2 - F&E, ABG
Transcript of 2 - F&E, ABG
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FluidsFluids
5050--60% of body60% of bodyweight is waterweight is water
Location:Location:
Within the cellsWithin the cells
Outside the cellsOutside the cells
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Within the cells = Intracellular fluidsWithin the cells = Intracellular fluids
Outside the cells = Extracellular fluidsOutside the cells = Extracellular fluids
60% of Body Weight is WATER
IntracellularFluid (40%)
ExtracellularFluid (20%)
Interstitial Fluid(15%)
Intravascular Fluid
(5%)
Transcellular Fluid CSF, Pleural, Peritoneal,
Synovial Fluids
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The volume of fluid in each locationThe volume of fluid in each location
varies with age and sexvaries with age and sex
Infants have higher proportion of bodyInfants have higher proportion of body
water than adultswater than adults
Infants have higher fluid turnInfants have higher fluid turn--over dueover due
to immature kidney and rapid RRto immature kidney and rapid RR
Water content of the body decreasesWater content of the body decreaseswith agewith age
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Gender & Body SizeGender & Body Size
Lean body has higher water contentLean body has higher water content
Women have higher body fatWomen have higher body fat
content but lesser water contentcontent but lesser water content
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Fluid IntakeFluid Intake
Average oral fluid intake in a healthyAverage oral fluid intake in a healthyadult : 2,500ml/dayadult : 2,500ml/day (1500(1500--3000 ml/ day)3000 ml/ day)
Daily fluid intakeDaily fluid intakestandard formulastandard formula (Kayser(Kayser--Jones et al., 1999;Mentes, 2000)Jones et al., 1999;Mentes, 2000)
100ml/kg for the 1100ml/kg for the 1stst
10 kg of wt, plus10 kg of wt, plus 50ml/kg for the next 10 kg of wt, plus50ml/kg for the next 10 kg of wt, plus
15ml/kg per remaining kg of wt15ml/kg per remaining kg of wt
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Sources of Body FluidsSources of Body Fluids
LiquidsLiquids
FoodFood
Other sources: IVF, TPN, Blood productsOther sources: IVF, TPN, Blood products
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Fluid OutputFluid Output
Average fluid loss amounts toAverage fluid loss amounts to2500ml/day2500ml/day counterbalancing thecounterbalancing theinput to maintain equilibriuminput to maintain equilibrium
RoutesRoutesUrinationUrination (1500ml/day: 30(1500ml/day: 30--50ml/hr: 0.550ml/hr: 0.5--1ml/kg/hr)1ml/kg/hr),,bowel eliminationbowel elimination (200ml),(200ml), perspiration &perspiration &breathingbreathing
Sensible lossSensible loss
Insensible loss = unnoticeable/Insensible loss = unnoticeable/unmeasurableunmeasurable
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Functions of the Body FluidsFunctions of the Body Fluids
Transporter of nutrients, etcTransporter of nutrients, etc
Medium or milieu forMedium or milieu for
metabolic processesmetabolic processesBody temperature regulationBody temperature regulation
Lubricant of musculoskeletalLubricant of musculoskeletaljointsjoints
Insulator and shock absorberInsulator and shock absorber
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Composition of Body FluidsComposition of Body Fluids
Composed ofComposed ofsolutesolute,, solventssolvents,,electrolytes, proteins,electrolytes, proteins, etcetc
Plasma and interstitial fluids containPlasma and interstitial fluids containessentially the same electrolytes andessentially the same electrolytes and
solutes, but plasma has a highersolutes, but plasma has a higher
protein contentprotein contentTheThe major ICFmajor ICF areare KK++, PO, PO--44 & Mg& Mg++++
TheThe major ECFmajor ECF areare NaNa++, HCO, HCO--33 & Cl& Cl--
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TranslocationTranslocationMovement back and forth of fluid andMovement back and forth of fluid and
exchange of chemicals from one locationexchange of chemicals from one location
to anotherto another
A continuous process in and among allA continuous process in and among all
areas where water is locatedareas where water is located
Chemicals involved:Chemicals involved:
ElectrolytesElectrolytes-- substances that when dissolvedsubstances that when dissolved
in fluid carry an electrical chargein fluid carry an electrical charge AcidsAcids-- substances that release Hsubstances that release H++ into fluidinto fluid
BasesBases-- substances that bind w/ Hsubstances that bind w/ H++
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The delicate balance of fluid,The delicate balance of fluid,
electrolytes, acids, and bases iselectrolytes, acids, and bases is
ensured by anensured by an Adequate intake of water and nutrientsAdequate intake of water and nutrients
Physiologic mechanisms that regulatePhysiologic mechanisms that regulate
fluid volumefluid volume
Chemical processes that buffer theChemical processes that buffer theblood to keep its pH nearly neutralblood to keep its pH nearly neutral
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Tonicity of Body FluidsTonicity of Body Fluids
Refers to the concentration of particles in aRefers to the concentration of particles in asolutionsolution
Body fluids are ISOTONIC comparable withBody fluids are ISOTONIC comparable with0.9% NaCl0.9% NaCl
HHYPERTONICYPERTONIC fluids have a higher orfluids have a higher orgreater conc. of solutes (usually sodium)greater conc. of solutes (usually sodium)
compared with plasma; ex. is 3%NaClcompared with plasma; ex. is 3%NaCl
HHYPOTONICYPOTONIC fluids have a lesser orfluids have a lesser orlower solute conc. than plasma; ex. islower solute conc. than plasma; ex. is
0.45%, 0.33%NaCl soln0.45%, 0.33%NaCl soln
TThe normal tonicity orhe normal tonicity or
osmolarity of body fluidsosmolarity of body fluidsisis 270270--300 mOsm/L300 mOsm/L
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Using the formula forUsing the formula for
calculating fluid intakecalculating fluid intakerequirementsrequirements
according to weight,according to weight,
how much oral fluidhow much oral fluid
per day is consideredper day is considered
adequate for a clientadequate for a clientwho weighs 176 lb?who weighs 176 lb?
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Answer: 2400mlAnswer: 2400ml
100ml/kg for the 1100ml/kg for the 1stst 10 kg of wt, plus10 kg of wt, plus
50ml/kg for the next 10 kg of wt, plus50ml/kg for the next 10 kg of wt, plus
15ml/kg per remaining kg of wt15ml/kg per remaining kg of wt
176 lb x 1 kg/2.2 lb = approx. 80kg176 lb x 1 kg/2.2 lb = approx. 80kg
11stst
10 kg x 100ml = 1000ml10 kg x 100ml = 1000mlNext 10 kg x 50ml = 500mlNext 10 kg x 50ml = 500ml
80kg80kg 20 kg = 60kg x 15ml = 900ml20 kg = 60kg x 15ml = 900ml
TOTAL: 1000ml+500ml+900ml = _____TOTAL: 1000ml+500ml+900ml = _____
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Fluid and Electrolyte RegulationFluid and Electrolyte Regulation
Under normal conditions, the followingUnder normal conditions, the followingmechanisms regulates normal fluid volumemechanisms regulates normal fluid volume
and electrolyte concentrationsand electrolyte concentrations
OsmoreceptorsOsmoreceptors
RAASRAAS
ANPANP
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OsmoreceptorsOsmoreceptors
Primarily, fluid volume is regulated byPrimarily, fluid volume is regulated by
intakeintake (thirst) and(thirst) and outputoutput (urine)(urine)
HOW?
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Specialized neurons in the hypothalamusSpecialized neurons in the hypothalamus
Highly sensitive toHighly sensitive to serum osmolalityserum osmolality Increased osmolalityIncreased osmolality osmoreceptors stimulatesosmoreceptors stimulates
hypothalamus to synthesize ADHhypothalamus to synthesize ADH
Decreased osmolalityDecreased osmolality ADH is inhibitedADH is inhibited
TriggersTriggers thirstthirst promoting increased fluidpromoting increased fluidintakeintake
Thirsty when ECF volume decreases by approxThirsty when ECF volume decreases by approx
700ml (2% of body weight)700ml (2% of body weight)
Also sensitive to changes in BV & BP throughAlso sensitive to changes in BV & BP through
the info relayed by baroreceptors (stretch)the info relayed by baroreceptors (stretch)
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A decrease in BV by 10%A decrease in BV by 10%
Systolic BP falls below 90 mm HgSystolic BP falls below 90 mm Hg
RA
is underfilledRA
is underfilled
OsmoreceptorsOsmoreceptors
ADH release
ADH is suppressed when BV, BP
increases and RA is overfilled
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ReninRenin--AngiotensinAngiotensin--Aldosterone SystemAldosterone System
(RAAS)(RAAS)
RENINA
ngiotensinogen
Angiotensin I
Angiotensin II
Blood vesselA
drenal gland (cortex)
ECF (BV)
BP
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ReninRenin--AngiotensinAngiotensin--Aldosterone SystemAldosterone System
(RAAS)(RAAS)
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Natriuretic PeptidesNatriuretic Peptides
HormoneHormone--like substances that act inlike substances that act in
oppositionopposition to the RAASto the RAAS3 types:3 types:
Atrial NPAtrial NP (hearts atrial muscle)(hearts atrial muscle)
Brain NPBrain NP ((ventricles of the heart)ventricles of the heart) CC--type NP (brain)type NP (brain)
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Natriuretic PeptidesNatriuretic Peptides
Overstretching (atrial &Overstretching (atrial &ventricular walls)ventricular walls) ANP &ANP &
BNP are releasedBNP are released
ANP & BNP inhibit theANP & BNP inhibit the
release of RENIN,release of RENIN,
ALDOSTERONE andALDOSTERONE and
ADH =ADH = Blood volumeBlood volume POTENT diureticPOTENT diuretic
NaNa--wastingwasting
((--) thirst) thirst
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GastroGastro--intestinal regulation:intestinal regulation:
The GIT digests foodThe GIT digests food
andand absorbsabsorbs waterwater
Passive & activePassive & active
transport oftransport of
, H, H22O,O,&& solutionssolutions,,
maintain themaintain the
fluid balancefluid balancein the body.in the body.
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Fluids & electrolytes moveFluids & electrolytes move
among cells, compartments,among cells, compartments,tissue spaces, and plasma bytissue spaces, and plasma by
the processes ofthe processes of
OsmosisOsmosis
FiltrationFiltration
Diffusion andDiffusion and
Active transportActive transport
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OsmosisOsmosisMovement ofMovement ofwater/liquid/solventwater/liquid/solvent across aacross a
semipermeable membrane from asemipermeable membrane from a lesserlesserconcentration to a higher concentrationconcentration to a higher concentration
Osmotic pressureOsmotic pressure -- the power of a solutionthe power of a solution
to draw water toward an area of greaterto draw water toward an area of greater
concentrationconcentration
Colloidal osmotic pressureColloidal osmotic pressure -- the osmoticthe osmoticpull exerted by plasma proteins (e.g.,pull exerted by plasma proteins (e.g.,
albumin, globulin, fibrinogen)albumin, globulin, fibrinogen)
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Blood vessel
(Intravascular fluid)
Plasma
CHON = Pulls H2O from ISto IV
ICFInterstitial fluid
H2O
H2O
H2O
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FiltrationFiltration
Movement of
Movement ofboth solute andboth solute andsolventsolvent across a semipermeableacross a semipermeable
membrane from anmembrane from an area of higherarea of higher
pressure to lower pressurepressure to lower pressureHydrostatic pressureHydrostatic pressure thethe
pressure exerted by the fluidspressure exerted by the fluids
within the closed system; pusheswithin the closed system; pusheswaterwater
If HP > OP = FiltrationIf HP > OP = Filtration
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DID you knowDID you know
180 L of fluid180 L of fluid
from the bloodfrom the bloodis filtered byis filtered by
the kidneythe kidneyeach dayeach day
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DIFFUSIONDIFFUSION Brownian orDownhill movementBrownian orDownhill movement
MMovementovement ofofparticles, solutes,particles, solutes,
moleculesmolecules from an area of higherfrom an area of higherconcentration to an area of a lowerconcentration to an area of a lowerconcentrationconcentration through a semipermeablethrough a semipermeablemembranemembrane
Factors affecting rate of diffusion:Factors affecting rate of diffusion:
a.a. SizeSize of the moleculesof the molecules-- larger size moves slowerlarger size moves slowerthan smaller sizethan smaller size
b.b. ConcentrationConcentration of solutionof solution-- wide difference inwide difference inconc. has a faster rate of diffusionconc. has a faster rate of diffusion
c.c. TemperatureTemperature -- in Tin Too == rate of diffusionrate of diffusion
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Facilitated DiffusionFacilitated Diffusion
Require assistanceRequire assistancefrom a carrierfrom a carrier
molecule to passmolecule to pass
through athrough a
semipermeablesemipermeable
membranemembrane E.g., insulinE.g., insulin--
glucoseglucose
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Active TransportActive Transport uphill movementuphill movement
Movement of solute from lowerMovement of solute from lowerconcentration to higher concentration usingconcentration to higher concentration using
energy (ATP)energy (ATP)
e.g., Na-K pump
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Electrolytes ionsElectrolytes ions
Substances present inSubstances present in
ICF & ECF that carryICF & ECF that carry
electrical chargeelectrical charge
cationscations
anionsanions
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Sources of ElectrolytesSources of Electrolytes
Food intake/ ingestedFood intake/ ingested
fluidsfluidsMedicationsMedications
IVF, TPN solutionsIVF, TPN solutions
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Dynamics of Electrolyte BalanceDynamics of Electrolyte Balance
DistributionDistribution Na, Ca, Cl concentration are higher in ECFNa, Ca, Cl concentration are higher in ECF
K, Mg, PO4 concentrations are higher in ICFK, Mg, PO4 concentrations are higher in ICF
ExcretionExcretion Urine, feces, surgical/wound drainage,Urine, feces, surgical/wound drainage,
pathological conditionspathological conditions
RegulationRegulation Kidneys, GIT, hormones (aldosterone,Kidneys, GIT, hormones (aldosterone,
ANF, PTH, calcitonin)ANF, PTH, calcitonin)
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1 tsp of table salt = 2000 mg
1 tsp soy sauce = 1029 mg
Average dietary
intake of sodium isabout 6-14 g/day
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Sodium (NaSodium (Na++)) 135135--145mEq/L (mmol/L)145mEq/L (mmol/L)
Major cation in ECF; major contributor ofMajor cation in ECF; major contributor of
plasma osmolalityplasma osmolality
ECF NaECF Na++ level determines whether water islevel determines whether water is
retained, excreted or translocatedretained, excreted or translocated
Regulated by kidney (aldosterone, ADH, NP)Regulated by kidney (aldosterone, ADH, NP)
serum Na = (serum Na = (--) aldosterone, (+) ADH & NP) aldosterone, (+) ADH & NP
serum Na = (+) aldosterone, (serum Na = (+) aldosterone, (--) ADH & NP) ADH & NP
Functions:Functions: Skeletal/ heart muscle contraction, nerve impulseSkeletal/ heart muscle contraction, nerve impulse
transmission, Normal ECF osmolality, Normaltransmission, Normal ECF osmolality, Normal
ECF volumeECF volume
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1 medium 1097 mg
1 medium banana = 451 mg
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CalciumCalcium++++ 99--10.5 mg/dl (2.2510.5 mg/dl (2.25--2.75 mmol/L)2.75 mmol/L)
2 forms: bound & unbound (ionized)2 forms: bound & unbound (ionized) BoundBound attached to CHON (albumin)attached to CHON (albumin)
IonizedIonized free calcium; active form; ECFfree calcium; active form; ECF
Functions:Functions: Bone strength & density, activation ofBone strength & density, activation of
enzymes or reactions, skeletal/ cardiacenzymes or reactions, skeletal/ cardiac
muscle contraction, nerve impulsemuscle contraction, nerve impulsetransmission, blood clottingtransmission, blood clotting
Regulated by: Vitamin D, PTH, thyrocalcitoninRegulated by: Vitamin D, PTH, thyrocalcitonin
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Phosphorus (P)Phosphorus (P) 33--4.5 mg/dl (0.974.5 mg/dl (0.97--1.45 mmol/L1.45 mmol/L
Major anion ICF (80% is in bones)
Major anion ICF (80% is in bones)
Functions:Functions:
Activating BActivating B--complex vitamins, ATP,complex vitamins, ATP,
assisting in cell division, cooperating inassisting in cell division, cooperating inCHO, CHON & FAT metabolism, acidCHO, CHON & FAT metabolism, acid--
base buffering, calcium homeostasis;base buffering, calcium homeostasis;
balanced & reciprocal relationship w/balanced & reciprocal relationship w/Ca++Ca++
Regulated by PTH:Regulated by PTH: PTH =PTH = PP
PTH =PTH = PP
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MagnesiumMagnesium (Mg(Mg++++)) 1.31.3--2.1 mg/dl (0.652.1 mg/dl (0.65--1.051.05mmol/L)mmol/L)
60% stored in bones & cartilages; much more60% stored in bones & cartilages; much moreis stored in ICF (heart, liver, skeletal muscles)is stored in ICF (heart, liver, skeletal muscles)
Functions:Functions:
ICFICF skeletal muscle contractions, CHOskeletal muscle contractions, CHOmetabolism, ATP formation, Vit.Bmetabolism, ATP formation, Vit.B--complexcomplex
activation, DNA synthesis, CHON synthesisactivation, DNA synthesis, CHON synthesis
ECFECF regulates blood coagulation & skeletalregulates blood coagulation & skeletal
muscle contractilitymuscle contractilityRegulated by the kidney & GIT (exactRegulated by the kidney & GIT (exact
mechanism are not known)mechanism are not known)
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ChlorideChloride (Cl(Cl--)) 9898--106 meq/L (mmol/L)106 meq/L (mmol/L)
Major ECF anion; work w/ NaMajor ECF anion; work w/ Na++to maintain ECF osmoticto maintain ECF osmotic
pressurepressure
Important in the formation ofImportant in the formation of
HCL in the stomachHCL in the stomach
Participates in chloride shiftParticipates in chloride shift(exchange between Cl(exchange between Cl-- &&
HCOHCO33--
))
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Fluid & ElectrolyteFluid & Electrolyte
ImbalancesImbalances
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Fluid ImbalancesFluid Imbalances
HypovolemiaHypovolemia
HypervolemiaHypervolemia
Third spacingThird spacing
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Hypovolemia (Fluid Volume Deficit)Hypovolemia (Fluid Volume Deficit)
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Hypovolemia (Fluid Volume Deficit)Hypovolemia (Fluid Volume Deficit)
Assessment findingsAssessment findings
Thirst = one of the earliest symptomsThirst = one of the earliest symptoms
Weight lossWeight loss 2lb/24 hr2lb/24 hr
BP,BP,
TT, rapid & weak thready pulse,, rapid & weak thready pulse,rapid & shallow respiration, scant & darkrapid & shallow respiration, scant & dark
yellow urine, dry & small volume stool,yellow urine, dry & small volume stool,
warm & flushed dry skin, poor skin turgorwarm & flushed dry skin, poor skin turgor
tents, sunken eyes, clear lungs,tents, sunken eyes, clear lungs,effortless breathing, weakness, flat jugulareffortless breathing, weakness, flat jugular
veins, reduced cognition, sleepyveins, reduced cognition, sleepy
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Medical ManagementMedical Management
Fluid deficit is restored by:Fluid deficit is restored by:
Treating its etiologyTreating its etiology
Increasing the volume ofIncreasing the volume oforal intakeoral intake
Administering IVF
Administering IVFreplacementreplacement
Controlling fluid lossesControlling fluid losses
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Nursing ManagementNursing Management
Gathers assessment dataGathers assessment dataPlans measures to restorePlans measures to restore
fluid balancefluid balanceEvaluates the outcomes ofEvaluates the outcomes of
interventionsinterventionsProvide health teachingProvide health teaching
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Health TeachingHealth Teaching
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Health TeachingHealth TeachingRespond to THIRST because it is an earlyRespond to THIRST because it is an early
indication of reduced fluid volumeindication of reduced fluid volume
Consume at least 8Consume at least 8--10 (8 ounce) glasses of fluid10 (8 ounce) glasses of fluid
each day, and more during hot, humid weathereach day, and more during hot, humid weather
Drink water as an inexpensive means to meetDrink water as an inexpensive means to meetfluid requirementsfluid requirements
Avoid beverages with alcohol & caffeineAvoid beverages with alcohol & caffeine
Include a moderate amount of table salt or foodsInclude a moderate amount of table salt or foodscontaining sodium each daycontaining sodium each day
Rise slowly from a sitting or lying position toRise slowly from a sitting or lying position to
avoid dizziness and potential injuryavoid dizziness and potential injury
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HypervolemiaHypervolemia
High volume of water in the IV compartmentHigh volume of water in the IV compartmentEtiology:Etiology:
Excessive oral intake, rapid IV infusionExcessive oral intake, rapid IV infusion
Heart failureHeart failure Kidney diseaseKidney disease
Excessive salt intakeExcessive salt intake
Adrenal gland dysfunctionAdrenal gland dysfunction Administration of corticosteroidsAdministration of corticosteroids
(prednisolone)(prednisolone)
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PathophysiologyPathophysiology
Circulatory overload;Circulatory overload;compromises cardiopulmonarycompromises cardiopulmonary
functionfunctionThe heart compensates:The heart compensates: BP,BP,
force of contractionforce of contraction
Pitting edema develops (if therePitting edema develops (if there
is 3L excess in IV volume)is 3L excess in IV volume)
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Diagnostic FindingsDiagnostic Findings
Hemodilution (Hemodilution ( blood cell count,blood cell count,
hematocrit)hematocrit)
Low Urine SGLow Urine SG
CVP (>10 cm HCVP (>10 cm H22O)O)
(
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Medical ManagementMedical Management
Treat the underlying causeTreat the underlying cause
Restriction of oral & parenteral fluid intakeRestriction of oral & parenteral fluid intake
Nursing Management
Implements prescribed interventions (limiting
Na+ & water intake)
Administering ordered medications
Elevates client head, legs, change position
q2, apply elastic stockings
Third SpacingThird Spacing
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Third SpacingThird Spacing
Translocation of fluid from the IV orTranslocation of fluid from the IV or
intercellular space to tissue compartmentsintercellular space to tissue compartments
& becomes trapped & useless& becomes trapped & useless
Associated withAssociated with
loss of colloids (hypoalbuminemia)loss of colloids (hypoalbuminemia)
BurnsBurns
severe allergic reaction that alter capillary &severe allergic reaction that alter capillary &
cellular membrane permeabilitycellular membrane permeability
It can lead to hypotension, shock &It can lead to hypotension, shock &
circulatory failurecirculatory failure
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Assessment FindingsAssessment Findings
S/sx of hypovolemia except weight lossS/sx of hypovolemia except weight lossEnlargement of organ cavities (ascites)Enlargement of organ cavities (ascites)
Anasarca brawny edemaAnasarca brawny edema
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ManagementManagement
Restoration of colloidalRestoration of colloidalosmotic pressure (albumin),osmotic pressure (albumin),
then diureticsthen diureticsNursing care combines theNursing care combines the
assessment techniques forassessment techniques for
detecting both hypovolemia &detecting both hypovolemia &
hypervolemiahypervolemia
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HyponatremiaHyponatremia
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HyponatremiaHyponatremia
Causes;Causes;
Profuse diaphoresis & diuresisProfuse diaphoresis & diuresis
Excessive ingestion of plainExcessive ingestion of plainwaterwater
Administration of electrolyte IVAdministration of electrolyte IVfluidsfluids
Prolonged vomiting, GIProlonged vomiting, GIsuctioning, draining fistulassuctioning, draining fistulas
Addisons diseaseAddisons disease
HyponatremiaHyponatremia
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HyponatremiaHyponatremia
Manifestations:Manifestations:Mental confusion, personalityMental confusion, personality
changeschanges
Muscular weaknessMuscular weakness
Anorexia, restlessnessAnorexia, restlessness
Elevated BT, tachycardia, N&VElevated BT, tachycardia, N&V
Severe: convulsions & comaSevere: convulsions & coma
HyponatremiaHyponatremia
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HyponatremiaHyponatremia
Management:Management:Underlying cause is correctedUnderlying cause is corrected
Mild deficits: oralMild deficits: oraladministration of Na+administration of Na+
Severe deficits: IV solutionsSevere deficits: IV solutions
HypernatremiaHypernatremia
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HypernatremiaHypernatremiaCauses:Causes: Profuse watery diarrheaProfuse watery diarrhea Excessive salt intake without sufficientExcessive salt intake without sufficient
water intakewater intake
High feverHigh fever Decreased water intake (elderly,Decreased water intake (elderly,
debilitated, unconscious clients)debilitated, unconscious clients)
Excessive administration of solutionsExcessive administration of solutions
containing Na+containing Na+ Excessive water loss withoutExcessive water loss without
accompanying loss of sodiumaccompanying loss of sodium
Severe burnsSevere burns
HypernatremiaHypernatremia
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HypernatremiaHypernatremia
Results inResults in ThirstThirst
Dry, sticky mucous membranesDry, sticky mucous membranes
Decreased UODecreased UO
FeverFever
Rough, dry toungeRough, dry tounge LethargyLethargy
Coma if severeComa if severe
HypernatremiaHypernatremia
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HypernatremiaHypernatremia
Treatment:Treatment:Depends on the causeDepends on the cause
Oral administration of plainOral administration of plainwaterwater
IV administration of hypotonicIV administration of hypotonicsolutionssolutions
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98/140
HypokalemiaHypokalemia
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99/140
HypokalemiaHypokalemia
Causes:Causes: KK++--wasting diuretics (furosemidewasting diuretics (furosemide [Lasix],[Lasix],
ethacrynic acid [Edecrin],ethacrynic acid [Edecrin],
hydrochlorothiazide [HydroDIURIL]hydrochlorothiazide [HydroDIURIL]
Severe vomiting & diarrhea, drainingSevere vomiting & diarrhea, draining
intestinal fistula, prolonged suctioningintestinal fistula, prolonged suctioning
Large doses of corticosteroidsLarge doses of corticosteroids
IV administration of insulin & glucoseIV administration of insulin & glucose
Prolonged administration of nonelectrolyteProlonged administration of nonelectrolyte
parenteral fluidsparenteral fluids
HypokalemiaHypokalemia
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HypokalemiaHypokalemia
Signs & symptoms:Signs & symptoms:
FatigueFatigue
WeaknessWeakness
AnorexiaAnorexia
N&VN&V
Cardiac dysrhythmiasCardiac dysrhythmias
Leg crampsLeg cramps
Muscle weakness, paresthesiasMuscle weakness, paresthesias
Severe: hypotension, flaccid paralysis,Severe: hypotension, flaccid paralysis,
DEATH from cardiac arrest/ respiratory arrestDEATH from cardiac arrest/ respiratory arrest
HypokalemiaHypokalemia
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HypokalemiaHypokalemiaECG changesECG changes
STST--segment depressionsegment depression
Flat or inverted T waveFlat or inverted T wave
Increased U waveIncreased U wave
HypokalemiaHypokalemia
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HypokalemiaHypokalemia
Treatment:Treatment:
Elimination of the causeElimination of the cause
Substitute KSubstitute K--wasting with Kwasting with K--
sparing diureticssparing diuretics(Spirinolactone(Spirinolactone [Aldactone][Aldactone]
Increase oral intake of KIncrease oral intake of K--richrich
foods/ K supplements (mildfoods/ K supplements (mildcases)cases)
KCL (severe cases)KCL (severe cases)
HyperkalemiaHyperkalemia
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HyperkalemiaHyperkalemia
Causes:Causes:
Renal failureRenal failure
Severe burnsSevere burns
Administration of KAdministration of K--sparing diureticssparing diuretics
Overuse of K supplements, saltOveruse of K supplements, saltsubstitutes (which contain K instead ofsubstitutes (which contain K instead ofNa), potassium rich foodsNa), potassium rich foods
Crushing injuriesCrushing injuries Addisons diseaseAddisons disease
Rapid administration of parenteral K saltsRapid administration of parenteral K salts
HyperkalemiaHyperkalemia
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HyperkalemiaHyperkalemia
Signs/Symptoms:Signs/Symptoms:
DiarrheaDiarrhea
NauseaNausea
Muscle weaknessMuscle weakness
ParesthesiasParesthesias
Cardiac dysrhythmiasCardiac dysrhythmias
Peak T wavesPeak T waves
Prolonged PR intervalsProlonged PR intervals
Flat or absent P waveFlat or absent P wave
Wide QRS complexWide QRS complex
HyperkalemiaHyperkalemia
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HyperkalemiaHyperkalemia
Treatment: depends on the cause andTreatment: depends on the cause andseverityseverity
Decrease KDecrease K--rich food intake, d/c oralrich food intake, d/c oralpotassium replacement until laboratorypotassium replacement until laboratory
values are normal (mild cases)values are normal (mild cases) Administration of cationAdministration of cation--exchange resinexchange resin
like sodium polystyrene sulfonatelike sodium polystyrene sulfonate
(kayexalate) or combination of IV regular(kayexalate) or combination of IV regularinsulin & glucose (severe cases)insulin & glucose (severe cases)
Peritoneal dialysis/ hemodialysis forPeritoneal dialysis/ hemodialysis forremoving toxic substances from the bloodremoving toxic substances from the blood
Nursing ManagementNursing Management (K+ Imbalances)(K+ Imbalances)
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Nursing ManagementNursing Management (K+ Imbalances)(K+ Imbalances)
Assess clients for conditions with theAssess clients for conditions with the
potential to cause potassiumpotential to cause potassium
imbalancesimbalances
Identifies signs & symptomsIdentifies signs & symptomsMonitors laboratory findingsMonitors laboratory findings
Administer medicationsAdminister medications
KCLKCL diluted in an IV solution &diluted in an IV solution &
administered at a rate below 10mEq/hradministered at a rate below 10mEq/hr
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HypocalcemiaHypocalcemia
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ypyp
Causes:Causes:
Vit D deficiencyVit D deficiency
HypoparathyroidismHypoparathyroidism
Severe burnsSevere burns
Acute pancreatitisAcute pancreatitis
CorticosteroidsCorticosteroids
Rapid administration of multiple units ofRapid administration of multiple units of
blood that contain an anticalcium additiveblood that contain an anticalcium additive Intestinal malabsoprtion d/oIntestinal malabsoprtion d/o
Accidental removal of parathyroid glandsAccidental removal of parathyroid glands
HypocalcemiaHypocalcemia
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HypocalcemiaHypocalcemiaSigns & symptoms:Signs & symptoms: Tingling sensations (extremities, aroundTingling sensations (extremities, around
the mouth)the mouth)
Muscle & abdominal crampsMuscle & abdominal cramps
Carpopedal spasms (+ Trousseaus sign)Carpopedal spasms (+ Trousseaus sign)
Mental changesMental changes
+ Chvosteks sign (spasm of facial muscle)+ Chvosteks sign (spasm of facial muscle)
Laryngeal spasmsLaryngeal spasms
Tetany (muscle twisting)Tetany (muscle twisting) SeizuresSeizures
BleedingBleeding
Cardiac dysrhythmiasCardiac dysrhythmias
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HypocalcemiaHypocalcemia
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HypocalcemiaHypocalcemia
Treatment:Treatment: Administration of oral CaAdministration of oral Ca++++ & Vitamin D& Vitamin D
(mild cases)(mild cases)
IV administration of CaIV administration of Ca++++
salts (Calciumsalts (Calciumgluconate)gluconate) severe casessevere cases
HypercalcemiaHypercalcemia
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HypercalcemiaHypercalcemia
Associated withAssociated with
Parathyroid gland tumorsParathyroid gland tumors
Multiple fracturesMultiple fractures
Pagets diseasePagets disease HyperparathyroidismHyperparathyroidism
Excessive doses of vitamin DExcessive doses of vitamin D
Prolonged immobilizationProlonged immobilization some chemotherapeutic agentssome chemotherapeutic agents
Certain malignant diseases (multipleCertain malignant diseases (multiplemyeloma, acute leukemia, lymphomas)myeloma, acute leukemia, lymphomas)
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HypercalcemiaHypercalcemia
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HypercalcemiaHypercalcemia
ManagementManagement
Determining & correcting the causeDetermining & correcting the cause
Increase fluid intake & limit CaIncrease fluid intake & limit Ca++++
consumption (mild cases)consumption (mild cases)
0.45% or 0.9%NaCL (acute cases)0.45% or 0.9%NaCL (acute cases)and diuretics: furosemide (Lasix); oraland diuretics: furosemide (Lasix); oralphosphates; calcitonin (Cibacalcin)phosphates; calcitonin (Cibacalcin)
Corticosteroids or plicamycinCorticosteroids or plicamycin(Mithracin)(Mithracin) used for malignantused for malignantdiseases that do not respond to otherdiseases that do not respond to other
forms of therapyforms of therapy
Nursing Management:Nursing Management: Ca++ ImbalancesCa++ Imbalances
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Nursing Management:Nursing Management: Ca++ ImbalancesCa++ Imbalances
HypoCaHypoCa++++::
Closely monitor for neurologicClosely monitor for neurologicmanifestationsmanifestations (tetany, seizures, spasms)(tetany, seizures, spasms)
Seizure precautionsSeizure precautions
Provide bed rest for comfort, avoidProvide bed rest for comfort, avoidfallsfalls
Cardiac dysrhythmias & airwayCardiac dysrhythmias & airwayobstructionobstruction
Check for signs of bruising or bleedingCheck for signs of bruising or bleeding
Nursing Management:Nursing Management: Ca++ ImbalancesCa++ Imbalances
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Nursing Management:Nursing Management: Ca ImbalancesCa Imbalances
HyperCaHyperCa++++
Encourage increased fluid intakeEncourage increased fluid intake
Collaborates with dietitian to limitCollaborates with dietitian to limit
food sources of Cafood sources of Ca++++
Ambulation as tolerated!!!Ambulation as tolerated!!!
Provide assistance; avoid fallsProvide assistance; avoid falls
Nursing Management:Nursing Management: Ca++ ImbalancesCa++ Imbalances
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Health teaching:Health teaching:
Follow the physicians recommendationsFollow the physicians recommendationsregarding the addition or restriction of Caregarding the addition or restriction of Ca++++ toto
the dietthe diet
Milk & dairy products, turnips, mustard greens,Milk & dairy products, turnips, mustard greens,
collards, kale, brocolli, canned fish with bones, Cacollards, kale, brocolli, canned fish with bones, Ca++++--
fortified orange juicefortified orange juice
LactoseLactose--free milk & nonprescriptions lactasefree milk & nonprescriptions lactase
enzymes are available for lactoseenzymes are available for lactose--intolerantintolerantclientsclients
Take prescribed or physicianTake prescribed or physician--recommendedrecommended
drugs as directed; do not exceed or omit a dosedrugs as directed; do not exceed or omit a dose
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HypomagnesemiaHypomagnesemia
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yp gyp g
Causes:Causes:
Chronic alcoholismChronic alcoholism
Diabetic ketoacidosisDiabetic ketoacidosis
Severe renal diseaseSevere renal disease
Severe burnsSevere burns Severe malnutritionSevere malnutrition
PIHPIH
Intestinal malabsorption syndromesIntestinal malabsorption syndromes Excessive diuresis (drug induced)Excessive diuresis (drug induced)
HyperaldosteronismHyperaldosteronism
Prolonged gastric suctionProlonged gastric suction
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120/140
HypomagnesemiaHypomagnesemia
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HypomagnesemiaHypomagnesemia
Management:Management:
Oral magnesium salts/Oral magnesium salts/
magnesium rich foodsmagnesium rich foods
IV magnesium sulfateIV magnesium sulfate
HypermagnesemiaHypermagnesemia
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Causes:Causes:
Renal failure, Addisons disease, Excessive useRenal failure, Addisons disease, Excessive useof antacids or laxatives, Hyperaldosteronismof antacids or laxatives, Hyperaldosteronism
Signs & symptoms:Signs & symptoms:
Flushing, warmth, hypotension, lethargy,Flushing, warmth, hypotension, lethargy,drowsiness, bradycardia, muscle weakness,drowsiness, bradycardia, muscle weakness,
depressed respirations, comadepressed respirations, coma
Management:Management:
Decrease oral magnesium intakeDecrease oral magnesium intake
Discontinue parenteral replacementDiscontinue parenteral replacement
Hemodialysis (severe cases)Hemodialysis (severe cases)
Nursing Management:Nursing Management: Mg++ ImbalancesMg++ Imbalances
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Closely observe for dysrhythmias &Closely observe for dysrhythmias &
early signs of neuromuscularearly signs of neuromuscularirritabilityirritability
If giving MgSOIf giving MgSO44, always check the, always check the
BP!!! (vasodilation)BP!!! (vasodilation)
Antidote: Calcium gluconate (keptAntidote: Calcium gluconate (kept
available)available)Monitor vital signsMonitor vital signs
Provide health teachingProvide health teaching
Identify the electrolyte imbalance eachIdentify the electrolyte imbalance each
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client is most likely manifesting:client is most likely manifesting:
Client 1.Client 1. nauseous & weak. The ECGnauseous & weak. The ECG
shows a U waveshows a U wave
Client 2. muscle twitching and tinglingmuscle twitching and tingling
around mouth. When the nurse applies aaround mouth. When the nurse applies aBP cuff to the clients arm and occludesBP cuff to the clients arm and occludes
blood flow for 3 minutes, the fingers andblood flow for 3 minutes, the fingers and
wrist become flexedwrist become flexedClient 3.Client 3. thirsty, lethargic and excretingthirsty, lethargic and excreting
only scant urine.only scant urine.
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ACIDACID--BASE BALANCEBASE BALANCE
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ACIDACID BASE BALANCEBASE BALANCEBody fluids containsBody fluids contains ACIDS & BASESACIDS & BASES asideaside
from electrolytesfrom electrolytes
HH22COCO33 acid & base content influence the pHacid & base content influence the pH
HCOHCO33 of the body (amount of H+ in a solution)of the body (amount of H+ in a solution)
Normal plasma pH is maintained byNormal plasma pH is maintained by
Chemical regulationChemical regulation (bicarbonate(bicarbonate--carbonic acidcarbonic acid
buffer system) 20:1buffer system) 20:1
Adding/ removing H
Adding/ removing H
++
ionsions Respiratory & renal regulationRespiratory & renal regulation
Releasing & conserving COReleasing & conserving CO22
Retaining or excreting HCORetaining or excreting HCO33
ACIDACID--BASE BALANCEBASE BALANCE
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ACIDACID BASE BALANCEBASE BALANCE
pH (7.35 7.45)PaO2 (80 100 mm Hg)
PaCO2 (35 45 mm Hg)
HCO3- (22 26 mEq/L or
mmol/L)
Base excess (-2 to +2 mEq/L)
O2 Saturation (95 98%)
ACIDACID--BASE IMBALANCEBASE IMBALANCE
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ACIDACID BASE IMBALANCEBASE IMBALANCE
pHpH HCOHCO--33 PaCOPaCO22
MetabolicMetabolic
acidosisacidosis
MetabolicMetabolicalkalosisalkalosis
RespiratoryRespiratory
acidosisacidosis
RespiratoryRespiratory
alkalosisalkalosis
METABOLIC ACIDOSISMETABOLIC ACIDOSIS
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There is increased organic acids (other thanThere is increased organic acids (other than
carbonic acid) or decreased bicarbonatecarbonic acid) or decreased bicarbonateCAUSE:CAUSE:
Anaerobic metabolism (formn of byproductAnaerobic metabolism (formn of byproduct
lactic acid) = shock & cardiac arrestlactic acid) = shock & cardiac arrestStarvation, diabetic ketoacidosis = fatty acidsStarvation, diabetic ketoacidosis = fatty acids
accumulationaccumulation
Kidney failure (cannot reabsorption of HCOKidney failure (cannot reabsorption of HCO33))Aspirin overdosage, profuse diarrhea, intestinalAspirin overdosage, profuse diarrhea, intestinal
wound drainage (HCOwound drainage (HCO33 is lost)is lost)
METABOLIC ACIDOSISMETABOLIC ACIDOSIS
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Assessment findings:Assessment findings:
Kussmauls breathing (deep & rapid breathing)Kussmauls breathing (deep & rapid breathing)
Anorexia, N & V, headache, confusion, flushing,Anorexia, N & V, headache, confusion, flushing,
lethargy, malaise, drowsiness, abdominal pain orlethargy, malaise, drowsiness, abdominal pain or
discomfort, weaknessdiscomfort, weakness cardiac dysrhythmias can develop, force ofcardiac dysrhythmias can develop, force of
cardiac contraction can be weakenedcardiac contraction can be weakened
Stupor & coma (severe cases)Stupor & coma (severe cases)
ABG:ABG: pH,pH, HCO3 (N toHCO3 (N to PaCO2)PaCO2)
Anion gap (>16mEq/L indicates Met.Acid)Anion gap (>16mEq/L indicates Met.Acid)
(Na + K)(Na + K) (Cl + HCO(Cl + HCO33))
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METABOLIC ACIDOSISMETABOLIC ACIDOSIS
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METABOLIC ACIDOSISMETABOLIC ACIDOSIS
Medical Management:Medical Management:
Treating the cause & replacingTreating the cause & replacing
F&E that may have been lostF&E that may have been lost
IV bicarbonate (severe cases)IV bicarbonate (severe cases)
METABOLIC ALKALOSISMETABOLIC ALKALOSIS
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There is increased bicarbonate or decreasedThere is increased bicarbonate or decreased
HH++ ion concentrationsion concentrations
Excessive oral or parenteral use ofExcessive oral or parenteral use of
bicarbonatebicarbonate--containing drugs or alkalinecontaining drugs or alkaline
saltssalts
Rapid decrease in ECF (diureticRapid decrease in ECF (diuretic
therapy)therapy)
Vomiting, prolonged gastric suctioning,Vomiting, prolonged gastric suctioning,
hypokalemia, hyperaldosteronismhypokalemia, hyperaldosteronism
(retention of sodium bicarbonate)(retention of sodium bicarbonate)
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RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS acute/ chronicacute/ chronicCC
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Causes:Causes:
Pneumothorax,Pneumothorax, Hemothorax,Hemothorax,
Pulmonary edemaPulmonary edema
Acute bronchial asthmaAcute bronchial asthma
AtelectasisAtelectasis
Hyaline membrane disease, RDS in NBHyaline membrane disease, RDS in NB
PneumoniaPneumonia
Drug overdose
Drug overdose
Head injuriesHead injuries
ChronicChronic-- emphysema, bronchiectasis, bronchialemphysema, bronchiectasis, bronchialasthma, cystic fibrosisasthma, cystic fibrosis
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
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Assessment findings:Assessment findings:
Client make frantic efforts to breathe, breath slowlyClient make frantic efforts to breathe, breath slowly
or irregularly, or stop breathingor irregularly, or stop breathing
Decreased expiratory volumesDecreased expiratory volumes
Tachycardia (dysrhythmias), CyanosisTachycardia (dysrhythmias), Cyanosis Behavioral changesBehavioral changes-- mental cloudiness, confusion,mental cloudiness, confusion,
disorientation, hallucinations (accumulation of COdisorientation, hallucinations (accumulation of CO22))
Tremors, muscle twitching, flushed skin, headache,Tremors, muscle twitching, flushed skin, headache,
weakness, stupor, comaweakness, stupor, coma
ABG:ABG: pH,pH, PaCO2 (N toPaCO2 (N to HCOHCO33))
RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS
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Medical managementMedical management
Treatment is individualized dependingTreatment is individualized dependingon the cause of imbalanceon the cause of imbalance
Mechanical ventilation (may beMechanical ventilation (may be
necessary to support respiratorynecessary to support respiratoryfunction)function)
IV NaHCOIV NaHCO33 if ventilation efforts do notif ventilation efforts do not
adequately restore a balanced pHadequately restore a balanced pH Bronchodilators, antibiotics, airwayBronchodilators, antibiotics, airway
suctioningsuctioning
RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS
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Results from carbonic acid deficitResults from carbonic acid deficit
Anxiety, high fever, thyrotoxicosis, early salicylateAnxiety, high fever, thyrotoxicosis, early salicylate
(aspirin) poisoning, hypoxemia, mechanical(aspirin) poisoning, hypoxemia, mechanical
ventilationventilation
Assessment findings:Assessment findings: RRRR
Lightheadedness, numbness & tingling of theLightheadedness, numbness & tingling of the
fingers & the toes, circumoral paresthesias,fingers & the toes, circumoral paresthesias,
sweating, panic, dry mouth, convulsions (severesweating, panic, dry mouth, convulsions (severecases)cases)
ABG:ABG: pH,pH, PaCOPaCO22 (N to(N to HCOHCO33))
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139/140
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