Fluids And Electrolytes Backup


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Fluids And Electrolytes Backup

  1. 1. Fluids and Electrolytes
  2. 6. <ul><li>Help maintain body temperature and cell shape </li></ul><ul><li>Help transport nutrients, gasses and wastes </li></ul>Fluids
  3. 7. Fluid <ul><li>Is used to indicate that other substances are also found in these compartments and that they influence the water balance in and between compartments. </li></ul>
  4. 8. Fluids <ul><li>60% of an adult’s body weight * 70 Kg adult male: 60% X 70= 42 Liters </li></ul><ul><li>Infants = more water </li></ul><ul><li>Elderly = less water </li></ul><ul><li>More fat = ↓water </li></ul><ul><li>More muscle = ↑water </li></ul><ul><li>Infants and elderly - prone to fluid imbalance </li></ul>
  5. 9. <ul><li> 60 % </li></ul>Intracellular Fluid 40% or 2/3 Intravascular 5% or 1/4 Transcellular fluid 1-2% ie csf, pericardial, synovial, intraocular, sweat Arterial Fluid 2% Extracellular Fluid 20% or 1/3 Interstitial 15% or 3/4 Venous Fluid 3% Total Body Water
  6. 10. Third-space fluid shift/Third “spacing” <ul><li>- loss of ECF into a space that does not contribute to equilibrium between ICF and ECF </li></ul><ul><li> ie ascites, burns, peritonitis, bowel obstruction, massive bleeding </li></ul>
  7. 11. Fluid Movement From Pressure Changes <ul><li>fluids from different compartments move from one compartment to the other to maintain fluid balance. </li></ul><ul><li>movement is dictated by the transport mechanism principle : A. PASSIVE B. ACTIVE TRANSPORT </li></ul>
  8. 12. A. Passive Transport Process – substances transported across the membrane w/o energy input from the cell - high to low concentration
  9. 13. 2 Types of Passive Transport <ul><li>1. Diffusion – substances/solutes move from high concentration to low concentration ie exchange of O2 and CO2 b/w pulmonary capillaries and alveoli </li></ul>
  10. 14. <ul><li>2. Filtration – water and solutes forced through membrane by fluid or hydrostatic pressure from intravascular to interstitial area </li></ul><ul><li>- solute containing fluid (filtrate) from higher pressure to lower pressure </li></ul>
  11. 15. B. Active Transport Process <ul><li>Cell moves substances across a membrane through ATP because: </li></ul><ul><li>They may be too large </li></ul><ul><li>Unable to dissolve in the fat core </li></ul><ul><li>Move uphill against their concentration gradient </li></ul>
  12. 16. Types of Active Transport <ul><li>1. Active transport – requires protein carriers using ATP to energize it </li></ul><ul><li>ie Amino acids Sodium potassium pump – 3Na out, 2K in </li></ul><ul><li>2. Endocytosis – moves substances into the cell </li></ul><ul><li>3. Exocytosis – moves substances out of the cell </li></ul>
  13. 17. Active Transport
  14. 18. <ul><li>Osmosis </li></ul><ul><li>Movement of water from low solute to high solute concentration in order to maintain balance between compartments. </li></ul><ul><li>Osmotic pressure – amount of hydrostatic pressure needed to stop the flow of water by osmosis </li></ul><ul><li>Oncotic pressure – osmotic pressure exerted by proteins </li></ul>
  15. 19. Osmosis
  16. 20. Osmosis Diffusion
  17. 21. Regulation of Body Fluid <ul><li>1. The Kidney </li></ul><ul><li>Regulates primarily fluid output by urine formation 1.5L </li></ul><ul><li>Releases RENIN </li></ul><ul><li>Regulates sodium and water balance </li></ul>
  18. 22. <ul><li>2. Endocrine regulation </li></ul><ul><li>thirst mechanism – thirst center in hypothalamus </li></ul><ul><li>ADH  increase water reabsorption on collecting duct </li></ul><ul><li>Aldosterone  increases Sodium and water retention retention in the distal nephron </li></ul><ul><li>ANP  Promotes Sodium excretion and inhibits thirst mechanism </li></ul>
  19. 23. Atrial Natriuretic Peptide: Regulates Na+ & H2O Excretion
  20. 24. ADH Regulation <ul><li>ADH - produced by the Hypothalamus </li></ul><ul><li>- stored and secreted by the posterior pituitary gland </li></ul><ul><li>less water in plasma, ADH secreted to conserve water by reducing urine output </li></ul><ul><li>fluid overload in plasma, ADH secretion stops to excrete fluid in the kidneys by increasing urine output </li></ul>
  21. 25. ADH Disorder <ul><li>Abnormally high ADH concentration - SIADH reduced urine output (oliguria) water retention (fluid overload) </li></ul><ul><li>Abnormally low ADH – Diabetes Insipidus increased urine output (polyuria) water loss (fluid deficit) </li></ul>
  22. 26. <ul><li>3. Gastro-intestinal regulation </li></ul><ul><li>- GIT digests food and absorbs water </li></ul><ul><li> - Only about 200 ml of water is excreted in the fecal material per day </li></ul><ul><li>4. Heart and Blood Vessel Functions - pumping action of heart circulates blood through kidneys </li></ul><ul><li>5. Lungs – insensible water loss through respiration </li></ul>
  23. 27. Other Mechanisms <ul><li>1. Baroreceptors – carotid sinus and aortic arch - causes vasoconstriction and increased blood pressure </li></ul><ul><li>Dec arterial pressure SNS inc cardiac rate, contraction, contractility, circulating blood volume, constriction of renal arterioles and increased aldosterone </li></ul>
  24. 28. <ul><li>2. Osmoreceptors – surface of hypothalamus senses changes in Na concentration </li></ul><ul><li>Inc osmotic pressure neurons dehydrated release ADH </li></ul>
  25. 30. Evaluation of fluid status <ul><li>Osmolality – concentration of fluid that affects movement of water between fluid compartments by osmosis </li></ul><ul><li>- measures the solute concentration per kg in blood and urine </li></ul><ul><li>- reported as mOsm/kg - normal value= 280-300 mOsm/kg </li></ul><ul><li>Osmolarity – concentration of solutions </li></ul><ul><li>- mOsm/L </li></ul>
  26. 31. Intake and Output <ul><li>I and O must be equal </li></ul><ul><li>2.6 L per day </li></ul><ul><li>Essential = Measurable = Sensible </li></ul><ul><li>Non essential = estimated Measurement= Insensible </li></ul>
  27. 32. Sources of Fluids Fluid Intake <ul><li>1. Exogenous sources </li></ul><ul><li>Fluid intake </li></ul><ul><li>oral liquids – 1, 300 ml </li></ul><ul><li>water in food – 1, 000 ml </li></ul><ul><li>water produced by metabolism – 300 ml </li></ul><ul><li>IVF </li></ul><ul><li>Medications </li></ul><ul><li>Blood products </li></ul><ul><li>2. Endogenous sources </li></ul><ul><li>By products of metabolism </li></ul><ul><li>secretions </li></ul>2, 600 ml
  28. 33. Fluid Output <ul><li>Sensible loss </li></ul><ul><li>Urine - 1, 500 ml </li></ul><ul><li>Fecal losses – 200 ml </li></ul><ul><li>Insensible loss </li></ul><ul><li>skin – 600 ml </li></ul><ul><li>Lungs – 300 ml </li></ul>2, 600 ml
  29. 34. I&O Imbalance <ul><li>Fluid Volume Deficit </li></ul><ul><li> output, normal intake </li></ul><ul><li>Normal output,  intake </li></ul><ul><li>No intake or prolonged decreased intake </li></ul>
  30. 35. Causes of FVD <ul><li>Vomiting, diarrhea, GI suctioning, sweating </li></ul><ul><li>Diabetes Insipidus </li></ul><ul><li>Adrenal insufficiency </li></ul><ul><li>Osmotic diuresis </li></ul><ul><li>Hemorrhage </li></ul><ul><li>3 rd space fluid shift </li></ul>
  31. 36. Assessment of FVD <ul><li>ICF cellular dehydration Acidosis </li></ul><ul><li>ITF skin poor skin turgor </li></ul><ul><li>IVF artery ↓BP, pulse (rapid thready) vein ↓CVP, ↓PAWP </li></ul>
  32. 37. Clinical manifestations <ul><li>Weight loss </li></ul><ul><li>Oliguria </li></ul><ul><li>Concentrated urine </li></ul><ul><li>Postural hypotension </li></ul><ul><li>Flattened neck veins </li></ul><ul><li>Increased Temp </li></ul><ul><li>Dec CVP </li></ul><ul><li>Thirst, anorexia </li></ul><ul><li>Muscle weakness and cramps </li></ul>
  33. 38. Laboratory <ul><li>BUN:Crea > 20:1 </li></ul><ul><li>Inc Hct – RBC suspended in Dec plasma volume </li></ul><ul><li>Dec K – GI and renal losses </li></ul><ul><li>Inc K – adrenal insufficiency </li></ul><ul><li>Dec Na – inc thirst and ADH </li></ul><ul><li>Inc Na – insensible losses and DI </li></ul>
  34. 39. Medical Management <ul><li>Oral intake when mild </li></ul><ul><li>IV route, acute or severe </li></ul><ul><li>Isotonic fluids ie LR for hypotensive patients to expand plasma volume </li></ul><ul><li>Assess I and O, weight, CVP, LOC, breath sounds and skin color </li></ul><ul><li>Fluid challenge test – 100-200 ml x 15 min </li></ul>
  35. 40. Nursing Management <ul><li>Monitor and measure I and O </li></ul><ul><li>Monitor VS closely </li></ul><ul><li>Monitor skin turgor and tongue furrows </li></ul><ul><li>Monitor urinary concentration </li></ul><ul><li>Monitor mental function </li></ul>
  36. 41. Fluid Volume Excess <ul><li> intake, normal output </li></ul><ul><li>Normal intake,  output </li></ul><ul><li>No output </li></ul>
  37. 42. Nursing Management <ul><li>Measure intake and output </li></ul><ul><li>Weigh daily 2 lb wt gain = 1 L fluid </li></ul><ul><li>Assess breath sounds </li></ul><ul><li>Monitor degree of edema </li></ul><ul><li>ie ambulatory – feet and ankles bedridden – sacral area </li></ul><ul><li>Promote rest – favors diuresis/inc venous return </li></ul><ul><li>Administer appropriate medication </li></ul>
  38. 43. Causes of FVE <ul><li>Heart failure, renal failure, cirrhosis of the liver – d/t aldosterone stimulation/Congestion </li></ul><ul><li>Increased consumption of table salt </li></ul><ul><li>Excessive administration of Na containing fluids in a patient w/ impaired regulatory mechanism </li></ul><ul><li>SIADH </li></ul>
  39. 44. Assessment of FVE <ul><li>ICF cellular edema ↓LOC pulmonary edema crackles (bibasilar), wheezing, shortness of breath, Inc RR </li></ul><ul><li>ITF skin bipedal pitting edema, periorbital edema and ANASARCA </li></ul><ul><li>IVF </li></ul><ul><li>artery ↑BP, pulse (rapid bounding) vein ↑CVP, ↑PAWP </li></ul>
  40. 45. Clinical Manifestations <ul><li>Distended neck veins </li></ul><ul><li>Tachycardia </li></ul><ul><li>Inc weight </li></ul><ul><li>Increased urine output </li></ul><ul><li>Shortness of breath and wheezing/crackles </li></ul><ul><li>Inc CVP </li></ul>
  41. 46. Edema <ul><li>common manifestation of FVE </li></ul><ul><li>d/t inc capillary fluid pressure, decreased capillary oncotic pressure, increased interstitial oncotic pressure </li></ul><ul><li>Localized or generalized </li></ul><ul><li>Etiology: obstruction to lymph flow, plasma albumin level < 1.5-2 g/dl, burns and infection, Na retention in ECF, drugs </li></ul>
  42. 47. <ul><li>Labs: Dec Hct, respiratory alkalosis and hypoxemia, dec serum Na and osmolality, inc BUN Crea, Dec Urine SG, dec urine Na level </li></ul><ul><li>Mgmt: diuretics, fluid restriction, elevation of extremities, elastic compression stockings, paracentesis, dialysis </li></ul>
  43. 48. Laboratory <ul><li>Dec BUN </li></ul><ul><li>Dec Hct </li></ul><ul><li>CRF – serum osmolality and Na level dec </li></ul><ul><li>Cxr – pulmonary congestion </li></ul>
  44. 49. Medical Management <ul><li>Discontinue administration of Na solution </li></ul><ul><li>Diuretics </li></ul><ul><li>ie Thiazide – block Na reabsorption in distal tubule Loop diuretics – block Na reabsorption in ascending loop of Henle </li></ul><ul><li>Restrict fluid and salt intake </li></ul><ul><li>Dialysis </li></ul>
  45. 50. Types of Fluid <ul><li>Tonicity - ability of solutes to cause osmotic driving forces </li></ul>
  46. 51. Isotonic Fluid - no movement of fluid.
  47. 52. Isotonic Fluids <ul><li>0.9% NaCl/ Normal Saline/NSS -Na=154 -Cl=154 -308 mOsm/L - not desirable as routine maintenance solution - only solution administered with blood products </li></ul><ul><li>Rx: hpovolemia, shock, DKA, metabolic alkalosis, hypercalcemia, mild NA deficit </li></ul><ul><li>CI: caution in renal failure, heart failure and edema </li></ul>
  48. 53. <ul><li>D5W - 5% Dextrose in water - 170 cal and free water - 252 mOsm/L Rx: hypernatremia, fluid loss and dehydration CI: early post op when ADH inc d/t stress, sole treatment in FVD (dilutes plasma), head injury (inc ICP), flid resuscitation (hyperglycemia), caution in renal and cadiac dse (fluid overload), px with NA deficiency (peripheral circulatory collapse and anuria) </li></ul><ul><li>10% Dextran 40 in 5% Dextrose isotonic (252 mOsm/L) </li></ul>
  49. 54. <ul><li>Lactated Ringer’s Solution isotonic - Na 130 mEq/L - K 4 mEq/L -Ca 3 mEq/L - Cl 109 mEq/L - 273 mOsm/L Rx:hypovelemia, burns, flids lost as bile/diarrhea, acute blood loss CI: ph>7.5, lactic acidosis, renal failure(cause HyperK)   </li></ul>
  50. 55. Hypotonic Fluid - fluid will enter the cell, the cell will swell
  51. 56. Hypotonic Fluids <ul><li>0.45% NaCl (half strength saline) - provides Na, Cl and free water </li></ul><ul><li>- Na 77 mEq/L - Cl 77 mEq/L - 154 mOsm/L </li></ul><ul><li>Rx: hypertonic dehydration, Na and Cl depletion, gastric fluid loss </li></ul><ul><li>CI : 3 rd space fluid shifts and inc ICP </li></ul>
  52. 57. Hypertonic Fluid - fluid will go out from the cell, the cell will shrink
  53. 58. Hypertonic Fluids <ul><li>3% NaCl (hypertonic saline) - no calories - Na 513 mEq/L - Cl 513 mEq/L -1026 mOsm/L Rx: critical situations to treat HypoNa, assist in removing ICF excess CI: administered slowly and cautiously (IVF overload and pulmonary edema) </li></ul><ul><li>5% NaCl </li></ul>
  54. 59. <ul><li>D10W - 10% Dextrose in water hypertonic (505 mOsm/L) </li></ul><ul><li>D10W - 20% Dextrose in water hypertonic (1011 mOsm/L) </li></ul><ul><li>D50W - 50% Dextrose in water hypertonic (1700 mOsm/L) </li></ul><ul><li>D5NS - 5% Dextrose & 0.9NaCl hypertonic (559 mOsm/L) </li></ul><ul><li>D10NS - 10% Dextrose & 0.9NaCl hypertonic (812 mOsm/L) </li></ul><ul><li>D5LR - 5% Dextrose in Lactated Ringers hypertonic (524 mOsm/L </li></ul>
  55. 60. Colloid solutions <ul><li>Dextran 40 in NS or 5% D5W </li></ul><ul><li>- volume/plasma expander - decrease coagulation - remains for 6H in circulatory system Rx: hypovolemia in early shock, improve microcirculation (dec RBC aggregation) CI: hemorrhage, thrombocytopenia, renal disease and severe dehydration </li></ul>
  57. 62. ELECTROLYTES <ul><li>elements or compounds when dissolved in water will dissociate into ions and are able to conduct an electric current. </li></ul><ul><li>FUNCTIONS: </li></ul><ul><li>1. Regulate fluid balance and osmolality </li></ul><ul><li>2. Transmission of nerve impulse </li></ul><ul><li>3. Stimulation of muscle activity </li></ul>
  58. 63. <ul><li>ANIONS - negatively charged ions: Bicarbonate, chloride, PO4-, CHON </li></ul><ul><li>CATIONS - positively charged ions: Sodium, Potassium, magnesium, calcium </li></ul>
  59. 64. Regulation of Electrolyte Balance <ul><li>1. Renal regulation </li></ul><ul><li>Occurs by the process of glomerular filtration, tubular reabsorption and tubular secretion </li></ul><ul><li>Urine formation </li></ul><ul><ul><li>If there is little water in the body, it is conserved </li></ul></ul><ul><ul><li>If there is water excess, it will be eliminated </li></ul></ul>
  60. 65. <ul><li>2. Endocrinal regulation </li></ul><ul><li>Aldosterone  promotes Sodium retention and Potassium excretion </li></ul><ul><li>ANP  promotes Sodium excretion </li></ul><ul><li>Parathormone  increased bone resorption of Ca, inc Ca reabsorption from renal tubule or GI tract </li></ul><ul><li>Calcitonin  oppose PTH </li></ul><ul><li>Insulin and Epinephrine – promotes uptake of Potassium by cells </li></ul>
  61. 66. The Cations <ul><li>SODIUM </li></ul><ul><li>POTASSIUM </li></ul><ul><li>CALCIUM </li></ul><ul><li>MAGNESIUM </li></ul>
  62. 67. SODIUM (Na) <ul><li>MOST ABUNDANT cation in the ECF </li></ul><ul><li>135-145 mEq/L </li></ul><ul><li>Aldosterone  increases sodium reabsorption </li></ul><ul><li>ANP  increases sodium excretion </li></ul><ul><li>Cl accompanies Na </li></ul><ul><li>FUNCTIONS: </li></ul><ul><li>1. assists in nerve transmission and muscle contraction </li></ul><ul><li>2. Major determinant of ECF osmolality </li></ul><ul><li>3. Primary regulator of ECF volume </li></ul>
  63. 68. a. HYPERNATREMIA <ul><li>Na > 145 mEq/L </li></ul><ul><li>Assoc w/ water loss or sodium gain </li></ul><ul><li>Etiology: inadequate water intake , excessive salt ingestion / hypertonic feedings w/o water supplements, near drowning in sea water, diuretics, Diabetes mellitus/ Diabetes Insipidus </li></ul>
  64. 69. <ul><li>S/SX: polyuria, anorexia, nausea, vomiting, thirst, dry and swollen tongue, fever, dry and flushed skin, restlessness, agitation, seizures, coma, muscle weakness, crackles, dyspnea, cardiac manifestations dependent on type of hypernatremia </li></ul><ul><li>Dx: inc serum sodium and Cl level, inc serum osmolality, inc urine sp.gravity, inc urine osmolality </li></ul>
  65. 70. <ul><li>Mgmt: sodium restriction, water restriction, diuretics, isotonic non saline soln. (D5W) or hypotonic soln, Desmopressin Acetate for Diabetes Insipidus </li></ul><ul><li>Nsg considerations </li></ul><ul><li>History – diet, medication </li></ul><ul><li>Monitor VS, LOC, I and O, weight, lung sounds </li></ul><ul><li>Monitor Na levels </li></ul><ul><li>Oral care </li></ul><ul><li>initiate gastric feedings slowly </li></ul><ul><li>Seizure precaution </li></ul>
  66. 71. b. HYPONATREMIA <ul><li>Na < 135 mEq/L </li></ul><ul><li>Etiology: diuretics , excessive sweating, vomiting, diarrhea, SIADH, aldosterone deficiency, cardiac, renal, liver disease </li></ul>
  67. 72. <ul><li>Dx: dec serum and urine sodium and osmolality, dec Cl </li></ul><ul><li>s/sx: headache, apprehension , restlessness, altered LOC, seizures(<115meq/l),coma, poor skin turgor, dry mucosa, orthostatic hypotension, crackles, nausea, vomiting, abdominal cramping </li></ul>
  68. 73. <ul><li>Mgmt: sodium replacement, water restriction, isotonic soln for moderate hyponatremia, hypertonic saline soln for neurologic manifestations, diuretic for SIADH </li></ul><ul><li>Nsg. Consideration </li></ul><ul><li>Monitor I and O, LOC, VS, serum Na </li></ul><ul><li>Seizure precaution </li></ul><ul><li>diet </li></ul>
  69. 74. Hyponatremia Hypernatremia
  70. 75. Potassium (K) <ul><li>MOST ABUNDANT cation in the ICF </li></ul><ul><li>3.5-5.5 mEq/L </li></ul><ul><li>Major electrolyte maintaining ICF balance </li></ul><ul><li>maintains ICF Osmolality </li></ul><ul><li>Aldosterone promotes renal excretion of K+ </li></ul><ul><li>Mg accompanies K </li></ul><ul><li>FUNCTIONS: </li></ul><ul><li>1. nerve conduction and muscle contraction </li></ul><ul><li>2. metabolism of carbohydrates, fats and proteins </li></ul><ul><li>3. Fosters acid-base balance </li></ul>
  71. 76. a. HYPERKALEMIA <ul><li>K+ > 5.0 mEq/L </li></ul><ul><li>Etiology: IVF with K+, acidosis, hyper-alimentation and excess K+ replacement, decreased renal excretion, diuretics, Cancer </li></ul><ul><li>s/sx: nerve and muscle irritability , tachycardia, colic, diarrhea, ECG changes, ventricular dysrythmia and cardiac arrest, skeletal muscle weakness, paralysis </li></ul><ul><li>Dx: inc serum K level ECG: peaked T waves and wide QRS </li></ul><ul><li>ABGs – metabolic acidosis </li></ul>
  72. 77. <ul><li>Mgmt: K restriction (coffee, cocoa, tea, dried fruits, beans, whole grain breads, milk, eggs) </li></ul><ul><li>diuretics Polystyrene Sulfonate (Kayexalate) IV insulin </li></ul><ul><li>Beta 2 agonist IV Calcium gluconate – WOF Hypotension </li></ul><ul><li>IV NaHCo3 – alkalinize plasma </li></ul><ul><li>Dialysis </li></ul><ul><li>Nsg consideration: </li></ul><ul><li>Monitor VS, urine output, lung sounds, Crea, BUN monitor K levels and ECG </li></ul><ul><li>observe for muscle weakness and dysrythmia, paresthesia and GI symptoms </li></ul>
  73. 78. <ul><li>K+ < 3.5 mEq/L </li></ul><ul><li>Etiology: use of diuretic, corticosteroids and penicillin, vomiting and diarrhea, ileostomy, villous adenoma, alkalosis, hyperinsulinism, hyperaldosteronism </li></ul><ul><li>s/sx: anorexia, nausea, vomiting, decreased bowel motility, fatigue, muscle weakness, leg cramps, paresthesias, shallow respiration, shortness of breath, dysrhythmias and increased sensitivity to digitalis, hypotension, weak pulse, dilute urine, glucose intolerance </li></ul>b. HYPOKALEMIA
  74. 79. <ul><li>Dx: dec serum K level </li></ul><ul><li>ECG - flattened , depressed T waves, presence of “U” waves ABGs - metabolic alkalosis </li></ul><ul><li>Medical Mgmt : diet ( fruits, fruit juices, vegetables, fish, whole grains, nuts, milk, meats) oral or IV replacement </li></ul><ul><li>Nsg mgmt : monitor cardiac function, pulses, renal function monitor serum potassium concentration IV K diluted in saline </li></ul><ul><li>monitor IV sites for phlebitis </li></ul>
  75. 80. <ul><li> Normal ECG </li></ul><ul><li>Hypokalemia </li></ul><ul><li>Hyperkalemia </li></ul>
  76. 81. CALCIUM (Ca) <ul><li>Majority of calcium - bones and teeth </li></ul><ul><li>Normal serum range 8.5-10.5 mg/dL </li></ul><ul><li>Ca has an inverse relationship with PO4 </li></ul><ul><li>FUNCTIONS </li></ul><ul><li>1. formation and mineralization of bones/teeth </li></ul><ul><li>2. muscular contraction and relaxation </li></ul><ul><li>3. cardiac function </li></ul><ul><li>4. blood coagulation </li></ul><ul><li>5. Promotes absorption and utilization of Vit B12 </li></ul>
  77. 82. <ul><li>Regulation: </li></ul><ul><li>GIT  absorbs Ca+ in the intestine with the help of Vitamin D </li></ul><ul><li>Kidney  Ca+ is filtered in the glomerulus and reabsorbed in the tubules </li></ul><ul><li>PTH  increases Ca+ by bone resorption, inc intestinal and renal Ca+ reabsorption and activation of Vitamin D </li></ul><ul><li>Calcitonin  reduces bone resorption, increase Ca and Phosphorus deposition in bones and secretion in urine </li></ul>
  78. 83. a. HYPERCALCEMIA <ul><li>Serum calcium > 10.5 mg/dL </li></ul><ul><li>Etiology: Overuse of calcium supplements and antacids, excessive Vitamin A and D, malignancy, hyperparathyroidism, prolonged immobilization, thiazide diuretic </li></ul><ul><li>s/sx: anorexia, nausea, vomiting, polyuria, muscle weakness, fatigue, lethargy </li></ul><ul><li>Dx: inc serum Ca ECG: Shortened QT interval, ST segments </li></ul><ul><li>inc PTH levels </li></ul><ul><li>xrays - osteoporosis </li></ul>
  79. 84. <ul><li>Mgmt: 0.9% NaCl </li></ul><ul><li>IV Phosphate Diuretics – Furosemide </li></ul><ul><li>IM Calcitonin corticosteroids dietary restriction (cheese, ice cream, milk, yogurt, oatmeal, tofu) </li></ul><ul><li>Nsg Mgmt: Assess VS, apical pulses and ECG, bowel sounds, renal function, hydration status </li></ul><ul><li>safety precautions in unconscious patients </li></ul><ul><li>inc mobility </li></ul><ul><li>inc fluid intake </li></ul><ul><li>monitor cardiac rate and rhythm </li></ul>
  80. 85. b. HYPOCALCEMIA <ul><li>Calcium < 8.5 mg/dL </li></ul><ul><li>Etiology: removal of parathyroid gland during thyroid surgery, Vit. D and Mg deficiency, Furosemide, infusion of citrated blood, inflammation of pancreas, renal failure, thyroid CA, low albumin, alkalosis, alcohol abuse, osteoporosis (total body Ca deficit) </li></ul><ul><li>s/sx: Tetany, (+) Chovstek’s (+) Trousseaus’s, seizures, depression, impaired memory, confusion, delirium, hallucinations, hypotension, dysrythmia </li></ul>
  81. 86. <ul><li>Dx: dec Ca level </li></ul><ul><li>ECG: prolonged QT interval </li></ul><ul><li>Mgmt: </li></ul><ul><li>Calcium salts </li></ul><ul><li>Vit D </li></ul><ul><li>diet (milk, cheese, yogurt, green leafy vegetables) </li></ul><ul><li>Nsg mgmt </li></ul><ul><li>monitor cardiac status, bleeding </li></ul><ul><li>monitor IV sites for phlebitis </li></ul><ul><li>seizure precautions </li></ul><ul><li>reduce smoking </li></ul>
  82. 87. Magnesium Mg <ul><li>Second to K+ in the ICF </li></ul><ul><li>Normal range is 1.3-2.1 mEq/L </li></ul><ul><li>FUNCTIONS </li></ul><ul><li>1. intracellular production and utilization of ATP </li></ul><ul><li>2. protein and DNA synthesis </li></ul><ul><li>3. neuromuscular irritability </li></ul><ul><li>4, produce vasodilation of peripheral arteries </li></ul>
  83. 88. a. HYPERMAGNESEMIA <ul><li>M > 2.1 mEq/L </li></ul><ul><li>Etiology: use of Mg antacids, K sparing diuretics, Renal failure, Mg medications, DKA, adrenocortical insufficiency </li></ul><ul><li>s/sx: hypotension, nausea, vomiting, flushing, lethargy, difficulty speaking, drowsiness, dec LOC, coma, muscle weakness, paralysis, depressed tendon reflexes, oliguria, ↓RR </li></ul>
  84. 89. <ul><li>Mgmt: discontinue Mg supplements </li></ul><ul><li>Loop diuretics </li></ul><ul><li>IV Ca gluconate Hemodialysis </li></ul><ul><li>Nsg mgmt: monitor VS observe DTR’s and changes in LOC </li></ul><ul><li>seizure precautions </li></ul>
  85. 90. b. HYPOMAGNESEMIA <ul><li>Mg < 1.5 mEq/l </li></ul><ul><li>Etiology : alcohol w/drawal, tube feedings, diarrhea, fistula, GIT suctioning, drugs ie antacid, aminoglycosides, insulin therapy, sepsis, burns, hypothermia </li></ul><ul><li>s/sx: hyperexcitability w/ muscle weakness, tremors, tetany, seizures, stridor, Chvostek and Trousseau’s signs, ECG changes, mood changes </li></ul>
  86. 91. <ul><li>Dx: serum Mg level </li></ul><ul><li>ECG – prolonged PR and QT interval, ST depression, Widened QRS, flat T waves </li></ul><ul><li>low albumin level </li></ul><ul><li>Mgmt: diet (green leafy vegetables, nuts, legumes, whole grains, seafood, peanut butter, chocolate) IV Mg Sulfate via infusion pump </li></ul><ul><li>Nsg Mgmt: </li></ul><ul><li>seizure precautions </li></ul><ul><li>Test ability to swallow, DTR’s </li></ul><ul><li>Monitor I and O, VS during Mg administration </li></ul>
  87. 92. The Anions <ul><li>CHLORIDE </li></ul><ul><li>PHOSPHATES </li></ul><ul><li>BICARBONATES </li></ul>
  88. 93. Chloride (Cl) <ul><li>The MAJOR Anion in the ECF </li></ul><ul><li>Normal range is 95-108 mEq/L </li></ul><ul><li>Inc Na reabsorption causes increased Cl reabsorption </li></ul><ul><li>FUNCTIONS </li></ul><ul><li>1. major component of gastric juice aside from H+ </li></ul><ul><li>2. together with Na+, regulates plasma osmolality </li></ul><ul><li>3. participates in the chloride shift – inverse relationship with Bicarbonate </li></ul><ul><li>4. acts as chemical buffer </li></ul>
  89. 94. a. HYPERCHLOREMIA <ul><li>Serum Cl > 108 mEq/L </li></ul><ul><li>Etiology: sodium excess, loss of bicarbonate ions </li></ul><ul><li>s/sx: tachypnea, weakness, lethargy, deep rapid respirations, diminished cognitive ability and hypertension, dysrhytmia, coma </li></ul>
  90. 95. <ul><li>Dx: inc serum Cl </li></ul><ul><li>dec serum bicarbonate </li></ul><ul><li>Mgmt: Lactated Ringers soln IV Na Bicarbonate Diuretics </li></ul><ul><li>Nsg mgmt: monitor VS, ABGs, I and O, neurologic, cardiac and respiratory changes </li></ul>
  91. 96. b. HYPOCHLOREMIA <ul><li>Cl < 96 mEq/l </li></ul><ul><li>Etiology: Cl deficient formula, salt restricted diets, severe vomiting and diarrhea </li></ul><ul><li>s/sx: hyperexcitability of muscles, tetany, hyperactive DTR’s, weakness, twitching, muscle cramps, dysrhytmias, seizures, coma </li></ul>
  92. 97. <ul><li>Dx: dec serum Cl level </li></ul><ul><li>ABG’s – metabolic alkalosis </li></ul><ul><li>Mgmt: </li></ul><ul><li>Normal saline/half strength saline </li></ul><ul><li>diet ( tomato juice, salty broth, canned vegetables, processed meats and fruits </li></ul><ul><li>avoid free/bottled water) </li></ul><ul><li>Nsg mgmt: </li></ul><ul><li>monitor I and O, ABG’s, VS, LOC, muscle strength and movement </li></ul>
  93. 98. Phosphates (PO4) <ul><li>The MAJOR Anion in the ICF </li></ul><ul><li>Normal range is 2.5-4.5 mg/L </li></ul><ul><li>Reciprocal relationship w/ Ca </li></ul><ul><li>PTH  inc bone resorption, inc PO4 absorption from GIT, inhibit PO4 excretion from kidney </li></ul><ul><li>Calcitonin  increases renal excretion of PO4 </li></ul><ul><li>FUNCTIONS </li></ul><ul><li>1. component of bones </li></ul><ul><li>2. needed to generate ATP </li></ul><ul><li>3. components of DNA and RNA </li></ul>
  94. 99. a. HYPERPHOSPHATEMIA <ul><li>Serum PO4 > 4.5 mg/dL </li></ul><ul><li>Etiology: excess vit D , renal failure, tissue trauma, chemotherapy, PO4 containing medications, hypoparathyroidism </li></ul><ul><li>s/sx: tetany, tachycardia, palpitations, anorexia, vomiting, muscle weakness, hyperreflexia, tachycardia, soft tissue calcification </li></ul>
  95. 100. <ul><li>Dx: inc serum phosphorus level </li></ul><ul><li>dec Ca level </li></ul><ul><li>xray – skeletal changes </li></ul><ul><li>Mgmt: </li></ul><ul><li>diet – limit milk, ice cream, cheese, meat, fish, carbonated beverages, nuts, dried food, sardines </li></ul><ul><li>Dialysis </li></ul><ul><li>Nsg mgmt: </li></ul><ul><li>dietary restrictions </li></ul><ul><li>monitor signs of impending hypocalcemia and changes in urine output </li></ul>
  96. 101. b. HYPOPHOSPHATEMIA <ul><li>Serum PO4 < 2.5 mg/dl </li></ul><ul><li>Etiology: administration of calories in severe CHON-Calorie malnutrition (iatrogenic), chronic alcoholism, prolonged hyperventilation, poor dietary intake, DKA, thermal burns, respiratory alkalosis, antacids w/c bind with PO4, Vit D deficiency </li></ul><ul><li>s/sx: irritability, fatigue, apprehension, weakness, hyperglycemia, numbness, paresthesias, confusion, seizure, coma </li></ul>
  97. 102. <ul><li>Dx: dec serum PO4 level </li></ul><ul><li>Mgmt: </li></ul><ul><li>oral or IV Phosphorus correction </li></ul><ul><li>diet (milk, organ meat, nuts, fish, poultry, whole grains) </li></ul><ul><li>Nsg mgmt: </li></ul><ul><li>introduce TPN solution gradually </li></ul><ul><li>prevent infection </li></ul>
  98. 103. Acid Base Balance
  99. 104. Acid Base Balance <ul><li>Acid - substance that can donate or release hydrogen ions ie Carbonic acid, Hydrochloric acid </li></ul><ul><ul><li>** Carbon dioxide – combines with water to form carbonic acid </li></ul></ul>
  100. 105. <ul><li>Base - substance that can accept hydrogen ions </li></ul><ul><ul><li>Ie Bicarbonate </li></ul></ul>
  101. 106. <ul><li>BUFFER - substance that can accept or donate hydrogen </li></ul><ul><li>- prevent excessive changes in pH </li></ul><ul><li>TYPES OF BUFFER </li></ul><ul><ul><li>1. Bicarbonate (HCO3): carbonic acid buffer (H2CO3) </li></ul></ul><ul><ul><li>2. Phosphate buffer </li></ul></ul><ul><ul><li>3. Hemoglobin buffer </li></ul></ul>
  102. 107. Dynamics of Acid Base Balance <ul><li>Acids and bases are constantly produced in the body </li></ul><ul><li>They must be constantly regulated </li></ul><ul><li>CO2 and HCO3 are crucial in the balance </li></ul><ul><li>A HCO3:H2CO3 ratio of 20:1 should be maintained </li></ul><ul><li>Respiratory and renal system are active in regulation </li></ul>
  103. 108. Kidney <ul><li>- Regulate bicarbonate level in ECF </li></ul><ul><li>1. RESPIRATORY/METABOLIC ACIDOSIS </li></ul><ul><li>- kidney excrete H and reabsorbs/generates Bicarbonate </li></ul><ul><li>2. RESPIRATORY/METABOLIC ALKALOSIS </li></ul><ul><li>- kidney retains H ion and excrete Bicarbonate </li></ul>
  104. 109. Lung <ul><li>Control CO2 and Carbonic acid content of ECF </li></ul><ul><li>1. METABOLIC ACIDOSIS - increased RR to eliminate CO2 </li></ul><ul><li>2. METABOLIC ALKALOSIS - decreased RR to retain CO2 </li></ul>
  105. 110. <ul><li>pH - measures degree of acidity and alkalinity - indicator of H ion concentration </li></ul><ul><li>- Normal ph 7.35-7.45 </li></ul>
  106. 111. <ul><li>ACIDOSIS </li></ul><ul><li>- decreased pH; < 7.35 </li></ul><ul><li>- increased Hydrogen </li></ul>
  107. 112. <ul><li>ALKALOSIS - increased pH-; > 7.45 - decreased Hydrogen </li></ul>
  108. 113. ACUTE AND CHRONIC METABOLIC ACIDOSIS <ul><li>Low pH </li></ul><ul><li>Increased H ion concentration </li></ul><ul><li>Low plasma Bicarbonate </li></ul><ul><li>Etiology: diarrhea, fistulas, diuretics, renal insufficiency, TPN w/o Bicarbonate, ketoacidosis, lactic acidosis </li></ul><ul><li>S/sx: headache, confusion, drowsiness, inc RR, dec BP, cold clammy skin, dysrrythmia, shock </li></ul>
  109. 114. <ul><li>Dx: ABG – low Bicarbonate, low pH, Hyperkalemia, ECG changes </li></ul><ul><li>Rx: Bicarbonate for pH < 7.1 and Bicarbonate level < 10 monitor serum K dialysis </li></ul>
  110. 115. ACUTE AND CHRONIC METABOLIC ALKALOSIS <ul><li>High pH </li></ul><ul><li>Decreased H ion concentration </li></ul><ul><li>High plasma Bicarbonate </li></ul><ul><li>Etiology: vomiting, diuretic, hyperaldosteronism, hypokalemia, excesive alkali ingestion </li></ul><ul><li>s/sx: tingling of toes, dizziness, dec RR, inc PR, ventricular disturbances </li></ul>
  111. 116. <ul><li>Dx:ABG – pH > 7.45, serum Bicarbonate > 26 mEq/L, inc PaCO2 </li></ul><ul><li>Rx: restore normal fluid balance correct hypokalemia Carbonic anhydrase inhibitors </li></ul>
  112. 117. ACUTE AND CHRONIC RESPIRATORY ACIDOSIS <ul><li>Ph < 7.35 PaCO2 > 42 mmHg </li></ul><ul><li>Etiology: pulmonary edema, aspiration, atelectasis, pneumothorax, overdose of seatives, sleep apnea syndrome, pneeumonia </li></ul><ul><li>s/sx: sudden hypercapnia produces inc PR, RR, inc BP, mental cloudinesss, feeling of fullness in head, papiledema and dilated conjunctival blood vessels </li></ul>
  113. 118. <ul><li>Dx: ABG – pH < 7.35 PaCO2 - > 42 mmHg </li></ul><ul><li>Rx: improve ventilation </li></ul><ul><li>pulmonary hygiene </li></ul><ul><li>mechanical ventilation </li></ul>
  114. 119. ACUTE AND CHRONIC RESPIRATORY ALKALOSIS <ul><li>pH > 7.45 </li></ul><ul><li>PaCO2 < 38 mmHg </li></ul><ul><li>Etiology: extreme anxiety, hypoxemia </li></ul><ul><li>s/sx: lightheadednes, inability to concentrate, numbness, tingling, loss of consciousness </li></ul>
  115. 120. <ul><li>Dx: ABG – pH > 7.45 </li></ul><ul><li> PaCO2 < 35 dec K </li></ul><ul><li>dec Ca </li></ul><ul><li>Rx: breathe slowly </li></ul><ul><li> sedative </li></ul>
  116. 121. ARTERIAL BLOOD GAS ANALYSIS Parameter Normal Value pH 7.35 – 7.45 PaCO2 35 – 45 mmHg HCO3 22-26mEq/L O2 saturation 93 - 98%
  117. 123. Evaluating ABG’s <ul><li>Note the pH </li></ul><ul><li>pH = 7.35 – 7.45 (normal) pH = < 7.35 (acidosis) pH = > 7.45 (alkalosis) </li></ul><ul><li>compensated – normal pH uncompensated – abnormal pH </li></ul>
  118. 124. <ul><li>2. Determine primary cause of disturbance 2.1 pH > 7.45 </li></ul><ul><li>a. PaCo2 < 40 mmHg – respiratory alkalosis b. HCO3 > 26 mEq/L – metabolic alkalosis </li></ul><ul><li>2.2 pH < 7.35 a. PaCo2 > 40 mmHg – respiratory acidosis b. HCO3 < 26 mEq/L – metabolic acidosis </li></ul>
  119. 125. <ul><li>3. Determine compensation by looking at the value other than the primary disturbance </li></ul>Uncompensated Respiratory acidosis Compensated Respiratory acidosis pH PaCO2 HCO3 7.20 60 mmHg 24 mEq/L 7.40 60 mmHg 37 mEq/l
  120. 126. <ul><li>4. Mixed acid-base disorders </li></ul>Metabolic and Respiratory Acidosis pH 7.21 Dec acid PaCO2 52 Inc acid HCO3 13 Dec acid
  121. 127. <ul><li>Thank You! </li></ul>