Fluid and electrolytes
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Fluid and electrolytes

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Fluid and electrolytes

Fluid and electrolytes

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Fluid and electrolytes Fluid and electrolytes Presentation Transcript

  • FLUID & ELECTROLYTE BALANCE
  • BODY FLUIDS - 60% BODY WEIGHT
    • WATER IS LARGEST SINGLE COMPONENT
    • 60-70% of body weight.
    • 45-50 % body weight in elderly
    • Variations based on age, gender & amt. of body fat
    • 80% neonate is water*
  • Major Compartments for Fluids
    • INTRACELLULAR FLUID (ICF)
    • Inside cell
    • Most of body fluid here - 40% weight
    • Decreased in elderly
    • EXTRACELLULAR FLUID (ECF)
    • Outside cell
    • Intravascular fluid - within blood vessels (5%)
    • Interstitial fluid - between cells & blood vessels (15%)
    • Transcellular fluid - cerebrospinal, pericardial , synovial
  •  
  • Distribution of solutes in body
    • Electrolytes
    • Non-Electrolytes
    • - glucose, urea, uric acid
    • - proteins ( albumin )
  • ELECTROLYTES
    • Substance when dissolved in solution separates into ions & is able to carry an electrical current
    • CATION - positively charged electrolyte
    • ANION - negatively charged electrolyte
    • Cations must = Anions for homeostatsis to exist in each fluid compartment
    • Commonly measured in milliequivalents / liter (mEq/L)
  •  
  • MILLIEQUIVALENT (mEq)
    • Unit of measure for an electrolyte
    • Describes electrolyte’s ability to combine & form other compounds
    • Equivalent weight is amount of one electrolyte that will react with a given amount of hydrogen
    • 1 mEq of any cation will react with 1 mEq of an anion
  • DEFINITIONS
    • SOLUTE - substance dissolved
    • SOLVENT - liquid in which the solute is dissolved
    • SELECTIVELY PERMEABLE MEMBRANES - found throughout body. cell membranes & capillary walls; allow water & some solutes to pass through them freely
  •  
  • METHODS OF FLUID & ELECTROLYTE MOVEMENT
    • Diffusion
    • Osmosis
    • Active Transport
    • Filtration
  • DIFFUSION
    • Process by which a solute in solution moves
    • Involves a gas or substance
    • Movement of particles in a solution
    • Molecules move from an area of higher concentration to an area of lower concentration
    • Evenly distributes the solute in the solution
    • Passive transport & requires no energy*
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  • FACILITATED DIFFUSION
    • Involves carrier system that moves substance across a membrane faster than it would with simple diffusion
    • Substance can only move from area of higher concentration to one of lower concentration
    • Example is movement of glucose with assistance of insulin across cell membrane into cell
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  • OSMOSIS
    • Movement of the solvent or water across a membrane
    • Involves solution or water
    • Equalizes the concentration of ions on each side of membrane
    • Movement of solvent molecules across a membrane to an area where there is a higher concentration of solute that cannot pass through the membrane
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  • OSMOTIC PRESSURE
    • Pull that draws solvent through the membrane to the more concentrated side (or side with solute )
    • Amt. determined by relative number of particles of solute on side of greater concentration
    • Proportional to # of particles per unit volume solvent
  • COLLOID OSMOTIC PRESSURE OR ONCOTIC PRESSURE
    • Special kind of osmotic pressure
    • Created by substances with a high molecular weight (like albumin)
  • ISOTONIC
    • ISO - means alike
    • TONICITY - refers to osmotic activity of body fluids; tells the extent that fluid will allow movement of water in & out cell
    • Means that solutions on both sides of selectively permeable membrane have established equilibrium
    • Any solution put into body with the same osmolality as blood plasma - 0.9% sodium chloride or 5% glucose
  • HYPOTONIC HYPERTONIC
    • Solution of lower osmotic pressure
    • Less salt or more water than isotonic
    • If infused into blood, RBCs draw water into cells ( can swell & burst )
    • Solutions move into cells causing them to enlarge
    • Solution of higher osmotic pressure
    • 3% sodium chloride is example
    • If infused into blood, water moves out of cells & into solution (cells wrinkle or shrivel)
    • Solutions pull fluid from cells
  •  
  • OSMOLALITY
    • Measure of solution’s ability to create osmotic pressure & thus affect movement of water
    • Number of osmotically active particles per kilogram of water
    • Plasma osmolality is 280- 300* mOsm/ kg
    • ECF osmolality is determined by sodium
    • MEASURE used in clinical practice to evaluate serum & urine
  • Osmolality In Clinical Practice *
    • Serum 280-300mOsm/kg; Urine 50-1400mOsm/kg
    • Serum osmolality can be estimated by doubling serum sodium
    • Urine specific gravity measures the kidneys’ ability to excrete or conserve water
    • Nl range 1.010 to 1.025 (compared to weight of distilled water with sp g of 1.000)
  • Other Lab Tests*
    • BUN - blood urea nitrogen; made up of urea an end-product of protein metabolism; Nl 10-20 mg/dL ; inc. with GI bleeding, dehydration, inc. protein intake, fever, & sepsis; dec. with starvation, end-stage liver dx., low protein diet, expanded fluid vol. (as with pregnancy)
    • Creatinine - end product of muscle metabolism; better indicator of renal function; nl 0.7-1.5 mg/dL
    • Hematocrit - vol. % of RBCs in whole blood; m- 44-52%, f- 39-47%
  • ACTIVE TRANSPORT SYSTEM
    • Moves molecules or ions uphill against concentration & osmotic pressure
    • Hydrolysis of adenosine triphosphate (ATP) provides energy needed
    • Requires specific “carrier” molecule as well as specific enzyme (ATPase)
    • Sodium, potassium, calcium, magnesium , plus some sugars, & amino acids use it
  •  
  • FILTRATION
    • Movement of fluid through a selectively permeable membrane from an area of higher hydrostatic pressure to an area of lower hydrostatic pressure
    • Arterial end of capillary has hydrostatic pressure > than osmotic pressure so fluid & diffusible solutes move out of capillary
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  • HYDROSTATIC PRESSURE
    • Force of the fluid pressing outward against vessel wall
    • With blood not only refers to weight of fluid against capillary wall but to force with which blood is propelled with heartbeat
    • “ Fluid- pushing pressure inside a capillary”*
  •  
  • THIRD SPACING
    • Large quantities of fluid from the intravascular compartment shift into the interstitial space; is inaccessible to the body
    • May be caused by lowered plasma proteins, increased capillary permeability & lymphatic blockage
    • Can be seen with trauma, inflammation, disease
  • PLASMA PROTEINS (Primarily Albumin)
    • Affect serum osmolarity
    • Are main negatively charged intravascular fluid anions
    • Balance the positive charge of sodium in osmolarity
    • Create colloid osmotic pressure which pulls in & holds water in the vascular bed as well as pulling water from interstitial space into vascular bed - “water magnet”*
  •  
  • INTAKE FLUIDS OUT
    • Ingested liquids 1500
    • Water in foods 800*
    • Water from oxidation 300*
    • TOTAL 2600*
    • INSENSIBLE
    • Skin 600*
    • Lungs through expired air 300*
    • Feces 200
    • Kidneys 1500*
    • TOTAL 2600*
  •  
  • THIRST
    • Conscious desire for water
    • Major factor that determines fluid intake
    • Initiated by the osmoreceptors in hypothalamus that are stimulated by increase in osmotic pressure of body fluids to initiate thirst
    • Also stimulated by a decrease in the ECF volume
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  • Neuro Endocrine Mechanisms
    • Central Nervous System Ischemic Response- massive hemorrhage causes decrease in ECF volume & response that constricts afferent arterioles & decreases GFR
    • Baroreceptor Reflex - stretch receptors in large arteries that react to a decrease in ECF & respond by decreasing GFR
  •  
  • ADH (Antidiuretic Hormone)
    • Made in hypothalamus; water conservation hormone
    • Stored in posterior pituitary gland
    • Acts on renal collecting tubule to regulate reabsorption or elimination of water
    • If blood volume decreases, then ADH is released & water is reabsorbed by kidney. Urine output will be lower but concentration will be increased.
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  • ALDOSTERONE
    • Produced by adrenal cortex
    • Released as part of RAA mechanism
    • Acts on renal distal convoluted tubule
    • Regulates water reabsorption by increasing sodium uptake from the tubular fluid into the blood but potassium is excreted
    • Responsible for reabsorption of sodium & water into the vascular compartment
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  • RENIN
    • Released by kidneys in response to decreased blood volume
    • Causes angiotensinogen (plasma protein) to split & produce angiotensin I
    • Lungs convert angiotensin I to angiotensinII
    • Angiotensin II stimulates adrenal gland to release aldosterone & causes an increase in peripheral vasoconstriction
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  • You just ate 4 bags of potato chips so what would you expect?
    • THIRST ?
    • ADH ?
    • OSMOLALITY ?
    • ALDOSTERONE ?
    • URINE OUTPUT ?
  • You decide to drink 5 gallons of water so what do you expect ?
    • THIRST ?
    • ADH ?
    • OSMOLALITY ?
    • BLOOD VOLUME ?
    • RENAL BLOOD VOLUME ?
    • URINE OUTPUT ?
  • Quiz ????
    • 1. Who has the highest body % of water? Infant? Adolescent? 50 year old? Elderly?
    • 2. The chief cation of the ICF is Sodium? Chloride? Potassium? Phosphorus
    • Aldosterone is associated with an increase in - Urine output? Potassium in serum? Sodium in serum? BP?
  • More Questions ????
    • 4. If you don’t drink any water or have lost a lot of water, what do you think will happen to: renal blood flow, renal BP, Glomerular filtration rate (GFR), ADH, Urine output
    • 5. Your patient’s blood volume is low due to hemorrhage. What do you expect to see with: BP ? HR ? Skin hot or cool ? Urine output ?
  • Methods of Monitoring Fluid Balance !!!!
    • BP - one of best tools to assess fluid vol
    • Review technique - ex. Cuff too small
    • Remember auscultatory gap
    • Orthostatic hypotension
  • Pulmonary Artery Catheter !!!!
    • Measure PAP, PACWP, CO & CVP
    • Mean PAP = 10- 20 mm Hg
    • PACWP = nl 6-12 mm Hg
    • CO = HR X SV = 4-8 L/min
    • CVP = 5-10 cm H2O or 0-7mm Hg
  • IV Fluid Tonicity !!!!
    • TONICITY
    • Hypotonic
    • Isotonic
    • Hypertonic
    • OSMOLALITY CELL
    • < 270 mOsm/kg Swelling
    • 275-295 mOsm/kg Nothing
    • > 300 mOsm/kg Shrinking
  • Dehydration !!!!
    • Disturbance of water balance
    • output greater than input
    • Decrease in body water below normal
    • May be the result of – pure water depletion
    • - pure salt depletion
    • - mixed
  • INTAKE & OUTPUT
    • Low INTAKE
    • Oral fluids - including ice, gelatin, etc.
    • Parenteral fluids
    • Tube feedings with flushes
    • Catheter irrigants that are not withdrawn
    • More OUTPUT
    • Urine output
    • Liquid feces
    • Vomitus
    • NG drainage
    • Excessive sweating
    • Wound drainage
    • Draining fistula
    • Rapid or labored RR
  • 1-Pure water Depletion
    • Occurs when water intake is not there and there is no loss of salts in the secretions.
    • CAUSES --- very weak or ill patient
    • - comatosed patient
    • - mentally upset
    • - dysphagia
    • - total inavailability of water
  • Pathophysiology and Effects
    • No water intake , use up of water stores , continuous obligatory water loss.
    • ECF becomes hypertonic
    • Water flows from ICC to ECC and causes cellular dehydration.
    • There is Thirst, Oliguria due to the release of ADH. BP may drop in late stage.
  • Biochemical findings
    • ECF is hypertonic
    • Blood urea may be slightly raised
    • Plasma volume decreases in late stage
    • Urine volume is scanty with raised specific gravity
    • Death occurs when water loss amounts to 15% of body weight.
  • 2- Pure Salt Depletion
    • Due to the loss of fluids of high Na or Cl content and replacement done by salt deficient fluids.
    • CAUSES : excessive sweating, loss of GI fluids, urinary loss of Na, diuretics.
  • Pathophysiology and effects
    • ECF becomes hypotonic
    • Decreased release of ADH and thus diuresis
    • Results in decrease in plasma and interstitial fluid volume.
    • Hypotonicity of ECF results in water entry into the cells and further fall in ECF volume.
    • NO thirst
    • Marked weakness and fainting
    • Loss of interstitial fluid causes sunken eyes and loss of skin elasticity
    • Decreased cardiac output and fall in BP.
    • Decreased glomerular filtration results in raised urea level.
  • Biochemical findings
    • ECF hypotonic
    • Low plasma volume
    • Haemoconcentration
    • Decreased plasma sodium
    • Raised blood urea
    • ----------------------------------------
    • Death by oligaemic shock and peripheral circulatory failure.
  • 3-FLUID VOLUME DEFICIT
    • Hypovolemia or FVD is result of water & electrolyte loss
    • Compensatory mechanisms include: Increased sympathetic nervous system stimulation with an increase in heart rate & cardiac contraction; thirst; plus release of ADH & aldosterone
    • Severe case may result in hypovolemic shock or prolonged case may cause renal failure
  • CAUSES OF FVD
    • Abnormal GI fluid loss such as N&V or drainage of GI tract
    • Abnormal fluid loss from skin such as high temperature or burns
    • Increased water vapor from the lungs such as hyperpnea
    • Conditions that increase renal excretion of fluids such as diuretics & hypersomolar tube feedings
    • Decrease in fluid intake
    • Third-space shift such as ascites or trauma
  • LAB VALUES IN FVD
    • INCREASE IN: HEMATOCRIT nl 44*-52*% M nl 39*-47% F BUN nl 10*-20 mg/dl URINE SPECIFIC GRAVITY nl 1.010*-1.025*
  • SIGNS & SYMPTOMS OF FVD
    • Dry mucous membranes
    • Weight loss -mild at 2%,moderate at 5%, & severe deficit at 8%
    • Orthostatic hypotension & increase in pulse rate
    • Body temperature usually subnormal
    • Flat neck veins & decrease in CVP
    • Decreased urinary output & altered sensorium
  • NURSING MANAGEMEMT OF FVD
    • Monitoring I&O on a regular schedule depending on the patient
    • If urine output is below 30 mL / hr. notify the physician
    • May check urine specific gravity q 8hrs.
    • Weigh patient daily at the same time & recognize that a change of 2.2 lbs. represents a loss of 1000 mL
    • Monitor skin turgor, oral membranes, lab
  • FLUID VOLUME EXCESS
    • Hypervolemia or FVE is result of expansion of fluid compartment from an increase in total sodium content
    • Kidney receives signal to save sodium & water to compensate for cirrhosis, CHF, renal failure, excessive Na-containing fluid
    • Labs may show dec.:hematocrit, serum Na, serum osmolality, urine sp. Gr; inc. BUN
  • SIGNS & SYMPTOMS OF FVE
    • SOB & orthopnea
    • Edema & weight gain
    • Distended neck veins & tachycardia
    • Increased blood pressure
    • Crackles & wheezes
    • Maybe ascites & pleural effusion
    • Increase in CVP
  • NURSING MANAGEMENT OF FVE
    • Monitor I & O plus monitor for physical signs of hypervolemia
    • Check for edema & weigh patient daily
    • Restrict sodium intake as prescribed
    • Limit intake of fluids
    • Watch for signs of potassium imbalance
    • Monitor for signs of pulmonary edema
    • Place patient in semi-Fowler’s position
  • Water Intoxication !!!!
    • Excess fluid moves from EC space to IC space
    • Happens with SIADH, rapid infusion of hypotonic IV sol or tap water as NG irrigant or enemas; can happen with psychogenic polydipsia ( may drink 12-18 L/day )
    • Findings Serum NA < 125 mEq/L Serum Osmolality < 280 mOsm/kg
  • ISOTONIC SOLUTIONS
    • 0.9% Sodium Chloride Solution
    • Ringer’s Solution
    • Lactated Ringer’s Solution
  • HYPOTONIC SOLUTIONS
    • 5% DEXTROSE & WATER
    • 0.45% SODIUM CHLORIDE
    • 0.33% SODIUM CHLORIDE
  • HYPERTONIC SOLUTIONS
    • 3% SODIUM CHLORIDE
    • 5% SODIUM CHLORIDE
    • WHOLE BLOOD
    • ALBUMIN
    • TOTAL PARENTERAL NUTRITION
    • TUBE FEEDINGS
    • CONCENTRATED DEXTROSE (>10%)
  • SODIUM (NA + )
    • DOMINANT EXTRACELLULAR ELECTROLYTE
    • CHIEF BASE OF BLOOD
    • NL SERUM LEVEL 135-145 mEq/L
  • SODIUM (NA)*
    • Main extracellular fluid (ECF) cation
    • Helps govern normal ECF osmolality
    • Helps maintain acid-base balance
    • Activates nerve & muscle cells
    • Influences water distribution (with chloride)
  • SODIUM (NA + )
    • SODIUM AFFECTS FLUID VOLUME & CONCENTRATION IN ECF
    • IS REGULATED BY : Aldosterone Renal blood flow Renin secretion Antidiuretic hormone (ADH) due to its effect on water Estrogen Carbonic anhydrase enzyme
  •  
  • HYPERNATREMIA
    • Serum Na + level > 148 mEq/L serum osmolality > 295 mOsm/kg & urine sp gr > 1.030 with nl kidneys
    • Collaborative management tries to gradually lower serum sodium by *infusion of 0.45% NaCl *monitoring U/O & serum sodium levels *administering fluids carefully *restricting sodium intake
    • The thirsty person will not get this !!!!
  • HYPONATREMIA
    • Serum Na + < 135 mEq/L (patient may be asymptomatic until level drops below 125)
    • Collaborative management seeks to correct cause & give sodium with caution due to possible rebound fluid excess by : *infusing isotonic saline in IV fluids *restricting oral & IV water intake *increasing dietary sodium *monitoring for signs of hypervolemia
  • POTASSIUM (K + )
    • DOMINANT INTRACELLULAR ELECTROLYTE
    • PRIMARY BUFFER IN CELL
    • NL SERUM LEVEL 3.5-5.5 *mEq/L
  • POTASSIUM (K)*
    • Dominant cation in intracellular fluid (ICF)
    • Regulates cell excitability
    • Permeates cell membranes, thereby affecting cell’s electrical status
    • Helps control ICF osmolality & ICF osmotic pressure
  • POTASSIUM (K + )
    • MOVEMENT INFLUENCED BY :Changes in pH Insulin Adrenal hormones Changes in serum sodium
    • IMPORTANT IN: Neuromuscular irritability Intracellular osmotic activity Acid-base balance
  • HYPERKALEMIA
    • K + > 5.5 mEq/L
    • Dangerous due to potential for fatal dysrhythmias, cardiac arrest
    • Major cause is renal disease
    • EKG shows tall, peaked T waves & dysrthythmias
    • Beware of pseudohyperkalemia due to prolonged tourniquet, hemolysis of blood, sampling above KCl infusion
  • HYPERKALEMIA TX
    • Watch EKG for fatal dysrthymias or cardiac arrest
    • Collaborative management may include: Calcium to counteract effect on heart Sodium bicarbonate to alkalinize fluids Hemodialysis or peritoneal dialysis Cation exchange resins (Kayexalate) by mouth or enema Small dose of insulin & dextrose Restrict dietary K +
  • HYPOKALEMIA
    • K + < 3.5mEq/L
    • Most common type of electrolyte imbalance
    • Major cause is increase renal loss most often associated with diuretics
    • EKG shows dysrhythmias, flattened T wave
    • Can increase the action of digitalis
    • NEVER GIVE K + IV PUSH & ALWAYS DILUTE IN IV FLUIDS
  • HYPOKALEMIA TX
    • Correct the cause
    • Oral or IV administration of potassium
    • Salt substitutes containing K +
    • Foods high in potassium : bananas, pears, dried apricots; fruit juices; tea, cola beverages; milk; meat, fish; baked potato; dried beans (cooked); ANYTHING THAT TASTES GOOD LIKE CHOCOLATE !!
  •  
  • ACID-BASE BALANCE
    • Governed by the regulation of hydrgen ion (H + ) concentration in the body
    • pH = negative logarithm of the H + concentration
    • Acids - proton donors & give up H +
    • Bases - H + acceptors
    • Acidic - inc. in concentration of H +
    • Basic - dec. in concentration of H +
  •  
  • HENDERSON - HASSELBALCH EQUATION
    • Expresses that the ratio of base to acid or HCO 3 - to H 2 CO 2 * ( 20: 1) determines the pH
    • pH < 7.35 ACIDOSIS
    • pH > 7.45 ALKALOSIS
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  • ACID-BASE REGULATORY MECHANISMS
    • CHEMICAL BUFFER SYSTEMS - bicarbonate, phosphate, protein, hemoglobin
    • LUNGS - carbonic acid broken down into CO 2 & H 2 O
    • KIDNEYS - increasing or decreasing bicarbonate ions
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  • Arterial Blood Gases (ABGs)
    • pH 7.35-7.45
    • PaCO 2 35-45 mm Hg
    • Pa O 2 80-100 mm Hg
    • O 2 sat. 95-99%
    • HCO 3 - 22-26mEq/L
  • ACID-BASE PARAMETERS
    • ACID
    • pH <7.35
    • PaCO2 >45
    • HCO3 <22
    • BASE
    • pH >7.45
    • PaCO2 <35
    • HCO3 >26
  • Which way will the scale tip???*
    • Acidosis vs. Alkalosis
  • Respiratory Acidosis*
    • pH < 7.35
    • PaCO 2 > 45mm Hg
    • Due to inadequate alveolar ventilation
    • Tx aimed at improving ventilation
    • R espiratory O pposite
  • Respiratory Alkalosis*
    • pH > 7.45
    • PaCO 2 < 35mm Hg
    • Due to alveolar hyperventilation & hypocapnia
    • Tx depends on underlying cause
  • Metabolic Acidosis*
    • pH < 7.35
    • HCO 3 < 22mEq/L
    • Due to gain of acids or loss of base (like excessive GI loss from diarrhea )
    • May have associated hyperkalemia
    • Tx aimed at correcting metabolic defect
    • M etabolic E ven
  • Metabolic Alkalosis*
    • pH > 7.45
    • HCO 3 > 26 mEq/L
    • Due to loss of acid or gain of base (most common is vomiting or gastric suction )
    • Hypokalemia may produce alkalosis
    • Tx aimed at underlying disorder
  • EVALUATING ABGs*
    • 1. List pH, P a CO 2 , & HCO 3 -
    • 2. Compare to normals & rate as ACID, BASE OR NORMAL . Write A (acid), B (base), or N (normal) or think ROME
    • 3. Circle any two letters that are the SAME to tell IMBALANCE.
    • pH 7.10 P a CO 2 80mmHg HCO 3 - 25mEq/l ???? IMBALANCE ????
    • Look at P a O 2 & S a O 2 for oxygenation
  • ABG ASSESSMENT*
    • 36 yo pt. complains of acute SOB, R sided pleuritic pain
    • pH 7.50
    • P a CO 2 29 mmHg
    • P a O 2 60 mmHg
    • HCO 3 - 24 mEq/l
    • S a O 2 78%
    • ? Meaning ?
    • 32 yo pt. with drug OD & breathing 5 times / minute
    • pH 7.25
    • P a CO 2 61 mmHg
    • P a O 2 74 mmHg
    • HCO 3 - 26 mEq/l
    • SaO 2 89%
    • ? Meaning ?
  • ABGs*
    • 70 year old diabetic with hx of not taking insulin
    • pH 7.26
    • PaCO 2 42
    • HCO 3 17
    • ????
    • 58 year old pt. With CHF for 6 mos. & placed on digoxin & Lasix
    • pH 7.48
    • PaCO 2 45
    • HCO 3 26
    • ????
  • FASTING BLOOD GLUCOSE 70-110mg/dl
    • GLUCOSE levels are controlled by insulin & glucagon
    • While fasting glucose levels are low & glucagon is secreted
    • Glucagon breaks glycagon to glucose in liver & blood glucose rises
    • Glucose goes up after eating & insulin is secreted
    • Insulin attaches to insulin receptors in cells which drive glucose into these target cells to be metabolized
    • Blood glucose levels go down
  • HYPER HYPOGLYCEMIA
    • CAUSED BY: DIABETES MELLITUS ; Acute stress response; Cushing’s syndrome; Pheochromocytoma; Chronic renal failure;Diuretic therapy; Corticosteroid therapy
    • CAUSED BY: INSULIN OVERDOSE; Insulinoma; Hypothyroidism; Hypopituitarism; Addison’s dx; Extensive liver dx; Starvation