NUR108_2014_student(1).pptx_1

8/10/2019 NUR108_2014_student(1).pptx_1

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NUR 108 - Spring

2014

Fluid and

Electrolyte

8/10/2019 NUR108_2014_student(1).pptx_1


Learning Outcomes

1. Discuss the function, distribution, movement,and regulation of uids and electrolytes in thebody.

2. Identify factors aecting normal body uid,

electrolyte and acid–base balance.

. Discuss the ris! factors and causes and eectsof uid and electrolyte imbalance

". #ollect assessment data related to the client$suid and electrolyte

%. Identify e&am'les of nursing diagnoses,outcomes, and interventions for clients (ith

altered uid ) electrolyte

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luid /egulation

luids move through the body by0

Osmosis

Diusion

iltration

ctive trans'ort

/egulated by uid Inta!e ) Out'ut

/egulated by the movement of substancesdissolved in (ater and its movement

bet(een body com'artments

1

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Diusion

#o'yright 2312 by 4earson

5ovement of molecules through asemi'ermeable membrane from an area ofhigher concentration to an area of lo(er

concentration.

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Osmosis


6ater molecules move from the lessconcentrated area to the moreconcentrated area, attem'ting to e7uali8ethe concentration of solutions on t(o sides

of a membrane.

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ctive +rans'ort

ATP energy is used to move Na and K molecules⁺ ⁺

across a semipermeable membrane against their

concentration gradients from a < concentration area

to one of > concentration.

2

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• Arterial blood pressure > colloid osmotic pressure, so that

water and dissolved substances move out of the capillary into

the interstitial space.• Venous blood pressure is < colloid osmotic pressure, so that

water and dissolved substances from the interstitial space

move into the capillary.

iltration

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Osmotic 4ressureOsmolality/Osmolarity is the concentration of a

solution which creates osmotic pressure

Osmolality: concentration of solutes per Kg/water

Osmolarity: concentration of solutes per L/sol.

Osmotic (oncotic) pressure is the pulling force of

a solution for water

Osmolality pressure: 275 2!5 mOsm/L

"#ult: 2$5 2!5 mOsm/L

%hil#: 275 2!& mOsm/L

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Osmotic 4ressure

'lasma protein (alumin) in loo# eert oncoticpressure that opposes the hy#rostatic pressure

an# hol#s flui# in the *ascular compartment to

maintain *ascular *olume.

Osmotic pressure will hol# flui#s in the *ascular

system ut increase# hy#rostatic pressure is

higher than the osmotic pressure an# causes flui#

to filter out.+o#ium ma,or solute in plasma

-rea (-) 0 1lucose increases serum

osmolality when present in large amts.

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Isotonic

Isotonic – has same osmolality asnormal 'lasma

9sed to re'lace e&tracellula uids

-&'and vascular volume 7uic!ly

:.;., /inger$s sol., Lactated

/inger$s <L/=D>60 <becomes hy'otonic (henmetaboli8ed and e&'ands

intra?e&tracellular uids=

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@y'otonic

@y'otonic – has lo(er osmolalitythan normal 'lasma A 2B3

6ater is 'ulled out of blood vessels

into the cells

Decreases vascular vol.

O.">C :;, 3.22>C :;

9sed to 'revent cellular dehydration

5onitor ;, LO#, circulatory

de'letion, cerebral edema. DO NOT

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@y'ertonic@y'otonic – has higher osmolality than

normal 'lasma A 2B3

#auses uids to shift from cells into

vascular com'artment, 'romotes diuresis

Increases vascular volume

C:;, >C:;

5onitor for vascular overload, urineout'ut, lung sounds, neuro status, serumsodium levels

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#olloid ;olutions#olloid – large solute <'rotein=, that does

not 'ass tErough cell or ca'illarymembranes

@y'ertonic olume e&'anders

Increases colloids – increases osmolality

4ulls uid from tissue into blood vessels by

osmosis

lbumin 2>C, De&tran, @etastarch

5anitol or Osmmitrol – 'ulls uid from

third s'aces, tissues and cells into blood

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/egulation of Fody luid

@omeostasis – regulates the volume )com'osition of body uids

/enal system

-ndocrine system

#ardiovascular system

/es'iratory system

Gastrointestinal system

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/egulating Fody luids

luid inta!e

+hirstmechanism

luid out'ut

9rine

Insensibleloss

eces

5aintaininghomeostasis

Hidneys

D@

/enin

angiotensinaldosteronesystem

trial natriuretic

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/egulating Fody luids3lui# inta4e alances flui# loss

hirst mechanism if the primary regulator of flui#

inta4e

63lui# is lost through routes:

-rine (8&&85&& mL/2 hrs.)

+4in perspiration (95&&& mL)

Lungs (95&&& mL y water *apor)

ntestines (chyme 85&& mL)

"t least 5&& mL of flui# is oligatory lost y

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#hemical /egulation of

luidsD@ – is released (hen F4 or bloodvolume decrease <or osmolality inceases=

/esults in renal reabsor'tion of (ater toincrease vascular volume

ldosterone – conserves sodium

Hidneys retain :aJ and e&crete HJ

Glucocorticoids – 'romote renal retentionof sodium and (ater

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#hemical /egulation of

luidstrial :atriuretic 4e'tide <:4= – lo(ersblood volume by0

#ausing vasodilation or

;u''ressing of the reninangiotensinsystem

Frain :atriuretic 4e'tide <F:4= – decreases

blood volume by0

asodilating arteries and veins

Decreasing the release of aldosterone

Diuresis ) e&cretion of :aJ and @2O

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Distribution of Fody

luids


1. Intracellular <I#= Inside cell 2? total bodyuids

2. -&tracellular<-#= Outside the cell

1? total bodyuids K intravascular23C

K interstitial *>C

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Fody luids +ranscellular uids:

• #;

• Lym'h uid

• Filiary uid

• 4ancreatic uids

• Intraocular uid• 4eritoneal uids

• ;ynovial uid

+hese uids are vital to normal cell

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Distribution of Fody luids

in Infantsdult Infant

-# 1>23C -# ">C

I# "3">C I# >C

Infants have a higher 'ercentage ofinterstitial uid

ullterm ne(born – body (t a''ro&. 3C4remature infant – a''ro&. B3C

dult <from 'uberty to age %3= – %3C

-lderly < %3 yrs= – ">C

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unctions of Fody luids6ater is vital to health ) normal cellular

function

vital medium for metabolic reactions

+rans'orts nutrients, (aste 'roducts,hormones, other substances

cts as a lubricant, insulator and shoc!

absorber/egulates body tem'erature

ids in digestion ) 'eristalsis

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;ources of Fody 6aterM;ources of body (ater

Ingested li7uids ) foods

+ube feeding ) 'arenteral li7uids

O&idation of foods ) body tissues

venues of normal loss of body (ater

Hidneys ) intestinal tract;!in eva'oration of 'ers'iration

-&haled moisture through lungs

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+y'es of 6ater Losses

omiting

Furns

6ounde&udate

Gastric suction

#olitis;tools

9rine

4aracentesis

Loss of inEureds'aces – as edema

+hird s'acing –intestinal 'ooling

Draining intestinal

Nstulae

Drainage tubes

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+hirds'acing of body uids

Fody uids shift into a body s'ace that isnot easily e&changed (ith the -#

4roduces uid vol. deNcit

4roduces uid vol. e&cess in s'aceunavailable for body use

4leural, 'eritoneal, 'ericardial, Eoint

cavity, interstitial s'ace, tissue <edema=,

+hirds'ace uid loss cannot be measured

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#linical 5anifestation

of +hirds'acingscites – >13 L or more larger amts.

cute 'eritonitis "% L in 2" hrs.

4ancreatitis %13 LFurns uid loss in 1st "*2 hrs.

4leural eusion

#rushing inEuries

Floc!age of lym'hatic system

@y'oalbuminemia osmotic 'ull of 'lasma

'roteins

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#auses of +hird ;'acing

InEury or inammation caused by trauma

5alnutrition lo( 'rotein albumin instarvation

Liver dysfunction – #irrhosis

@igh vascular hydrostatic 'ressure – fromheart failure, -;/D, vascular . overload

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#linical 5anifestation of luid olume DeNcit <D=

+achycardia, hy'otension r?t reduced bloodvolume

Decreased urine volue ! "0 #

4ostural hy'otension

Lo( central venous 'ressure

4oor s!in turgor and tongue turgor

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Dehydration #once't

Isotonic dehydration0 involves e7ual lossesof all uid com'onents

@y'otonic dehydration0 involves greaterlosses of electrolytes

Decreases osmolality, -# decreases

@y'ertonic dehydration0 involves greaterlosses of -# volume that electrolytes

Increases osmolality

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ssessing Dehydration

+hirst, or e&cessive thirst9rine concentration, dar!, lo( urine volume

;'eciNc gravity 1.33

Dry s!in, dry mucous membranes

Decrease turgor ) s!in elasticity

;un!en eyes, sun!en fontaneles A 1 mo.

@y'otension, 'ostural hy'otension

6ea!ness, lightheadedness, synco'e

cute (eight loss

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Diagnostic Lab alues

@emoconcentration – 'lasma is moreconcentrated than normal

-levated @ct, F9:, ;odium, Glucose-levated s'eciNc gravity

-levated osmolality < 33 mOsm?Hg=

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/is! actorsge0 Infants and -lderly

Gender and body fat

Obesity <fat holds less (ater than muscle=

cute illness0 gastroenteritis <n?v=, burns,sto!es, ;ID@ – causing diabetes insi'idus

;urgery resulting in uid or blood loss

:G suctioning Large (ound drainageLiver disease, renal disease, D5

5edications and e&cess alcohol consum'tion

@eat e&'osure, malnutrition

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:ursing Diagnoses

luid volume deNcit?e&cess r?t e&cessive uidloss or decrease uid inta!e

/is! for deNcient uid volume r?t :?

/is! for hy'ovolemic shoc! r?t uid loss

/is! for inEury r?t altered sensorium?ordi88iness

/is! for im'aired s!in integrity r?t s!in andmucous membrane dryness

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::D :ursing Diagnoses

luid ) -lectrolyte Imbalances as evidenceof0 <etiology=

Impaired Oral Mucous Membrane

Impaired Skin Integrity

Decreased Cardiac Output

Activity Intolerance

Risk for Injury

Acute Confusion

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:ursing Interventions

5onitor ;, ) mucous membranes

5onitor lung sounds

5onitor mental status

5onitor I)Os and I uids

5onitor urine status

Oral or 'arenteral re'lacement of uids5onitor I uids <'revent overload=

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-lectrolytes

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/egulating -lectrolytes

;odium :a

4otassium H

#alcium #a

5agnesium 5g

#hloride #l

4hos'hate 4O"Ficarbonate @#O

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Sodiu $Na%&

1>1"> m-7?L @y'er?@y'onatremia

5ost abundant electrolyte in -#

#ontributes to serum osmolality –has a 'rofound eect on cellulardehydration

/easorbed or e&creted by !idneys

4ulls chloride and (ater along (ith

it

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/is! actors0 ;odiumImbalance

Infants0 immature !idneys u' to age 2Lose more uid via s!in for their si8e than

adults

@igh F5/, 'roduce more heat, re7. more (ater

-lderly0 have less (ater com'osition

Less muscle mass ) more fat com'osition

Hidneys function decreases, cannotcom'ensate imbalances or e&crete heavysolute loads <tube feedings=

Diminished thirst, 'ancreatic function ) glucose

tolerance

di b l i

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ssess ;odium Imbalance in0

GI, 4osto', cancer, (ounds – uid loss, n?v,diarrhea, :G suction

Furns – loss of ) electrolytes thru tissuedamage

Frain trauma – #, tumors, cerebral edema,altered D@ regulation

Liver disease – altered serum albumin

/enal disease – decrease out'ut, altered . )electrolytes

D5 – osmotic changes in hy'erhy'oglycemia

'otassiu $(%&

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'otassiu $(%&

;erum0 .> – >.3 m-7?L @'er?@y'o!alemia

I#0 12>1"3 m-7?L

5aEor intracellular uid cation

ital for muscular ) cardiac function

ids in maintaining acidbase balance

Daily inEestion needed

oods0 fruits, vegetables, meats, Nsh andsalt substitutes

4 i I b l

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ssess 4otassium Imbalancein09se of 'otassium(asting diuretics

-&cessive GI loss

;tarvation, bulimia

@y'erglycemia Diabetes insi'idus, #ushing$ssyndrome

Increase aldosterone0 heart failure,

hy'ertensive crisis, cirrhosis, renal disease

@eatinduced dia'horesis

+

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+reatment0

4otassium re'lacement in hy'o!alemia5edication0

5onitor labs

5onitor .;, cardiac status <teley or monitor=

I infusion0 HJ is a vesicant causes 'hlebitis) tissue necrosis <avoid I4 or I5=

4.O. – never crush or brea! tab?ca'sules,adm. after meals to 'revent GI u'set

void salt substitutes

)lac* )o+,arning

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#auses of @y'er!alemia

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#auses of @y'er!alemia

Flood transfusionsDrugs

Fetabloc!ers, H s'aring diuretics, :;ID$s,minoglycosides, #hemothera'y

Increased dietary inta!e (ith decreased urineout'ut

-&cessive salt substitute or H su''lements

cute or chronic renal failure, DiabetesFurns, severe infections, trauma, crush

inEuries

5etabolic acidosis, Insulin deNciency

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;?;& of @y'er!alemia

:euromuscular alerts

5uscle (ea!ness in lo(er e&tremities

laccid 'aralysis

5uscle hy'eractivity or Irritability,

Cardiac Alerts

↓ HR, B, cardiac output, arrhythmias, cardiac arrest

GI 4roblems:ausea, e&'losive diarrhea, abdominal

cram'ing

G9 4roblems0 oliguria, anuria

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ssessent o3 Diagnostic Tests

;erum H greater then > m-7?L

Decreased arterial '@, <indicating acidosis=

-#G abnormalities0 rrhythmias

!C" chan#es$

+all, tented + (ave

lattened 4 (ave

4rolonged 4/ interval

6idened P/; com'le&

De'ressed ;+ segment

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TreatentIn 5ild cases

Loo' diuretics /estricted dietary H

In 5oderate to ;evere cases

cute sym'tomatic cases need hemodialysis

Haye&alate (ith sorbitol results in loose F5$s

-mergency measures

5onitor -#Gs +reat acidosis

9se I regular insulin thera'y

dminister I$s

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Nursing ctions

ssess vital signsntici'ate cardiac monitoring

5onitor I ) O re'ort out'ut A 3 mL?hr

dm. a slo( I infusion of #alciumGluconate

ssess for clinical signs of hy'oglycemia

5uscle (ea!ness

;ynco'e

@unger

Dia horesis

alciu $a%&

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alciu $a%&

;erum0 .> – 13.> mg?dL

hy'er?@y'ocalcemia

BBC body #aJ stored in s!eletal system

-ssential for muscle contraction, nerveim'ulse conduction, bone ) teeth rigidity,lactation, clotting regulation in converting'rothrombin to thrombin

/egulated by 4+@ vs. #alcitonin hormone

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/is! actors0 #alciumImbalance

DeNciencies in it. D

@igh inta!e of 'hos'horus, 'roteins

#alcium interferes (ith iron absor'tion

/a'id massive infusions of bloodtransfusions

#itrate to&icity leading to hy'ocalcemia

lcoholism

ssess #alcium Imbalance in0

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ssess #alcium Imbalance in0

:euromuscular irritability

+rousseau$s sign car'al s'asms ( F4 cuination

#hvoste!$s sign – facial nerve ta''ing causest(itching

4ostmeno'ausal (omen

Osteo'orosis, osteo'enia /ic!etts disease

4ost thyroidectomy, 'arathyroidectomy

#hron$s disease @y'othyroidism

Immobility0 clients in 'rolong bedrest

5 l i

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56pocalceia

InsuQcient inta!e or e&cessive loss

Occurs (ith malabsor'tion 'roblems

Total seru a 7 89 gd#Ionied seru a 7 4.gd#

#auses

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#auses

Drugs #is'latin,Gentamycin

Lo( albumin levels

l!alosisFreast eeding

4ancreaticinsuQciency

• ;evere burns,Infections

• lcoholics (ith'oor nutritionalinta!e

/enal alerts

Diuretics

-s'ecially loo'diuretics

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;igns and ;ym'toms

Fe alert for :eurological changesn&iety, #onfusion, Irritability

;ei8ures

+(itching, muscle cram's, tremors,tetany

@y'eractive dee' tendon ree&es

• Decreased cardiac out'ut and arrhythmias

Diarrhea

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Treatent

cute hy'ocalcemia re7uires I #a

5ag re'lacement may also be needed

#hronic hy'ocalcemia needs vitamin D

su''lementDietary changes

Diagnostic tests0 -#G, labs

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Nursing ctions

ssess for ris! of hy'ocalcemia

5onitor vital signs, res'iratory status

#ardiac monitor

#hec! #hvoste!Rs and +rousseau$s signs

ssess and monitor I line and I meds

5onitor labs

#lient teaching

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56poagneseia

GI and G9 systems regulate 5ag levels

5ust measure along (ith serum albumin

5ust also consider #a, H, 4O" levels and 4h

5ost common ris! factor ofhy'ermagnesemia is

/enal insuQcienc

7 1. /#

56peragneseia

2. /#

auses o3 56poagneseia

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auses o3 56poagneseia

4oor dietary inta!e of magnesium#hronic alcoholism

4rolonged I uids in clients on +4:

bsor'tion 'roblems5alabsor'tion syndromes, steatorrhea

9lcerative colitis, #rohn$s disease, Fo(el

resection4ancreatic insuQciency, cancer

GI 'roblems

4rolonged diarrhea, Nstulas, la&ative abuse,

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auses o3

56poagneseia9rinary 4roblems4rimary aldosteronism, hy'er'arathyroidism

Diabetic !etoacidosis

9se of am'hotericin F, cis'latin,aminoglycosides

Loo' or thia8ide diuretics

Other causes;e'sis

;erious burns

6ounds re7uiring debridement

;igns and ;ym'toms

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; g s a d ;y ' o s

#:;;ei8ures

ltered LO#

#onfusion

Delusions

De'ression

@allucinations

-motional lability

#ardiovascular +achycardia

@y'ertension

-#G changes

GI tract

nore&ia

:ausea

omiting

Dys'hagia

;igns and ;ym'toms

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;igns and ;ym'toms

:euromuscular system

+remors, t(itching, tetany

5uscle (ea!ness, leg and foot cram's

#hvoste!$s sign and +rousseau$s sign

@y'eractive dee' tendon ree&es

muscle (ea!ness (hich leads to0Laryngeal stridor /es'iratory

diQculties

4aresthesia

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Treatent

aries (ith cause and degree of severity9sually involves re'lacement thera'y

/eal im'ortant to read the label on the 5ag.

;ulfate vial as it comes in more than oneconcentration

oods0 suno(er seeds, legumes, dar! greenleafy vegetables, cocoa, seafood (hole grains

and nuts

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Nursing ctions

ssess mental status, neuromuscular status,and dys'hagia

-s'ecially chec! D+/$s, tremors, tetany,

#hvoste!$s – acial t(itching (hen the facialnerve is ta''ed

+rousseau$s signs #ar'al s'asm (hen the

u''er arm is com'ressed

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;eor6 <ogger; S sei8ures

+ S tetany

S anore&ia and arrhythmias

/ S ra'id heart rate

S vomiting

- S emotional lability

D S dee' tendon ree&es increased

=l id $l &

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=loride $l>&

@y'ochloremia0 A B> m-7?L@y'erchloremia0 13 m-7?L

-ssential for acidbase ) electrolyte balances

#lT imbalance occur (ith sodium imbalancects as a buer bet(een O2 ) #O2 e&change

9tili8ed in forming @#L acid in the stomach

oods0 table salt, eggs, mil!, cheese, dates,canned vegetables, crabs, Nsh, olives, rye,tur!ey

@y'ochloremia

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y'

#auses0

:a, H imbalances, metabolic al!alosis

Diabetic acidosis, ;ID@, #@

cute infections

5etabolic stress conditions0 burns, feversheat e&haustion

omiting, bulimia, diarrhea, ta' (ater enemas

+reatment

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+reatment

/e'lacement thera'y0 a''ro'riate foods, oralsalt tablets, or H#L tablets

I infusions of :a#l or H#L for criticalconditions

Dietary changes

Obtain FGs maintain acidbase balance

'anic value: 7 80 /#


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ssess for0 5uscle t(itching, tremors, ;lo(shallo( breathing, @y'otension, cardiacsym'toms, anore&ia

5onitor for uid imbalances0 -# loss,vomiting, 'ers'iration, diarrhea

Dietary teaching0 lo( sodium diet, revie(foods high in chloride

@y'erchloremia

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@y'erchloremia

#auses0

:a, H, #O2 imbalances, metabolic acidosis

InEections of drugs0 salicylates,corticosteriods, some diurectics

Dehydration states, endocrine disturbances

GI losses, renal changes

6atch for0 dee' ra'id breathing, (ea!ness,lethargy, stu'or, unconsciouness

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:ursing Intervention

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:ursing Intervention

5onitor acidbase, res'irations, cardiac status

5onitor ; and I)O

Increase uid inta!e, dietarychanges

5aintain ade7uate hydration

I sol. 3.">C :a#L or D>6 <act ashy'otonic=

#lient education0 avoid foods high in chloride,restrict 'rocessed foods

4hos'hate <4O"T=

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' < =

maEor com'onent of +4 in cellularmetabolism

:e(borns have t(ice the adult level

-ssential for /F#, :; and muscle function:eeded for bone and teeth formation

@el's regulate calcium and renal acidbase

/ole in metabolism of #@O, 4roteins, fats

oods0 organ meats, meat, Nsh, 'oultry,eggs, mil!, legumes, (hole grains, nuts

@y'o'hos'hatemia

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@y'o'hos'hatemia7 2. ? 4. gd# or7 1@ to 2A /#

#auses

dm. Of glucose, insulin and +4: can shift

4O" into cells from -#

Decreased intestinal absor'tion from it. DdeNciency, malabsor'tion, starvation

4hos'hate binders, antacids <mag.,aluminum=

DH, alcoholism, severe burns, res'.

al!alosis

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ssess for0

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Levels A 2.3nemia, bruising, bleeding

;lurred s'eech, confusion, sei8ures, coma

5uscle (ea!ness, tremors, tetany

#hest 'ain, dysrhythmias r?t decreased O2,

hy'o&emia

Decreased GI functions0 gastric atony, ileus6ill lead to acidbase imbalance, cardiac

arrest

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:ursing 5anagement

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:ursing history4hysical assessment

#linical measurement

/evie( of laboratory test results

-valuation of edema

:ursing diagnosis

4lanning

Im'lementation ) -valuation


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g g

Fluid olume De!cient Fluid olume "#cess

Risk for Imbalanced Fluid olume

Risk for De!cient Fluid volume

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luid ) -lectrolyte Imbalances as evidence of0<etiology=


Impaired Skin Integrity Decreased Cardiac Output


Risk for Injury Acute Confusion

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Desired Outcomes

5aintain or restore normal uid balance5aintain or restore normal balance of

electrolytes

4revent associated ris!s +issue brea!do(n, decreased cardiac

out'ut, confusion, other neurologic signs

4 i G id li f

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4ractice Guidelines foracilitating luid Inta!e

-&'lain reason for re7uired inta!e ) amt.needed

-stablish 2" hour 'lan for ingesting uids

Identify uids client li!es and use those

@el' clients select foods that becomeli7uid at room tem'erature

;u''ly cu's, glasses, stra(s;erve uids at 'ro'er tem'erature

-ncourage 'artici'ation in recording inta!e

Fe alert to cultural im'lications

i id li

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4ractice Guidelines

/estricting luid Inta!e-&'lain reason and amount of restriction

@el' client establish ingestion schedule

Identify 'references and obtain

;et short term goals 'lace uids in smallcontainers

Oer ice chi's and mouth care

+each avoidance of ingesting che(y, salty,s(eet foods or uids

-ncoura e artici ation in recordin inta!e

-valuation of -dema

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-valuation of -dema


4al'ate for edema overthe tibia, behind themedial malleolus, and overthe dorsum of each foot

our'oint scale forgrading edema.


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5onitoring

luid inta!e and out'ut

#ardiovascular and res'iratory status

/esults of laboratory tests

ssessing

#lient$s (eight

Location and e&tent of edema, if 'resent

;!in turgor and s!in status

;'eciNc gravity of urine

Level of consciousness, and mental status

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luid inta!e modiNcationsDietary changes, dietary consult

4arenteral uid, electrolyte, and blood

re'lacementOther a''ro'riate measures such as0

dministering /U medications and

o&ygen4roviding s!in care and oral hygiene

4ositioning the client a''ro'riately

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4romoting luid and

-lectrolyteFalance#onsume % glasses (ater daily

void foods (ith e&cess salt, sugar, caeine

-at (ellbalanced diet

Limit alcohol inta!e

Increase uid inta!e before, during, after

strenuous e&ercise/e'lace lost electrolytes

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4romoting luid and

-lectrolyte Falance5aintain normal body (eight

Learn about, monitor, manage side eectsof medications

/ecogni8e ris! factors

;ee! 'rofessional health care for notablesigns of uid imbalances

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+eaching #lient to 5aintainluid and -lectrolyte Falance

4romoting ) monitor uid and electrolytebalance

5aintaining food and uid inta!e4romote ;afety

5edications

5easures s'eciNc to client$s 'roblems/eferrals

#ommunity agencies and other sources of

hel'

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#orrecting Imbalances

Oral re'lacementIf client is not vomiting or e&'eriencing

e&cessive uid loss

If GI tract is intactIf gag ) s(allo( ree&es are intact

luid restrictions may be necessary for

uid retentionary from :4O to 'recise amt. ordered

Dietary changes

Oral ;u''lements

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''

4otassium <H#L=

#alcium

5ultivitamins

;'orts drin!

4arenteral uid and electrolytere'lacement interventions are re7uiredif oral su''lements cannot be ingested

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P ti 1

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Puestion 1

n elderly nursing home resident hasrefused to eat or drin! for several daysand is admitted to the hos'ital. +henurse should assess for (hich of the

follo(ingV

1. Increased blood 'ressure

2. 6ea!, ra'id 'ulse. 5oist mucous membranes

". Wugular vein distention

/ationales 1

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/ationales 1

1. Increased blood 'ressure indicates uidvolume e&cess.

2 orrect client that has not eaten ordran! anything for several days (ould be

e&'eriencing uid volume deNcit.. 5oist mucous membranes indicates uid

volume e&cess.

". Wugular vein distention <WD= indicatesuid volume e&cess.

/esearch ) 4resent

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/esearch ) 4resent1. @y'er!alemia vs. @y'o!alemia

2. @y'ernatremia vs. @y'onatremia

. @y'ercalcemia vs. @y'ocalcemia

". @y'er'hosh'atemia vs. @y'o'hos'hatemia

>. @y'ermagnesemia vs. @y'omagnesemia

%. @y'erchloremia vs. @y'ochloremia

*. 5etabolic al!alosis. 5etabolic acidosis

>2

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#ha'ter >2

cidFaseFalance

/egulation cid Fase

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/egulation cidFase'@ Falance


5uanBlood@4

Fuers

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Fuers

/es'iratory system

/enal system04revent e&cessive

changes in '@

5aEor buer in -# is@#O and @2#O

Other buers include0

4lasma 'roteins

#o'yright 2312 by 4earson-ducation, Inc.

Fody uids are maintained bet(een '@ of

*.> and *."> by0

Lungs

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Lungs/egulate acidbase balance by eliminating or

retaining carbon dio&ide

Does this by altering rate?de'th ofres'irations

aster rate?more de'th S get rid ofmore #O2 and '@ rises

;lo(er rate?less de'th S retain#O2 and '@ lo(ers

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actors ecting Fody luid,

-lectrolyte, and cidFaseFalancege

Gender

Fody si8e

-nvironmental tem'erature

Lifestyle

#hronic diseases

cute conditions

5edications +reatments

-&tremes of age

Inability to accessfood and uids

/is! actors for -lectrolyte and

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/is! actors for -lectrolyte andcidFase Imbalances

#hronic diseases

#ancer

#D, #@, #D-ndocrine disorders <#ushing$s ) D5=

5alnutrition

4ulmonary disease

/enal disease


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cidFase Imbalances +rauma

#rush inEuries @ead inEuries

Furns

Drug +hera'y

Diuretics

;teriodsldactone, aldosterone inhibiting

agents

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cidFase ImbalancesGastroenteritis

:asogastric suctioning

istulas

I +hera'y +4:

cidFase Imbalances

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/es'iratory acidosis

/es'iratory al!alosis

5etabolic acidosis5etabolic al!alosis

i i

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:ursing @istory#urrent history ) 'ast medical history

Diabetes mellitus

#hronic lung diseases

5edications

unctional ) socioeconomic factors

Develo'mental factors

luid and :utritional inta!e

luid out'ut

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:ursing @istory0

#hronic Diseases;espiratory: %O'<= "sthma= %ystic 3irosis

>eart failure

Ki#ney #iseases%ushing?s syn#rome= "##ison?s #isease

%ancer

@alnutrition= "noreia ner*osa= ulimia

leostomy

:ursing @istory0

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:ursing @istory0cute #onditions

"cute gastroenteritis

owel ostruction

>ea# in,ury or #ecrease# LO%

rauma: urns= crushing in,uries

+urgery

3e*er= #raining woun#s= fistulas

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:ursing @istory0 +reatments%hemotherapy

A therapy an# '

asogastric suction

Bnteral fee#ings

@echanical *entilation

@e#s: <iuretic= "ntihypertensi*e therapy=

%orticosteroi#s= +"< #rugs

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4hysical ssessment0 ;HI:

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#olor, tem', moist, turgor, edema

lushed, 'ale

6arm, very dry or cool, dia'horectic

4oor turgor0 remains tented several seconds.-yes0 'eriorbital edema <'uy=,

-dema0 rings are tight, shoes Nt tight or eaveim'ressions on feet

ontanels in infants0 sun!en, soft vs. Fulging,Nrm

#om'ress ) ins'ect s!in over dorsal foot,

4h sical ssessment

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4hysical ssessment0

Oral #avity5a!e a visual ins'ection

5ucous membranes dry, dull in

a''earance +ongue dry (ith crac!s

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4hysical ssessment0

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4hysical ssessment0:eurological ;ystem

:euro0 LO#, lethargy, stu'or or coma

/es'onse to stimuli

Disoriented, confused, diQculty concentrating

5otor function0 (ea!ness, decreased motorstregth

Dee' tendon /ee& <D+4= – hy'eractive or

de'ressed

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4hysical ssessment0

:eurological ;ystem#hvoste!$s sign

ta' over facial nerve

Observe t(itching of facial muscles

#alcium de'letion

+rousseau$s sign

#ar'al s'asm ocurring during ination of F4

cu

hy'oclacemia

4hysical ssessment0

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4hysical ssessment0

LF results

+erum electrolytes%omplete loo# count hematocrit= &C5C

+erum osmolality: a= glucose= -

-rine p> 5&&$&& mOsm/4g.

• -rine p>: ormal p>: D.&

-rine specific gra*ity n#icates urine concentration

8.&8& 8.&25

4hysical ssessment0

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4hysical ssessment0FGs

B*aluates aci#ase 0 oygenation.

p>: 7.95 7.5 aci#ic or al4alosis

'aO2: $&8& mm>g

'a%O2: 955 mm>g

>%O9: 222D mBE/L

ase ecess: 2 to F2 mBE/LO2 saturation(+pO2): !5C to !$C

/es'iratory cidosis0@y'erca'nia

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@y'erca'nia

state of e&cessive carbon dio&ide in thebody.

p5 A *.>

'aO20 "> mm@g <e&cess #O2 ) carbonicacid=

5O"0 normal, 2% m-7?L (ith renal

com'ensation

/es'iratory l!alosis

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state of e&cessive loss of carbon dio&ide inthe body.

p5 *.">

'aO20 A > mm@g <inade7uate #O2 )carbonic acid=

5O"0 normal, A 22 m-7?L (ith renal

com'ensation

5etabolic cidosis

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condition characteri8ed by a deNciency ofbicarbonate ions in the body in relation to theamt. of carbonic acid in the body

p5 A *.>

'aO20 normal, A > mm@g (ith res'iratorycom'ensation

5O": A 22 m-7?L <inade7uate

bicarbonate=

5etabolic l!alosis

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condition characteri8ed by an e&cess ofbicarbonate ions in the body in relation to theamt. of carbonic acid in the body

p5 *.">

'aO20 normal, "> mm@g (ith res'iratory

com'ensation

5O": 2% m-7?L <e&cess bicarbonate=

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6hen naly8ing FGs

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6hen naly8ing FGs@#O Ficarbonate0

If A 22 m-7?L, bicarbonatelevels are lo(er than normal,indicting acidosis.

If A 2% m-7?L, bicarbonatelevels are higher than normal,indicating al!alosis.

Determine he cause of the acidbaseimbalance <loo! at '@=

Determine if the origin of the imbalance is

6hen naly8ing FGs

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Loo! for evidence of com'ensation.Loo! at the value that does notmatch the '@.

If 4a#O2 or @#O is (ithin normal range, there is nocom'ensation.

If 4a#O2 or @#O is above or belo( normal range,the body is com'ensation..

::D :ursing Diagnosis

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De!cient or "#cess Fluid olume

Risk for Imbalanced of De!cient Fluidolume

Impaired $as "#c%ange


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::D :ursing Diagnosisluid and cidbase Imbalances as

evidence of0 <etiology=


Impaired Skin Integrity

Decreased Cardiac Output

Ine&ective 'issue (erfusion


Risk for Injury

Acute Confusion

4lanning

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g

5aintain or restore normal uid balance5aintain or restore normal electrolyte balance

intracellular ) e&tracellular com'artments.

5aintain ) restore 'ulmonary ventilation )o&ygenation.

4revent associated ris!s0 tissue brea!do(n,decreased cardiac out'ut, confusion, other

neurological signs.

-lectrolyte /e'lacement

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-lectrolyte /e'lacement

5odify uids0 Y'ushZ

#hange diet to meet electrolyte demands

Oral electrolyte su''lements

4arenteral luid administration

NUR108_2014_student(1).pptx_1

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