HYPOMAGNESEMIA

CONFUSIONCONFUSION

DEPRESSIONDEPRESSION

CRAMPSCRAMPS

TETANYTETANY CONVULSIONSCONVULSIONS

COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT• Recognition of people at risk: people taking loop diuretics and Recognition of people at risk: people taking loop diuretics and

digoxin should be encouraged to eat foods rich in magnesium, digoxin should be encouraged to eat foods rich in magnesium, such as fruits, vegetables, cereals, and milksuch as fruits, vegetables, cereals, and milk

• Recognition of signs and symptoms of magnesium deficiencyRecognition of signs and symptoms of magnesium deficiency• Magnesium is essential for potassium resorption, so if Magnesium is essential for potassium resorption, so if

hypokalemia does not respond to potassium replacement, hypokalemia does not respond to potassium replacement, hypomagnesemia should be suspectedhypomagnesemia should be suspected

• Treatment of the underlying cause is the first consideration in Treatment of the underlying cause is the first consideration in hypomagnesemiahypomagnesemia

• Severe: parenteral magnesium replacement is indicatedSevere: parenteral magnesium replacement is indicated• IV therapy: continuous cardiac monitoringIV therapy: continuous cardiac monitoring• Safety measures for patients with mental status changesSafety measures for patients with mental status changes

HYPERMAGNESEMIA: Serum Mg level 2.5 mEq/LHYPERMAGNESEMIA: Serum Mg level 2.5 mEq/L• Seldom develops in the presence of normal renal functionSeldom develops in the presence of normal renal function• May occur as a result of Mg replacementMay occur as a result of Mg replacement• May occur when MgSO4 is administered to prevent seizures May occur when MgSO4 is administered to prevent seizures

resulting from eclampsiaresulting from eclampsia• Careful monitoring is imperativeCareful monitoring is imperative

PATHOPHYSIOLOGYPATHOPHYSIOLOGYRenal failure, Excessive IV infusion of Renal failure, Excessive IV infusion of

magnesium, Decreased GI elimination magnesium, Decreased GI elimination and/or absorption, etc.and/or absorption, etc.

Accummulation of Mg in the bodyAccummulation of Mg in the body

Diminishing of reflexes, drowsiness, lethargyDiminishing of reflexes, drowsiness, lethargy

Mg Level RisesMg Level Rises

Severe Respiratory DepressionSevere Respiratory Depression

RESPIRATORY ARREST may occurRESPIRATORY ARREST may occur

Altered Electrical ConductionAltered Electrical Conduction

Slowed heart Slowed heart rate and AV rate and AV

BlockBlock

Peripheral Peripheral vasodilationvasodilation

Hypotension, flushing, and Hypotension, flushing, and increased skin warmthincreased skin warmth

COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT• Identification of patients at risk: those with impaired renal Identification of patients at risk: those with impaired renal

function to avoid OTC that contain magnesium such as Milk of function to avoid OTC that contain magnesium such as Milk of Magnesia and some Mg-containing antacidsMagnesia and some Mg-containing antacids

• Any patient receiving parenteral magnesium therapy should be Any patient receiving parenteral magnesium therapy should be assessed frequently for signs of hypermagnesemiaassessed frequently for signs of hypermagnesemia

• Mild hypermagnesemia: withholding magnesium-containing Mild hypermagnesemia: withholding magnesium-containing medications may sufficemedications may suffice

• Renal failure: dialysisRenal failure: dialysis• Severe: may require treatment with calcium gluconate (10-20 Severe: may require treatment with calcium gluconate (10-20

mL of 10% Ca Gluconate administered over 10 minutes)mL of 10% Ca Gluconate administered over 10 minutes)• If cardiorespiratory collapse is imminent, the patient may If cardiorespiratory collapse is imminent, the patient may

require temporary pacemaker and ventilator supportrequire temporary pacemaker and ventilator support

NURSING MANAGEMENT OF NURSING MANAGEMENT OF PATIENT WITH FLUID AND PATIENT WITH FLUID AND

ELECTROLYTE IMBALANCESELECTROLYTE IMBALANCES

Parameter_____Fluid Excess___ Parameter_____Fluid Excess___ Fluid Loss/Electrolyte Imbalance____Fluid Loss/Electrolyte Imbalance____Behavior Tires easily; Change in behavior, confusion, apathy

Head, neck Facial edema, distended neck Headache, thirst, dry mucous membranes veins

Upper GI Anorexia, nausea, vomiting

Skin Warm, moist, taut, cool feeling Dry, decreased turgor where edematous

Respiration Dyspnea, orthopnea, productive Changes in rate and depth of respirationcough, moist breath sounds

Circulation Loss of sensation in edematous Pulse rate changes, dysrhythmia, posturalareas, pallor, bounding pulse, hypotension increased blood pressure

Abdomen Increased girth, fluid wave Distention, abdominal cramps

Elimination Constipation Diarrhea, constipation

Extremities Dependent edema, “pitting” Muscle weakness, tingling, tetany , discomfort from weight of bedclothes

Pitting edemaPitting edema

Dependent edemaDependent edema

Refractory EdemaRefractory Edema

LABORATORY VALUESLABORATORY VALUESFLUID DEFICITFLUID DEFICIT FLUID EXCESSFLUID EXCESS

HemoconcentrationHemoconcentration HemodilutionHemodilution

↑ ↑ Hct, BUN, E+ levelsHct, BUN, E+ levels ↓ ↓ Hct, BUN, E+ levelsHct, BUN, E+ levels

↑ ↑ Urine Specific GravityUrine Specific Gravity ↓ Urine Specific Gravity ↓ Urine Specific Gravity

Determined from analysis of patient dataDetermined from analysis of patient data

Diagnostic TitleDiagnostic Title Possible Etiologic FactorsPossible Etiologic Factors

11 Deficient fluid volumeDeficient fluid volume Active fluid volume loss Active fluid volume loss (hemorrhage, diarrhea, gastric (hemorrhage, diarrhea, gastric

intubation, wounds, diaphoresis), intubation, wounds, diaphoresis), inadequate fluid inadequate fluid intake, failure of intake, failure of regulatory mechanisms, regulatory mechanisms,

sequestration of body fluidssequestration of body fluids

22 Excess Fluid Volume Excess fluid intake, excess sodium Excess Fluid Volume Excess fluid intake, excess sodium intake, compromised regulatory intake, compromised regulatory

processesprocesses

EXPECTED PATIENT OUTCOMESEXPECTED PATIENT OUTCOMES

1,2.1,2. Will maintain functional fluid volume as evidenced by Will maintain functional fluid volume as evidenced by adequate urinary output, stable weight, normal vital adequate urinary output, stable weight, normal vital

signs, normal urine specific gravity, moist mucus signs, normal urine specific gravity, moist mucus membranes, balanced intake and output, elastic skin membranes, balanced intake and output, elastic skin turgor, prompt capillary refill, and absence of edematurgor, prompt capillary refill, and absence of edema

22 Will verbalize understanding of treatment plan and Will verbalize understanding of treatment plan and causative factors that led to the imbalancecausative factors that led to the imbalance

1,21,2 Intake and Output MonitoringIntake and Output Monitoring- Type and amount of fluid the patient has received and the - Type and amount of fluid the patient has received and the route by which they were administeredroute by which they were administered-- Record of solid food intake. Gelatin or Popsicles are Record of solid food intake. Gelatin or Popsicles are recorded as fluidsrecorded as fluids-- Ice chips are recorded by dividing the amount of chips Ice chips are recorded by dividing the amount of chips by by ½ (60 mL of chips = 30 mL water)½ (60 mL of chips = 30 mL water)-- Accurate output record and described by color, content, Accurate output record and described by color, content, and and odor (Normally, gastric contents are watery and pale odor (Normally, gastric contents are watery and pale yellow-green; they usually have a sour odor)yellow-green; they usually have a sour odor)-- With acid-base balance upset, gastric secretions may With acid-base balance upset, gastric secretions may have a fruity odor because of ketone bodieshave a fruity odor because of ketone bodies-- Bile: thicker than gastric juice, dark green to brown, Bile: thicker than gastric juice, dark green to brown, acrid odor, bitter taste when vomitingacrid odor, bitter taste when vomiting-- NGT irrigation added to intakeNGT irrigation added to intake-- Stools: difficult to estimate amount; consistency, color, Stools: difficult to estimate amount; consistency, color, and and number of stools provide a reasonable estimatenumber of stools provide a reasonable estimate-- Peritoneal or pleural fluid drainage is recorded as output Peritoneal or pleural fluid drainage is recorded as output as as with its amount, color, and clarity with its amount, color, and clarity -- Character and volume of urine. Place signs and Character and volume of urine. Place signs and materials materials so so that an accurate record of UO is maintainedthat an accurate record of UO is maintained

1,21,2 Intake and Output MonitoringIntake and Output Monitoring- Evaluate and refer urine specific gravity as appropriate - Evaluate and refer urine specific gravity as appropriate

(normal value is 1.003 – 1.030). The implications are:(normal value is 1.003 – 1.030). The implications are:HighHigh DehydrationDehydrationLowLow SIADH, overhydrationSIADH, overhydration

-- Drainage, fluid aspirated from any body cavity must be Drainage, fluid aspirated from any body cavity must be measured. With dressings, fluid loss is the difference measured. With dressings, fluid loss is the difference between the wet dressings and the dry weight of the between the wet dressings and the dry weight of the

dressingdressing-- Accurate recording of the temperature to help the Accurate recording of the temperature to help the

physician determine how much fluid should be replaced physician determine how much fluid should be replaced 1,21,2 Daily WeightDaily Weight

-- Evaluate trends in weight (An increase in 1kg in weight Evaluate trends in weight (An increase in 1kg in weight is equal to the retention of 1L of fluid in an edematous is equal to the retention of 1L of fluid in an edematous patient)patient)

Considerations: Considerations: -- Daily weights early in the morning after voiding Daily weights early in the morning after voiding

but before he or she has eaten or defecatedbut before he or she has eaten or defecated

11 Replacement of Fluid and ElectrolytesReplacement of Fluid and ElectrolytesGeneral Principles:General Principles:

-- Either by oral intake (healthiest way), tube feeding, Either by oral intake (healthiest way), tube feeding, intravenous infusion, and/or total parenteral nutritionintravenous infusion, and/or total parenteral nutrition

-- Normal saline solution and plain water should also be Normal saline solution and plain water should also be given by slow drip to replace daily fluid lossgiven by slow drip to replace daily fluid loss-- IV administration per doctor’s ordersIV administration per doctor’s orders-- Fluid replacement considerations:Fluid replacement considerations:

** Most effective when apportioned over 24 hr period Most effective when apportioned over 24 hr period (Better regulation, (Better regulation, ↓potential for calculi formation and ↓potential for calculi formation and

subsequent renal damage, ↓potential for circulatory subsequent renal damage, ↓potential for circulatory overload which may cause in fluid and electrolyte overload which may cause in fluid and electrolyte shifts)shifts)

** Administer concentrated solutions of Na, Glucose or Administer concentrated solutions of Na, Glucose or protein because they require body fluids for dilutionprotein because they require body fluids for dilution

** Consider the size of the patient (small adult has less Consider the size of the patient (small adult has less fluid in each compartment, especially in the fluid in each compartment, especially in the intravascular compartment)intravascular compartment)

-- Promote oral intake as appropriatePromote oral intake as appropriate** Caution with coffee, tea, and some colasCaution with coffee, tea, and some colas

** small amount at frequent intervals is more useful than a small amount at frequent intervals is more useful than a large amount presented less oftenlarge amount presented less often** Always give consideration to cultural and aesthetic Always give consideration to cultural and aesthetic aspects of eatingaspects of eating-- Give mouth care to a dehydrated patient before and after Give mouth care to a dehydrated patient before and after meals and before bedtime (Xerostomia may lead to meals and before bedtime (Xerostomia may lead to disruption disruption of tissues in the oral cavity)of tissues in the oral cavity)-- Avoid irritating foodsAvoid irritating foods-- Stimulation of saliva may be aided by hard candy or chewing Stimulation of saliva may be aided by hard candy or chewing gum or carboxymethylcellulose (artificial saliva)gum or carboxymethylcellulose (artificial saliva)-- Keep lips moist and well lubricatedKeep lips moist and well lubricated-- Give salty broth or soda crackers for sodium replacement Give salty broth or soda crackers for sodium replacement and tea or orange juice for potassium replacement as and tea or orange juice for potassium replacement as appropriate. Bananas, citrus fruits and juices, some fresh appropriate. Bananas, citrus fruits and juices, some fresh vegetables, coffee, and tea are relatively high in potassium vegetables, coffee, and tea are relatively high in potassium and and low in sodium. Milk, meat, eggs, and nuts are high in low in sodium. Milk, meat, eggs, and nuts are high in protein, sodium and potassium.protein, sodium and potassium.-- Offer milk for patients with draining fistulas from any portion Offer milk for patients with draining fistulas from any portion of the GI tract. Lactose intolerance is not necessarily a of the GI tract. Lactose intolerance is not necessarily a contraindication (Lactase enzyme preparations are available)contraindication (Lactase enzyme preparations are available)- - Increase usual daily requirement of foods when losses must Increase usual daily requirement of foods when losses must be restored, as toleratedbe restored, as tolerated

** Patients with cardiac and renal impairments are Patients with cardiac and renal impairments are instructed to avoid foods containing high levels instructed to avoid foods containing high levels of sodium, potassium and bicarbonateof sodium, potassium and bicarbonate

-- Administer replacement solutions through tube feeding as isAdminister replacement solutions through tube feeding as is** Either water, physiologic solution of NaCl, high protein Either water, physiologic solution of NaCl, high protein

liquids, or a regular diet can be blended, diluted and liquids, or a regular diet can be blended, diluted and given by gavagegiven by gavage** The water content in the tube feeding needs to be The water content in the tube feeding needs to be

increased if:increased if:11 the patient complains of thirstthe patient complains of thirst22 the protein or electrolyte content of the tube the protein or electrolyte content of the tube

feeding is highfeeding is high33 the patient has fever or disease causing an the patient has fever or disease causing an

increased metabolic rateincreased metabolic rate44 UO is concentratedUO is concentrated55 signs of water deficit developsigns of water deficit develop

-- Administer parenteral fluids as necessaryAdminister parenteral fluids as necessary

** Types of solutionsTypes of solutions-- D5W (hypotonic) is given short-term for hyponatremiaD5W (hypotonic) is given short-term for hyponatremia-- D5NSS may be given depending on the serum levels of D5NSS may be given depending on the serum levels of sodium and vascular volume + KCl to meet normal sodium and vascular volume + KCl to meet normal intake needs intake needs and replace losses for hyponatremiaand replace losses for hyponatremia-- Dextrose 5% in 0.2% normal saline is generally used as Dextrose 5% in 0.2% normal saline is generally used as a a maintenance fluidmaintenance fluid-- Dextrose 5% in ½ normal saline is generally used as a Dextrose 5% in ½ normal saline is generally used as a replacement solution for losses caused by replacement solution for losses caused by gastrointestinal gastrointestinal drainagedrainage-- PNSS is given primarily when large amounts of sodium PNSS is given primarily when large amounts of sodium have have been lost and for patients with hyponatremiabeen lost and for patients with hyponatremia-- LRS is also isotonic because it remains in the LRS is also isotonic because it remains in the extracellular extracellular spacespace-- Fructose or 10-20% glucose in distilled water are Fructose or 10-20% glucose in distilled water are hypertonic hypertonic solutions and may partially meet body solutions and may partially meet body needs for CHOsneeds for CHOs-- Dextran (commonly-used plasma expander) increases Dextran (commonly-used plasma expander) increases plasma volume by increasing oncotic pressure. May plasma volume by increasing oncotic pressure. May cause cause prolonged bleeding time and is CI in patients prolonged bleeding time and is CI in patients with renal with renal failure, bleeding disorders, or severe CHFfailure, bleeding disorders, or severe CHF

** AdministrationAdministration-- The rate should be regulated according to the patient’s The rate should be regulated according to the patient’s needs needs and condition per doctor’s ordersand condition per doctor’s orders-- Monitor UO carefully. Refer marked decreases!Monitor UO carefully. Refer marked decreases!-- Verify orders for potassium administration in patients Verify orders for potassium administration in patients with with renal failure and untreated adrenal insufficiencyrenal failure and untreated adrenal insufficiency-- Usual rate for fluid loss replacement: 3ml/minUsual rate for fluid loss replacement: 3ml/min-- Recognize signs of pulmonary edema (bounding pulse, Recognize signs of pulmonary edema (bounding pulse, engorged peripheral veins, hoarseness, dyspnea, engorged peripheral veins, hoarseness, dyspnea, cough, and cough, and rales) that can result from rales) that can result from ↑IV rate↑IV rate-- If infiltration occurs, the infusion should be stopped If infiltration occurs, the infusion should be stopped immediately and relocated. Peripheral IV sites are immediately and relocated. Peripheral IV sites are generally generally rotated every 72 hoursrotated every 72 hours-- For dextran and other plasma expanders, observe for For dextran and other plasma expanders, observe for anaphylactic reaction (apprehension, dyspnea, anaphylactic reaction (apprehension, dyspnea, wheezing, wheezing, tightness of chest, angioedema, tightness of chest, angioedema, itching, hives and itching, hives and hypotension). If this happens, hypotension). If this happens, switch infusion to switch infusion to nonprotein solution and run at KVO nonprotein solution and run at KVO rate, notify physician and rate, notify physician and monitor VSmonitor VS-- Pronounced and continued thirst despite administration Pronounced and continued thirst despite administration of of fluids is not normal and should be reported (may fluids is not normal and should be reported (may indicate DM indicate DM or hypercalcemia)or hypercalcemia)

** Patient/Family EducationPatient/Family Education-- Include the signs and symptoms of water excess in Include the signs and symptoms of water excess in

discharge instructionsdischarge instructions-- With drug therapy, instruct patient and family regarding With drug therapy, instruct patient and family regarding

correct method of administration, correct dose, and correct method of administration, correct dose, and therapeutic and adverse effectstherapeutic and adverse effects

-- Instruct to read labels for nutritional contentInstruct to read labels for nutritional content* For K restriction: avoid organ meats, fresh and dried * For K restriction: avoid organ meats, fresh and dried

fruits, and salt substitutesfruits, and salt substitutes-- Skin assessment and care, positioning techniques for Skin assessment and care, positioning techniques for

patients with mobility restrictionspatients with mobility restrictions

** Achievement of outcomes is successful in disturbances in fluid Achievement of outcomes is successful in disturbances in fluid and electrolyte balance:and electrolyte balance:

11 Maintains functional fluid volume level with adequate UO, Maintains functional fluid volume level with adequate UO, VS within the patient’s normal limits, sp gr of urine VS within the patient’s normal limits, sp gr of urine within 1.003-within 1.003-1.035, moist mucous membranes, stable 1.035, moist mucous membranes, stable weight, weight, Intake=output, elastic skin turgor, and no edemaIntake=output, elastic skin turgor, and no edema

22 States possible causes of imbalance and plan to prevent States possible causes of imbalance and plan to prevent recurrence of imbalancesrecurrence of imbalances

33 Reports a decrease or absence of symptoms causing Reports a decrease or absence of symptoms causing discomfortdiscomfort

DRAWING ARTERIAL BLOOD GASESDRAWING ARTERIAL BLOOD GASES

ALLEN’S TESTALLEN’S TESTARTERIAL PUNCTUREARTERIAL PUNCTURE

NORMAL ACID-BASE BALANCENORMAL ACID-BASE BALANCE

Estimated HCO3 concentration after fully Estimated HCO3 concentration after fully oxygenated arterial blood has been oxygenated arterial blood has been equilibrated with CO2 at a PCO2 of 40 equilibrated with CO2 at a PCO2 of 40 mmHg at 38C; eliminates the influence of mmHg at 38C; eliminates the influence of respiration on the plasma HCO3 respiration on the plasma HCO3 concentrationconcentration

22-2622-26 mEq/L mEq/LStandard HCO3Standard HCO3

Partial pressure of CO2 in the arterial Partial pressure of CO2 in the arterial blood:blood:PCO2<35 mmHg = respiratory alkalosisPCO2<35 mmHg = respiratory alkalosisPCO2>45 mmHg = respiratory acidosisPCO2>45 mmHg = respiratory acidosis

21-30 mmHg21-30 mmHgPaCO2PaCO2

Identifies whether there is acidemia or Identifies whether there is acidemia or alkalemia:alkalemia:pH<7.35 = acidosis; pH>7.45 = alkalosispH<7.35 = acidosis; pH>7.45 = alkalosis

7.35-7.457.35-7.45pHpH

Partial pressure of oxygen in arterial Partial pressure of oxygen in arterial blood (decreases with age)blood (decreases with age)In adults < 60 years:In adults < 60 years: 60-80 mmHg = mild hypoxemia60-80 mmHg = mild hypoxemia 40-60 mmHg = moderate hypoxemia40-60 mmHg = moderate hypoxemia < 40 mmHg = severe hypoxemia< 40 mmHg = severe hypoxemia

80-100 Hg80-100 HgPaO2PaO2

Definition and ImplicationsDefinition and ImplicationsNormal ValueNormal ValueParameterParameter

BASIC REGULATION OF ACID-BASE BALANCEBASIC REGULATION OF ACID-BASE BALANCE

CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3

The lungs help control acid-base balance by blowing off or The lungs help control acid-base balance by blowing off or retaining CO2. The kidneys help regulate acid-base balance by retaining CO2. The kidneys help regulate acid-base balance by

excreting or retaining HCO3excreting or retaining HCO3

TYPES OF ACID-BASE DISTURBANCESTYPES OF ACID-BASE DISTURBANCES

Depression of the central Depression of the central nervous system, as nervous system, as evidenced by disorientation evidenced by disorientation followed by comafollowed by coma

Overexcitability of the Overexcitability of the nervous system; muscles nervous system; muscles

may go into a state of tetany may go into a state of tetany and convulsioonsand convulsioons

INTERPRETING ARTERIAL BLOOD GASES RESULTSINTERPRETING ARTERIAL BLOOD GASES RESULTS

Look at the unrelated value. Decide whether or not compensation is happening

22-26

21-30

7.35-7.45

NORMALNORMAL

Decide as to what may be the direct cause of the change in pH. pCO2 or HCO3? If PCO2, it’s respiratory, if HCO3, it’s metabolic

Look at the HCO3 level. Is it normal or abnormal?

Look at the pCO2. Is it normal or abnormal?

Is the pH acidic or alkaline?

ALKALOSISALKALOSISACIDOSISACIDOSISCONDITIONCONDITION

RESPIRATORY ACIDOSIS: CARBONIC ACID EXCESSRESPIRATORY ACIDOSIS: CARBONIC ACID EXCESSDamage to the respiratory center in the medulla, drug or narcotic use, obstruction Damage to the respiratory center in the medulla, drug or narcotic use, obstruction

of respiratory passages, respiratory and respiratory muscle disordersof respiratory passages, respiratory and respiratory muscle disorders

Decrease in the rate of pulmonary ventilationDecrease in the rate of pulmonary ventilation

Increase in the concentration of CO2, carbonic acid, Increase in the concentration of CO2, carbonic acid, and hydrogen ionsand hydrogen ions

RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS

Potassium moves out of the cellsPotassium moves out of the cells

HYPERKALEMIAHYPERKALEMIA

VENTRICULAR FIBRILLATIONVENTRICULAR FIBRILLATION

NURSING MANAGEMENT OF RESPIRATORY ACIDOSISNURSING MANAGEMENT OF RESPIRATORY ACIDOSISASSESSMENTASSESSMENT** Health Hx: complaints of headache, confusion, lethargy, Health Hx: complaints of headache, confusion, lethargy,

nausea, irritability, nausea, irritability, anxiety, dyspnea, and nausea, irritability, nausea, irritability, anxiety, dyspnea, and blurred vision, preexisting conditionsblurred vision, preexisting conditions** Physical Examination: lethargy to stupor to coma, tachycardia, Physical Examination: lethargy to stupor to coma, tachycardia, hypertension, cardiac dysrhythmias, airway patencyhypertension, cardiac dysrhythmias, airway patency

NURSING DIAGNOSES include but are not limited to:NURSING DIAGNOSES include but are not limited to:Diagnostic TitleDiagnostic Title Possible Etiologic FactorsPossible Etiologic Factors

11 Impaired gas exchangeImpaired gas exchange HypoventilationHypoventilation22 Disturbed thought processesDisturbed thought processes Central nervous system depressionCentral nervous system depression33 AnxietyAnxiety Hypoxia, hospitalizationHypoxia, hospitalization44 Risk for ineffective familyRisk for ineffective family Illness of a family member Illness of a family member copingcoping55 Ineffective airway clearanceIneffective airway clearance Hypoventilation, secretionsHypoventilation, secretions66 Ineffective breathing patternIneffective breathing pattern Hypoventilation, dyspneaHypoventilation, dyspnea

NURSING MANAGEMENT OF RESPIRATORY ACIDOSISNURSING MANAGEMENT OF RESPIRATORY ACIDOSIS

EXPECTED PATIENT OUTCOMES include but are not limited to:EXPECTED PATIENT OUTCOMES include but are not limited to:11 Will maintain airway patency and adequate breathing rate and Will maintain airway patency and adequate breathing rate and

rhythm will return of ABGs to patient’s normal levelrhythm will return of ABGs to patient’s normal level22 Will be alert and oriented to time, place, and person, or to his Will be alert and oriented to time, place, and person, or to his

or her normal baseline level of consciousnessor her normal baseline level of consciousness33 Will cope with anxietyWill cope with anxiety44 Will exhibit effective coping and awareness of effective Will exhibit effective coping and awareness of effective support systemssupport systems55 Will have secretions that are normal for self in amount and can Will have secretions that are normal for self in amount and can

be raisedbe raised66 Will maintain adequate rate and depth of respirations using Will maintain adequate rate and depth of respirations using

pursed lip and other breathing techniques when necessary (as pursed lip and other breathing techniques when necessary (as in the patient with COPD)in the patient with COPD)

NURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSISNURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSIS

INTERVENTIONSINTERVENTIONS11 Supporting effective gas exchangeSupporting effective gas exchange

-- Provide a position of comfort to allow ease of respirationProvide a position of comfort to allow ease of respiration-- Obtain and monitor ABG results and VS. Refer accordinglyObtain and monitor ABG results and VS. Refer accordingly-- Provide and monitor supplemental oxygen as orderedProvide and monitor supplemental oxygen as ordered-- Turn the patient q2 and PRNTurn the patient q2 and PRN-- Provide pulmonary hygiene PRNProvide pulmonary hygiene PRN-- Maintain adequate hydrationMaintain adequate hydration-- Provide comfort measures such as mouth careProvide comfort measures such as mouth care-- Assist with ADLsAssist with ADLs-- Instruct patient regarding coughing and deep breathing and Instruct patient regarding coughing and deep breathing and

management of disease condition, especially COPDmanagement of disease condition, especially COPD22 Coping with disturbed thought processesCoping with disturbed thought processes

-- Do frequent neurologic assessmentsDo frequent neurologic assessments-- Monitor and document person’s baseline LOC frequentlyMonitor and document person’s baseline LOC frequently


-- Reorient as necessary by providing calendars, clocks, etc.Reorient as necessary by providing calendars, clocks, etc.

33 Relieving anxietyRelieving anxiety

-- Provide a calm, relaxed environmentProvide a calm, relaxed environment

-- Give clear, concise explanations of treatment plansGive clear, concise explanations of treatment plans

-- Encourage expression of feelingsEncourage expression of feelings

-- Provide support and information to patient and familyProvide support and information to patient and family

-- Teach relaxation techniquesTeach relaxation techniques

-- Assist the patient to identify coping mechanisms to deal with Assist the patient to identify coping mechanisms to deal with anxiety and stressanxiety and stress

44 Enhancing coping mechanismsEnhancing coping mechanisms

-- Provide support and information to family members about the Provide support and information to family members about the patient’s ongoing conditionpatient’s ongoing condition

-- Reassure them that there is a physiologic cause for the Reassure them that there is a physiologic cause for the patient’s behaviorpatient’s behavior


-- Encourage questions and open communicationEncourage questions and open communication

55 Promote airway clearancePromote airway clearance

-- Implement regular breathing and coughing exercisesImplement regular breathing and coughing exercises

-- Do suctioning as necessaryDo suctioning as necessary

-- Maintain good hydrationMaintain good hydration

-- Do chest physiotherapy as appropriateDo chest physiotherapy as appropriate

66 Promoting an effective breathing patternPromoting an effective breathing pattern

-- Maintain alveolar ventilationMaintain alveolar ventilation

-- Teach the patient proper breathing techniques as well as Teach the patient proper breathing techniques as well as panic panic control breathingcontrol breathing


EVALUATION. Achievement of outcomes is successful when the patient:EVALUATION. Achievement of outcomes is successful when the patient:

1a.1a. Demonstrates improved ventilation and oxygenationDemonstrates improved ventilation and oxygenation

1b1b Has vital signs, ABGs, and cardiac rhythm within own normal Has vital signs, ABGs, and cardiac rhythm within own normal rangerange

22 Returns to baseline LOCReturns to baseline LOC

33 Reports reduced anxietyReports reduced anxiety

44 Family uses adequate coping mechanismsFamily uses adequate coping mechanisms

55 Is able to raise secretions on ownIs able to raise secretions on own

66 Demonstrate effective breathing techniquesDemonstrate effective breathing techniques

RESPIRATORY ALKALOSIS: CARBONIC ACID DEFICITRESPIRATORY ALKALOSIS: CARBONIC ACID DEFICIT

Anxiety, hysteria, fever, hypoxia, pain, pulmonary disorders, lesions Anxiety, hysteria, fever, hypoxia, pain, pulmonary disorders, lesions affecting the respiratory center in the medulla, brain tumor, affecting the respiratory center in the medulla, brain tumor,

encephalitis, meningitis, hyperthyroidism, gram-negative sepsisencephalitis, meningitis, hyperthyroidism, gram-negative sepsis

Hyperventilation: Excessive pulmonary ventilationHyperventilation: Excessive pulmonary ventilation

Decrease in hydrogen ion concentrationDecrease in hydrogen ion concentration

RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS

NURSING MANAGEMENT OF RESPIRATORY ALKALOSISNURSING MANAGEMENT OF RESPIRATORY ALKALOSISASSESSMENTASSESSMENT** Health Hx: anxiety, shortness of breath, muscle cramps or Health Hx: anxiety, shortness of breath, muscle cramps or weakness, palpitations, panic, dyspneaweakness, palpitations, panic, dyspnea** Physical Examination: light-headedness, confusion as a result of Physical Examination: light-headedness, confusion as a result of

cerebral hypoxia, hyperventilation, tachycardia or arrhythmia, cerebral hypoxia, hyperventilation, tachycardia or arrhythmia, muscle weakness, (+) Chvostek’s sign or Trousseau’s sign muscle weakness, (+) Chvostek’s sign or Trousseau’s sign

indicating a low ionized serum calcium level secondary to indicating a low ionized serum calcium level secondary to hyperventilation and alkalosis, hyperactive deep tendon reflexes, hyperventilation and alkalosis, hyperactive deep tendon reflexes, unsteady gait, muscle spasms to tetany, agitation, psychosis, unsteady gait, muscle spasms to tetany, agitation, psychosis, seizures in extreme cases, decreased potassium levelsseizures in extreme cases, decreased potassium levels


11 AnxietyAnxiety Stress, fearStress, fear22 Ineffective breathing patternIneffective breathing pattern Hyperventilation, anxietyHyperventilation, anxiety33 Disturbed thought processesDisturbed thought processes CNS excitability; irritabilityCNS excitability; irritability44 Risk for injuryRisk for injury Change in LOC, and potential for Change in LOC, and potential for seizuresseizures

NURSING MANAGEMENT OF RESPIRATORY ALKALOSISNURSING MANAGEMENT OF RESPIRATORY ALKALOSIS

EXPECTED PATIENT OUTCOMES include but are not limited to:EXPECTED PATIENT OUTCOMES include but are not limited to:11 Will report decreased anxiety; verbalizes methods to cope with Will report decreased anxiety; verbalizes methods to cope with

anxietyanxiety22 Will return to normal respiratory rate and rhythm or at least Will return to normal respiratory rate and rhythm or at least decreased hyperventilation, with return to baseline ABGsdecreased hyperventilation, with return to baseline ABGs33 Will exhibit reorientation to person, place, and time as per Will exhibit reorientation to person, place, and time as per patient’s baselinepatient’s baseline44 Will be free from injuryWill be free from injury

INTERVENTIONSINTERVENTIONS11 Allay anxietyAllay anxiety

-- Give antianxiety medications as orderedGive antianxiety medications as ordered-- Have patient breath into a paper bagHave patient breath into a paper bag-- Teach relaxation techniques when initial anxiety attack Teach relaxation techniques when initial anxiety attack

is is overover


INTERVENTIONSINTERVENTIONS22 Promoting an Effective Breathing PatternPromoting an Effective Breathing Pattern

-- Encourage the patient to slow his or her RREncourage the patient to slow his or her RR-- Maintain a calm and comforting attitudeMaintain a calm and comforting attitude-- Position the patient to promote maximal ease of inspirationPosition the patient to promote maximal ease of inspiration-- Assist the patient with relaxation techniquesAssist the patient with relaxation techniques

33 Coping with Disturbed Thought ProcessesCoping with Disturbed Thought Processes-- Do frequent reorientationDo frequent reorientation-- Encourage family to participate in patient’s careEncourage family to participate in patient’s care-- Use simple, direct statements or directionsUse simple, direct statements or directions-- Allow the patient adequate time to respondAllow the patient adequate time to respond

44 Preventing injuriesPreventing injuries-- Perform neurologic assessment frequently and documentPerform neurologic assessment frequently and document-- Institute safety and seizure precautionsInstitute safety and seizure precautions-- Assess frequently for muscle strength and coordinationAssess frequently for muscle strength and coordination



11 Reports reduction in anxiety levelsReports reduction in anxiety levels

2a2a Demonstrates effective normal breathing patternsDemonstrates effective normal breathing patterns

2b2b Has ABG results within patient’s normal baselineHas ABG results within patient’s normal baseline

33 Returns to normal baseline LOC and orientation levelReturns to normal baseline LOC and orientation level

44 Remains free from injury; no seizure activityRemains free from injury; no seizure activity

METABOLIC ACIDOSIS: BICARBONATE DEFICITMETABOLIC ACIDOSIS: BICARBONATE DEFICIT

Increased acid production, uncontrolled diabetes mellitus, Increased acid production, uncontrolled diabetes mellitus, alcoholism, starvation, renal acidosis, lactic acidosis, increased acid alcoholism, starvation, renal acidosis, lactic acidosis, increased acid ingestion, ethanol, salicylates, loss of bicarbonate, severe diarrhea, ingestion, ethanol, salicylates, loss of bicarbonate, severe diarrhea,

intestinal fistulas, adrenal insufficiency, hypoparathyroidismintestinal fistulas, adrenal insufficiency, hypoparathyroidism

Excess organic acids are added to body fluids or Excess organic acids are added to body fluids or bicarbonate is lostbicarbonate is lost

Decrease in bicarbonate concentrationDecrease in bicarbonate concentration

METABOLIC ACIDOSISMETABOLIC ACIDOSIS

NURSING MANAGEMENT OF METABOLIC ACIDOSISNURSING MANAGEMENT OF METABOLIC ACIDOSISASSESSMENTASSESSMENT** Health Hx: anorexia, nausea, vomiting, abdominal pain, Health Hx: anorexia, nausea, vomiting, abdominal pain,

headache, thirst if the patient is dehydratedheadache, thirst if the patient is dehydrated** Physical Examination: confusion, hyperventilation, warm, Physical Examination: confusion, hyperventilation, warm, flushed skin, bradycardia and other dysrhythmias, decreasing flushed skin, bradycardia and other dysrhythmias, decreasing

LOC, nausea, vomiting, diarrhea, Kussmaul respirations, and LOC, nausea, vomiting, diarrhea, Kussmaul respirations, and acetone breath, especially if acidosis is due to ketoacidosis. acetone breath, especially if acidosis is due to ketoacidosis. Symptoms may progress to coma if untreatedSymptoms may progress to coma if untreated


11 Disturbed thought processesDisturbed thought processes Secondary to CNS depressionSecondary to CNS depression22 Decreased cardiac outputDecreased cardiac output DysrhythmiasDysrhythmias33 Risk for injuryRisk for injury Secondary to altered mental stateSecondary to altered mental state44 Risk for imbalanced fluid Risk for imbalanced fluid Diarrhea, renal failureDiarrhea, renal failurevolumevolume

NURSING MANAGEMENT OF METABOLIC ACIDOSISNURSING MANAGEMENT OF METABOLIC ACIDOSIS

EXPECTED PATIENT OUTCOMES include but are not limited to:EXPECTED PATIENT OUTCOMES include but are not limited to:11 Will return to usual baseline LOCWill return to usual baseline LOC22 Will return to normal baseline parameters for vital signs with Will return to normal baseline parameters for vital signs with

improved CO and decreased or resolved dysrhythmiasimproved CO and decreased or resolved dysrhythmias33 Will remain in a safe, secure environment without injuryWill remain in a safe, secure environment without injury44 Will maintain fluid and electrolyte balance and stable renal Will maintain fluid and electrolyte balance and stable renal statusstatus

INTERVENTIONSINTERVENTIONS11 Coping with disturbed thought processesCoping with disturbed thought processes

-- Monitor LOC and reorient as necessaryMonitor LOC and reorient as necessary-- Monitor VS, esp. RRR, BP, and TMonitor VS, esp. RRR, BP, and T-- Monitor ABGs to assess the effects of treatmentMonitor ABGs to assess the effects of treatment-- Institute cardiac monitoring as orderedInstitute cardiac monitoring as ordered

NURSING MANAGEMENT OF PATIENT WITH METABOLIC ACIDOSISNURSING MANAGEMENT OF PATIENT WITH METABOLIC ACIDOSIS

22 Supporting cardiac outputSupporting cardiac output-- Monitor VS, MIO, and fluid and electrolyte balanceMonitor VS, MIO, and fluid and electrolyte balance-- Institute cardiac monitoring to evaluate cardiac statusInstitute cardiac monitoring to evaluate cardiac status

33 Promoting safetyPromoting safety-- Provide a safe, secure and monitored environmentProvide a safe, secure and monitored environment-- Institute safety precautionsInstitute safety precautions

44 Promoting return of fluid and electrolyte balancePromoting return of fluid and electrolyte balance-- Monitor MIOMonitor MIO-- Administer medications per medical orderAdminister medications per medical order

NURSING MANAGEMENT OF PATIENT WITH METABOLIC ACIDOSISNURSING MANAGEMENT OF PATIENT WITH METABOLIC ACIDOSIS


11 Exhibits baseline-level consciousness and orientationExhibits baseline-level consciousness and orientation

22 Returns to normal baseline parameters for vital signs and Returns to normal baseline parameters for vital signs and Cardiac Output with cardiac dysrhythmias resolvedCardiac Output with cardiac dysrhythmias resolved

33 Remains free from injuryRemains free from injury

44 Maintains fluid and electrolyte balance and stable renal functionMaintains fluid and electrolyte balance and stable renal function

METABOLIC ALKALOSIS: BICARBONATE EXCESSMETABOLIC ALKALOSIS: BICARBONATE EXCESS

Loss of stomach acid, gastric suctioning, persistent vomiting, excess Loss of stomach acid, gastric suctioning, persistent vomiting, excess alkali intake, intestinal fistulas, hypokalemia, Cushing’s syndrome or alkali intake, intestinal fistulas, hypokalemia, Cushing’s syndrome or

aldosteronism, potassium-diuretic therapyaldosteronism, potassium-diuretic therapy

Excessive amounts of acid substance and Excessive amounts of acid substance and hydrogen ions are lost from the body or large hydrogen ions are lost from the body or large

amounts of bicarbonate or lactate are added orally amounts of bicarbonate or lactate are added orally or IVor IV

Excess of base elementsExcess of base elements

METABOLIC ALKALOSISMETABOLIC ALKALOSIS

NURSING MANAGEMENT OF METABOLIC ALKALOSISNURSING MANAGEMENT OF METABOLIC ALKALOSISASSESSMENTASSESSMENT

** Health HxHealth Hx: Prolonged vomiting or nasogastric suctioning, : Prolonged vomiting or nasogastric suctioning, frequent self-induced vomiting, muscle weakness, light-frequent self-induced vomiting, muscle weakness, light-

headedness, ingestion of large amounts of licorice or headedness, ingestion of large amounts of licorice or antacids, use of diuretics, muscle cramping, twitching, or antacids, use of diuretics, muscle cramping, twitching, or tinglingtingling** Physical ExaminationPhysical Examination: mental confusion, dizziness, changes in : mental confusion, dizziness, changes in

LOC, hyperreflexia, tetany, dysrhthmias, seizurees, respiratory LOC, hyperreflexia, tetany, dysrhthmias, seizurees, respiratory failure, positive Chvostek’s or Trosseau’s sign if the patient has failure, positive Chvostek’s or Trosseau’s sign if the patient has a low ionized serum calcium level, decreased hand grasps, a low ionized serum calcium level, decreased hand grasps,

generalized muscle weakness, decreased serum calcium or generalized muscle weakness, decreased serum calcium or potassium level, impaired concentration, seizures, ECG changes potassium level, impaired concentration, seizures, ECG changes consistent with hypokalemiaconsistent with hypokalemia


11 Disturbed thought processesDisturbed thought processes CNS excitationCNS excitation22 Decreased cardiac output Dysrhythmias and electrolyte Decreased cardiac output Dysrhythmias and electrolyte imbalancesimbalances

33 Risk for injuryRisk for injury Muscle weakness, tetany, confusion and possible Muscle weakness, tetany, confusion and possible seizuresseizures

44 Risk for imbalanced fluid Nasogastric drainage, diuretic therapyRisk for imbalanced fluid Nasogastric drainage, diuretic therapyvolumevolume fistulafistula

NURSING MANAGEMENT OF METABOLIC ALKALOSISNURSING MANAGEMENT OF METABOLIC ALKALOSISEXPECTED PATIENT OUTCOMES include but are not limited to:EXPECTED PATIENT OUTCOMES include but are not limited to:

11 Will return to usual baseline LOC and orientationWill return to usual baseline LOC and orientation22 Will return to normal baseline parameters for vital signs with Will return to normal baseline parameters for vital signs with

improved CO with resolution of electrolyte imbalances and improved CO with resolution of electrolyte imbalances and decreased or resolved cardiac dysrhythmiasdecreased or resolved cardiac dysrhythmias33 Will remain in a safe, secure environment without injuryWill remain in a safe, secure environment without injury44 Will maintain fluid and electrolyte balance Will maintain fluid and electrolyte balance

INTERVENTIONSINTERVENTIONS11 Coping with disturbed thought processesCoping with disturbed thought processes

-- Monitor LOC and reorient as necessaryMonitor LOC and reorient as necessary-- Monitor VS, esp. RRR, BP, and TMonitor VS, esp. RRR, BP, and T-- Monitor ABGs to assess the effects of treatmentMonitor ABGs to assess the effects of treatment-- Institute cardiac monitoring as orderedInstitute cardiac monitoring as ordered

NURSING MANAGEMENT OF PATIENT WITH METABOLIC ALKALOSISNURSING MANAGEMENT OF PATIENT WITH METABOLIC ALKALOSIS

22 Supporting cardiac outputSupporting cardiac output-- Monitor VS, MIO, and fluid and electrolyte balanceMonitor VS, MIO, and fluid and electrolyte balance-- Institute cardiac monitoring to evaluate cardiac statusInstitute cardiac monitoring to evaluate cardiac status

33 Promoting safetyPromoting safety-- Provide a safe, secure and monitored environmentProvide a safe, secure and monitored environment-- Institute safety precautionsInstitute safety precautions

44 Promoting return of fluid and electrolyte balancePromoting return of fluid and electrolyte balance-- Monitor MIOMonitor MIO-- Administer medications per medical orderAdminister medications per medical order

NURSING MANAGEMENT OF PATIENT WITH METABOLIC ALKALOSISNURSING MANAGEMENT OF PATIENT WITH METABOLIC ALKALOSIS


11 Manifests mental status has returned to baselineManifests mental status has returned to baseline

22 Is free from cardiac dysrhythmiasIs free from cardiac dysrhythmias

33 Remains free from injuryRemains free from injury

44 Maintains fluid balance at baseline levelMaintains fluid balance at baseline level

CRITICAL THINKING EXERCISES

A patient on your unit has a diagnosis of dehydration. The physician has ordered

“force fluids”. You must make a judgment as to the type and amount since these

were not specified in the order. Identify the additional patient data needed to make an

appropriate nursing decision

CRITICAL THINKING EXERCISES

A 32-year-old administrative assistant comes to the urgent care center with a 72-hour history of vomiting secondary to influenza. She is lethargic and states, “My muscles are twitching.” Her RR is 18/min and HR is 110 bpm, T=100.4F. Her blood pressure is 110/68 which she states “is about normal for me.” Her ABG values are as follows:

pH: 7.57PaO2: 92PaCO2: 41HCO3: 36

Describe her acid-base status, probable cause for the imbalance and treatment

EXPECTED DIRECTIONAL CHANGES WITH ACID-BASE IMBALANCESEXPECTED DIRECTIONAL CHANGES WITH ACID-BASE IMBALANCES

↑↑↑

↓↓↓

Normal↓↓

Normal↑↑

HCO3HCO3

Normal↑↑

↑↑

Normal

Metabolic AlkalosisUncompensatedPartly CompensatedCompensated

Normal↓↓

↓↓

Normal

Metabolic AcidosisUncompensatedPartly CompensatedCompensated

↓↓↓

↑↑

Normal

Respiratory AlkalosisUncompensatedPartly CompensatedCompensated

↑↑↑

↓↓

Normal

Respiratory AcidosisUncompensatedPartly CompensatedCompensated

PCO2PCO2pHpHCONDITIONCONDITION

Date post:	23-Aug-2014
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