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  • Sequence An action potential arrives at the presynpatic terminal causing Ca2+ channels to open, increasing the Ca2+ permeability of the presynpatic terminal. Calcium ions enter the presynpatic terminal and initiate the release of a neruotransmitter, acetylcholine (Ach), from synaptic vesicle into the presynaptic cleft. Diffusion of Ach across the synaptic cleft and binding of Ach to its receptors on the postsynaptic muscle fiber membrane opens Na+ channels and increases the permeability of the postsynaptic membrane to Na+ The increase in Na+ permeability results in depolarization of the postsynaptic membrane; once threshold has been reached a postsynaptic action potential results.

    1. 1. Water, Electrolyte, and Acid-Base Balance
    2. 2. <ul><li>Help maintain body temperature and cell shape </li></ul><ul><li>Help transport nutrients, gasses and wastes </li></ul>Fluids
    3. 3. 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. 4. 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>
    6. 6. <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
    7. 7. Function of Water : Most of cellular activities are performed in water solutions.
    8. 8. Intracellular Fluid Compartment <ul><li>Includes all the water and electrolytes inside the cells of the body. </li></ul><ul><li>Contains high concentrations of: </li></ul><ul><ul><li>potassium, </li></ul></ul><ul><ul><li>phosphate, </li></ul></ul><ul><ul><li>magnesium and </li></ul></ul><ul><ul><li>sulfate ions, </li></ul></ul><ul><ul><li>along with most of the proteins in the body. </li></ul></ul>
    9. 10. Extracellular Fluid Compartment <ul><li>Includes all the fluid outside the cells : </li></ul><ul><ul><li>interstitial fluid, plasma, lymph, secretions of glands, fluid within subcompartments separated by epithelial membranes. </li></ul></ul><ul><li>Contains high concentrations of : </li></ul><ul><ul><li>sodium, </li></ul></ul><ul><ul><li>chloride and </li></ul></ul><ul><ul><li>bicarbonate. </li></ul></ul><ul><li>One-third of the ECF is in plasma. </li></ul>
    10. 11. Extracellular Fluid Osmolality <ul><li>Osmolality </li></ul><ul><ul><li>Adding or removing water from a solution changes this </li></ul></ul><ul><li>Increased osmolality </li></ul><ul><ul><li>Triggers thirst and ADH secretion </li></ul></ul><ul><li>Decreased osmolality </li></ul><ul><ul><li>Inhibits thirst and ADH secretion </li></ul></ul>
    11. 12. Transcellular Exchange Mechanisms: <ul><li>ACTIVE TRANSPORT </li></ul><ul><li>PASSIVE TRANSPORT </li></ul><ul><ul><li>Diffusion </li></ul></ul><ul><ul><li>Osmosis </li></ul></ul><ul><ul><li>Filtration </li></ul></ul><ul><ul><li>Facilitated diffusion </li></ul></ul>
    12. 13. Movement of Water Between Body Fluid Compartments: <ul><li>HYDROSTATIC PRESSURE- pressure in the blood vessels resulting from the weight of the water and cardiac contraction </li></ul><ul><li>OSMOTIC PRESSURE- pressure exerted by proteins in plasma which pulls water into the circulatory system </li></ul>
    13. 14. 16% TBW 40% TBW 4% TBW - makes up ~60% of total body weight (TBW) - distributed in three fluid compartments. Body Fluid
    14. 15. 16% TBW 40% TBW 4% TBW Fluid is continually exchanged between the three compartments.
    15. 16. 16% TBW 40% TBW 4% TBW Exchange between Blood & Tissue Fluid <ul><li>- determined by four factors: </li></ul><ul><ul><li>capillary blood pressure </li></ul></ul><ul><ul><li>plasma colloid osmotic pressure </li></ul></ul><ul><ul><li>interstitium Hydrostatic Pressure </li></ul></ul><ul><ul><li>Interstitium colloid osmotic pressure </li></ul></ul>
    16. 17. 16% TBW 40% TBW 4% TBW - not affected by electrolyte concentrations   - Edema = water accumulation in tissue fluid Exchange between Blood & Tissue Fluid
    17. 18. 16% TBW 40% TBW 4% TBW Exchange between Tissue Fluid & Intracellular Fluid <ul><li>- determined by two: </li></ul><ul><li>1) intracellular osmotic pressure </li></ul><ul><ul><li>electrolytes </li></ul></ul><ul><li>2) interstitial osmotic pressure </li></ul><ul><li>electrolytes </li></ul>
    18. 19. Water Gain Water is gained from three sources. 1) food (~700 ml/day) 2) drink – voluntarily controlled 3) metabolic water (200 ml/day) --- produced as a byproduct of aerobic respiration
    19. 20. Routes of water loss 1) Urine – obligatory (unavoidable) and physiologically regulated, minimum 400 ml/day 2) Feces -- obligatory water loss, ~200 ml/day 3) Breath – obligatory water loss, ~300 ml/day 4) Cutaneous evaporation -- obligatory water loss, ~400 ml/day 5) Sweat – for releasing heat, varies significantly
    20. 21. Regulation of Water Intake - governed by thirst.  blood volume and  osmolarity  peripheral volume sensors central osmoreceptors  hypothalamus  thirst felt
    21. 22. Regulation of Urine Concentration and Volume <ul><li>Volume and composition depends on the condition of the body. </li></ul><ul><li>blood concentration = kidney produce urine. </li></ul><ul><ul><li>To eliminate solutes and conserve water – help to lower blood concentration </li></ul></ul><ul><li>Blood concentration = kidney produce urine </li></ul><ul><ul><li>Water is lost, solutes are conserved, blood concentration increases. </li></ul></ul>
    22. 23. Regulation of Water Output - The only physiological control is through variations in urine volume. - urine volume regulated by hormones
    23. 24. Water Content Regulation <ul><li>Content regulated so total volume of water in body remains constant </li></ul><ul><li>Kidneys primary regulator of water excretion </li></ul><ul><li>Regulation processes </li></ul><ul><ul><li>Osmosis </li></ul></ul><ul><ul><li>Osmolality </li></ul></ul><ul><ul><li>Baroreceptors </li></ul></ul><ul><ul><li>Learned behavior </li></ul></ul><ul><li>Sources of water </li></ul><ul><ul><li>Ingestion </li></ul></ul><ul><ul><li>Cellular metabolism </li></ul></ul><ul><li>Routes of water loss </li></ul><ul><ul><li>Urine </li></ul></ul><ul><ul><li>Evaporation </li></ul></ul><ul><ul><ul><li>Perspiration </li></ul></ul></ul><ul><ul><ul><li>Respiratory passages </li></ul></ul></ul><ul><ul><li>Feces </li></ul></ul>
    24. 25. HORMONAL MECHANISMS Helps to regulate blood composition and blood volume.
    25. 26. 1. ANTIDIURETIC HORMONE (ADH) <ul><li>Secreted by posterior pituitary gland into circulation to the kidney </li></ul><ul><li>Function: </li></ul><ul><ul><li>to regulate the amount of water reabsorbed </li></ul></ul><ul><ul><li>RETAINS WATER </li></ul></ul>BLOOD VOL BLOOD PRESSURE CONC. URINE
    26. 27. <ul><li>ADH </li></ul><ul><ul><li>permeability to water of the kidney </li></ul></ul><ul><ul><li>= more water is reabsorbed </li></ul></ul><ul><ul><li>= CONCENTRATED URINE </li></ul></ul><ul><li>ADH </li></ul><ul><ul><li>Kidney is less permeable to water </li></ul></ul><ul><li>= DILUTED URINE </li></ul>1. ANTIDIURETIC HORMONE (ADH)
    27. 28. 1) ADH dehydration   blood volume and/or  osmolality  hypothalamic receptors / peripheral volume sensors  posterior pituitary to release ADH   H 2 O reabsorption  Water retention
    28. 29. 2. ATRIAL NATRIURETIC FACTOR <ul><li>Secreted by the cells in the RIGHT ATRIUM when the BP in the RA is </li></ul><ul><li>Function: </li></ul><ul><ul><li>Reduces the ability of the kidney to concentrate urine </li></ul></ul><ul><ul><li>PRODUCTION OF LARGE VOLUME OF URINE </li></ul></ul><ul><ul><li>BLOOD VOLUME </li></ul></ul><ul><ul><li>CAUSES BP </li></ul></ul>
    29. 30. 2) Atrial Natriuretic Factor  blood volume =↑ BP  atrial volume sensors  atria to release ANF  inhibits Na + and H 2 O reabsorption   water output = ↓ BP
    30. 31. 3. ALDOSTERONE <ul><li>Secreted by ADRENAL GLAND </li></ul><ul><li>Function: </li></ul><ul><ul><li>regulates the rate of active transport in the kidney </li></ul></ul><ul><ul><li>REABSORPTION OF NaCl </li></ul></ul>
    31. 32. 3. ALDOSTERONE <ul><li>ABSENCE of aldosterone = Na + and Cl - remain in nephron = part of the urine </li></ul>
    32. 33. 4. RENIN AND ANGIOTENSIN <ul><li>FUNCTION: regulate aldosterone secretion </li></ul><ul><li>RENIN secreted by the cells in the juxtaglomerular apparatus in the kidney. </li></ul><ul><ul><li>An enzyme that acts on proteins produce by liver </li></ul></ul>
    33. 34. <ul><ul><li>Liver: In the protein, certain amino acids are removed leaving ANGIOTENSIN I. </li></ul></ul><ul><ul><li>ANGIOTENSIN I is rapidly converted into smaller peptide called ANGIOTENSIN II. </li></ul></ul><ul><ul><li>ANGIOTENSIN II acts on the adrenal gland causing it to secrete </li></ul></ul><ul><ul><li>ALDOSTERONE!!! </li></ul></ul>RENIN AND ANGIOTENSIN
    34. 35. <ul><ul><li>BP </li></ul></ul><ul><ul><li>Na + </li></ul></ul><ul><ul><li>K + </li></ul></ul><ul><ul><li>BP = RENIN IS RELEASED </li></ul></ul><ul><ul><li>Na + reabsorbed by nephron </li></ul></ul><ul><ul><li>H 2 O is reabsorbed </li></ul></ul><ul><ul><li>CONSERVE WATER = PREVENT IN BP </li></ul></ul>RENIN production
    35. 36. <ul><li>Dehydration </li></ul><ul><li>- decrease in body fluid </li></ul><ul><li>Causes </li></ul><ul><ul><ul><li>the lack of drinking water </li></ul></ul></ul><ul><ul><ul><li>2) excessive loss of body fluid due to: </li></ul></ul></ul><ul><ul><ul><ul><ul><li>overheat </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>diabetes </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>overuse of diuretics </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>diarrhea </li></ul></ul></ul></ul></ul>
    36. 37. <ul><li>Edema </li></ul><ul><li>- the accumulation of fluid in the interstitial spaces </li></ul><ul><li>caused by: </li></ul><ul><ul><li>increased capillary filtration, </li></ul></ul><ul><ul><li>or </li></ul></ul><ul><ul><li>2) reduced capillary reabsorption, or </li></ul></ul><ul><ul><li>3) obstructed lymphatic drainage </li></ul></ul>
    37. 38. HORMONE REGULATION: Insulin and Epinephrine = cause K+ and phosphate to move from extracellular fluid into cells Parathyroid hormone = cause Ca++ and phosphate to move from bone to extracellular fluid Calcitonin = moves calcium to bones ELECTROLYTE BALANCE
    38. 39. Electrolytes = small ions that carry charges
    39. 41. Na + K + Ca ++ Cl - PO 4 --- Distribution of Electrolytes Cell Extracellular space
    40. 42. Ions <ul><li>Factors which influence the concentration of water and solutes inside the cells: </li></ul><ul><ul><li>Transport mechanisms </li></ul></ul><ul><ul><li>Permeability of the cell membrane </li></ul></ul><ul><ul><li>Concentration of water and solutes in the extracellular fluid </li></ul></ul>
    41. 43. Ions - 285 – 295 mosm/kg Osmolality 24 mg = 1 mmol 1.8 – 3.0 mg/dL Magnesium (Mg 2+ ) 31 mg = 1 mmol 2.5 – 4.5 mg/dL Phosphorus 40 mg = 1 mmol 8.5 – 10.5 mg/dL Calcium (Ca 2+ ) 61 mg = 1 meq 22 – 26 meq/L Bicarbonate (HCO 3 - ) 35 mg = 1 meq 98 – 107 meq/L Chloride (Cl - ) 39 mg = 1 meq 3.5 – 5.0 meq/L Potassium (K + ) 23 mg = 1 meq 135 – 145 meq/L Sodium (Na + ) Mass Conversion Normal Plasma Values NORMAL VALUES AND MASS CONVERSION FACTORS
    42. 44. Sodium <ul><li>Dominant extracellular ion. </li></ul><ul><li>About 90 to 95% of the osmotic pressure of the extracellular fluid results from sodium ions and the negative ions associated with them. </li></ul><ul><li>Recommended dietary intake is less than 2.5 grams per day. </li></ul><ul><li>Kidneys provide the major route by which the excess sodium ions are excreted. </li></ul>
    43. 45. 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>
    44. 46. Sodium <ul><li>Primary mechanisms that regulate the sodium ion concentration in the extracellular fluid: </li></ul><ul><ul><li>Changes in the blood pressure </li></ul></ul><ul><ul><li>Changes in the osmolality of the extracellular fluid </li></ul></ul>
    45. 47. <ul><li>Regulation of plasma Na + </li></ul><ul><li>Aldosterone </li></ul><ul><li>plasma Na + </li></ul><ul><li> </li></ul><ul><li> aldosterone </li></ul><ul><li> </li></ul><ul><li>renal Na + excretion </li></ul><ul><li> </li></ul><ul><li> plasma Na + </li></ul>Na + plasma
    46. 48. <ul><li>Renin-angiotensin-II </li></ul><ul><li>renin </li></ul><ul><li> </li></ul><ul><li>angiotensin-II </li></ul><ul><li> </li></ul><ul><li> aldosterone </li></ul><ul><li> </li></ul><ul><li> renal Na + excretion </li></ul><ul><li> </li></ul><ul><li> plasma Na + </li></ul>Na + plasma
    47. 49. 3) ADH increases water reabsorption in kidneys  water retention  dilute plasma Na + plasma Na + H 2 O
    48. 50. <ul><li>Atrial Natriuretic Factor </li></ul><ul><li>inhibits renal reabsorption of Na + and H 2 O and the excretion of renin and ADH </li></ul><ul><li> </li></ul><ul><li>eliminate more sodium and water </li></ul><ul><li> </li></ul><ul><li> plasma Na + </li></ul>Na + plasma Na +
    49. 51. <ul><li>Sodium imbalance </li></ul><ul><ul><li>hypernatremia </li></ul></ul><ul><ul><ul><ul><li>plasma sodium > 145 mEq/L, </li></ul></ul></ul></ul><ul><ul><li>hyponatremia </li></ul></ul><ul><ul><li> plasma sodium < 130 mEq/L </li></ul></ul>
    50. 53. HYPERNATREMIA <ul><li>Na > 145 mEq/L </li></ul><ul><li>Assoc w/ water loss or sodium gain </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>inadequate water intake , </li></ul></ul><ul><ul><li>excessive salt ingestion / hypertonic feedings w/o water supplements, </li></ul></ul><ul><ul><li>near drowning in sea water, </li></ul></ul><ul><ul><li>diuretics </li></ul></ul>
    51. 54. HYPERNATREMIA <ul><li>S/SX: </li></ul><ul><li>Polyuria </li></ul><ul><li>Anorexia </li></ul><ul><li>Nausea/vomiting, </li></ul><ul><li>Thirst </li></ul><ul><li>Dry and swollen tongue </li></ul><ul><li>Fever </li></ul><ul><li>Dry and flushed skin </li></ul><ul><li>Altered LOC </li></ul><ul><li>Seizure </li></ul><ul><li>Muscle weakness </li></ul><ul><li>Crackles </li></ul><ul><li>Dyspnea </li></ul><ul><li>Cardiac manifestations dependent on type of hypernatremia </li></ul><ul><li>Dx: </li></ul><ul><li>inc serum sodium and Cl level, </li></ul><ul><li>inc serum osmolality, </li></ul><ul><li>inc urine sp.gravity, </li></ul><ul><li>inc urine osmolality </li></ul>
    52. 55. <ul><li>Mgt: </li></ul><ul><ul><li>sodium restriction, </li></ul></ul><ul><ul><li>water restriction, </li></ul></ul><ul><ul><li>diuretics, </li></ul></ul><ul><ul><li>isotonic non saline soln. (D5W) or hypotonic soln, </li></ul></ul><ul><ul><li>Desmopressin Acetate for Diabetes Insipidus </li></ul></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>
    53. 56. HYPONATREMIA <ul><li>Na < 135 mEq/L </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>diuretics , </li></ul></ul><ul><ul><li>excessive sweating, </li></ul></ul><ul><ul><li>vomiting, </li></ul></ul><ul><ul><li>diarrhea, </li></ul></ul><ul><ul><li>SIADH, </li></ul></ul><ul><ul><li>aldosterone deficiency, </li></ul></ul><ul><ul><li>cardiac, renal, liver disease </li></ul></ul>
    54. 57. HYPONATREMIA <ul><li>s/sx: </li></ul><ul><li>headache, </li></ul><ul><li>apprehension , </li></ul><ul><li>restlessness, </li></ul><ul><li>altered LOC, </li></ul><ul><li>seizures(<115meq/l), </li></ul><ul><li>coma, </li></ul><ul><li>poor skin turgor, </li></ul><ul><li>dry mucosa, </li></ul><ul><li>orthostatic </li></ul><ul><li>hypotension, </li></ul><ul><li>crackles, </li></ul><ul><li>nausea/vomiting, </li></ul><ul><li>abdominal cramping </li></ul><ul><li>Dx: </li></ul><ul><ul><li>dec serum and urine sodium and osmolality, </li></ul></ul><ul><ul><li>dec Cl </li></ul></ul>
    55. 58. <ul><li>Mgt: </li></ul><ul><ul><li>sodium replacement, </li></ul></ul><ul><ul><li>water restriction, </li></ul></ul><ul><ul><li>isotonic soln for moderate hyponatremia, </li></ul></ul><ul><ul><li>hypertonic saline soln for neurologic manifestations, </li></ul></ul><ul><ul><li>diuretic for SIADH </li></ul></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>
    56. 59. Hyponatremia Hypernatremia
    57. 60. 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>
    58. 62. Potassium <ul><li>Electrically excitable tissue such as muscle and nerves are highly sensitive to slight changes in extracellular potassium concentration. </li></ul><ul><li>concentration of potassium must be maintained within a narrow range for tissues to function normally. </li></ul>
    59. 63. Potassium <ul><li>CONDITIONS THAT MAKE K+ BECOME MORE CONC </li></ul><ul><ul><li>Circulatory system shock resulting from plasma loss </li></ul></ul><ul><ul><li>dehydration </li></ul></ul><ul><ul><li>tissue damage </li></ul></ul><ul><li>In response, aldosterone secretion increases and causes potassium secretion to increase. </li></ul>
    60. 64. <ul><li>Regulation of Potassium </li></ul><ul><li>by aldosterone </li></ul><ul><ul><li>Aldosterone </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>stimulates K + </li></ul></ul><ul><ul><li>secretion by the kidneys </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li> Plasma K + </li></ul></ul>K + plasma K +
    61. 65. <ul><li>Potassium Imbalance </li></ul><ul><ul><li>hyperkalemia (> 5.5 mEq/L) </li></ul></ul><ul><ul><li>hypokalemia (< 3.5 mEq/L) </li></ul></ul>
    62. 66. Abnormal Concentration of Potassium Ions
    63. 67. HYPERKALEMIA
    64. 68. a. HYPERKALEMIA <ul><li>K+ > 5.0 mEq/L </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>IVF with K+, </li></ul></ul><ul><ul><li>acidosis, </li></ul></ul><ul><ul><li>hyper-alimentation </li></ul></ul><ul><ul><li>excess K+ replacement, </li></ul></ul><ul><ul><li>decreased renal excretion, </li></ul></ul><ul><ul><li>Diuretics </li></ul></ul><ul><li>s/sx: </li></ul><ul><ul><li>nerve and muscle irritability </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><li>ECG changes </li></ul></ul><ul><ul><li>ventricular dysrythmia and </li></ul></ul><ul><ul><li>cardiac arrest </li></ul></ul><ul><ul><li>skeletal muscle weakness, paralysis </li></ul></ul><ul><li>Dx: </li></ul><ul><ul><li>inc serum K level </li></ul></ul><ul><ul><li>ECG: peaked T waves and wide QRS </li></ul></ul><ul><ul><li>ABGs – metabolic acidosis </li></ul></ul>
    65. 69. <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 </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>
    66. 70. Abnormal Concentration of Potassium Ions
    67. 71. HYPOKALEMIA
    68. 72. b. HYPOKALEMIA <ul><li>K+ < 3.5 mEq/L </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>use of diuretic, </li></ul></ul><ul><ul><li>corticosteroids and penicillin, </li></ul></ul><ul><ul><li>vomiting and diarrhea, </li></ul></ul><ul><ul><li>ileostomy, </li></ul></ul><ul><ul><li>villous adenoma, </li></ul></ul><ul><ul><li>alkalosis, </li></ul></ul><ul><ul><li>hyperinsulinism, </li></ul></ul><ul><ul><li>hyperaldosteronism </li></ul></ul><ul><li>s/sx: </li></ul><ul><ul><li>anorexia, </li></ul></ul><ul><ul><li>Nausea/vomiting, </li></ul></ul><ul><ul><li>decreased bowel motility, </li></ul></ul><ul><ul><li>fatigue, </li></ul></ul><ul><ul><li>muscle weakness, </li></ul></ul><ul><ul><li>leg cramps, </li></ul></ul><ul><ul><li>paresthesias, </li></ul></ul><ul><ul><li>shallow respiration, </li></ul></ul><ul><ul><li>SOB </li></ul></ul><ul><ul><li>dysrhythmias and increased sensitivity to digitalis, </li></ul></ul><ul><ul><li>hypotension, </li></ul></ul><ul><ul><li>weak pulse, </li></ul></ul><ul><ul><li>dilute urine, </li></ul></ul><ul><ul><li>glucose intolerance </li></ul></ul>
    69. 73. <ul><li>Dx: </li></ul><ul><ul><li>dec serum K level </li></ul></ul><ul><ul><li>ECG - flattened , depressed T waves, presence of “U” waves </li></ul></ul><ul><ul><li>ABGs - metabolic alkalosis </li></ul></ul><ul><li>Medical Mgmt : </li></ul><ul><ul><li>diet ( fruits, fruit juices, vegetables, fish, whole grains, nuts, milk, meats) </li></ul></ul><ul><ul><li>oral or IV replacement </li></ul></ul><ul><li>Nsg mgmt : </li></ul><ul><ul><li>monitor cardiac function, pulses, renal function </li></ul></ul><ul><ul><li>monitor serum potassium concentration </li></ul></ul><ul><ul><li>IV K diluted in saline </li></ul></ul><ul><ul><li>monitor IV sites for phlebitis </li></ul></ul>
    70. 74. <ul><li> Normal ECG </li></ul><ul><li>Hypokalemia </li></ul><ul><li>Hyperkalemia </li></ul>
    71. 75. 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 PO 4 </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>
    72. 76. <ul><li>Functions of Ca ++ </li></ul><ul><ul><li>- lends strength to the skeleton </li></ul></ul><ul><ul><li>- activates muscle contraction </li></ul></ul>Excitation Contraction [ Ca ++ ] i (Action Potentials) (shortening)
    73. 77. <ul><li>Functions of Ca ++ </li></ul><ul><ul><li>- lends strength to the skeleton </li></ul></ul><ul><ul><li>- activates muscle contraction </li></ul></ul><ul><ul><li>- serves as a second messenger for some hormones and neurotransmitters </li></ul></ul>
    74. 78. <ul><li>Functions of Ca ++ </li></ul><ul><ul><li>- lends strength to the skeleton </li></ul></ul><ul><ul><li>- activates muscle contraction </li></ul></ul><ul><ul><li>- serves as a second messenger for some hormones and neurotransmitters </li></ul></ul><ul><ul><li>- activates exocytosis </li></ul></ul><ul><ul><li>of neurotransmitters and </li></ul></ul><ul><ul><li>other cellular secretions </li></ul></ul>
    75. 79. Muscle Contraction
    76. 80. <ul><li>Functions of Ca ++ </li></ul><ul><ul><li>- lends strength to the skeleton </li></ul></ul><ul><ul><li>- activates muscle contraction </li></ul></ul><ul><ul><li>- serves as a second messenger for some hormones and neurotransmitters </li></ul></ul><ul><ul><li>- activates exocytosis of neurotransmitters and other cellular secretions </li></ul></ul><ul><ul><li>- essential factor </li></ul></ul><ul><ul><li>in blood clotting. </li></ul></ul>Ca ++
    77. 81. <ul><li>Functions of Ca ++ </li></ul><ul><ul><li>- lends strength to the skeleton </li></ul></ul><ul><ul><li>- activates muscle contraction </li></ul></ul><ul><ul><li>- serves as a second messenger for some hormones and neurotransmitters </li></ul></ul><ul><ul><li>- activates exocytosis of neurotransmitters and other cellular secretions </li></ul></ul><ul><ul><li>- essential factor in blood clotting. </li></ul></ul><ul><ul><li>- activates many cellular </li></ul></ul><ul><ul><li>enzymes </li></ul></ul>
    78. 82. Dynamics of Calcium Ca ++ plasma Ca ++ Ca ++ Ca ++
    79. 83. <ul><li>Regulation of calcium </li></ul><ul><ul><li>1) parathyroid hormone (PTH): </li></ul></ul><ul><ul><ul><li>dissolving Ca ++ in bones </li></ul></ul></ul><ul><ul><ul><li>Respond ↓blood Ca++ -> ↑ PTH production </li></ul></ul></ul><ul><ul><ul><li>= ↑ blood Ca++ </li></ul></ul></ul><ul><ul><ul><li>- reducing renal excretion of Ca ++ </li></ul></ul></ul>plasma Ca ++ Ca ++ PTH increases Vit. D synthesis in the kidney which increases Ca2+ absorption in the small intestine. PTH decreases urinary Ca2+ excretion and increases urinary phosphate excretion.
    80. 84. 2) calcitonin (secreted by C cells in thyroid gland):
    81. 85. 2) calcitonin (secreted by C cells in thyroid gland): depositing Ca ++ in bones Respond when high Ca ++ in the blood plasma Ca ++ Ca ++
    82. 86. 3) calcitrol ( derivative of vitamin D): - enhancing intestinal absorption of Ca ++ from food plasma Ca ++ Ca ++ Ca ++
    83. 87. <ul><li>Calcium imbalances </li></ul><ul><ul><ul><li>hypocalcemia (< 4.5 mEq/L) </li></ul></ul></ul><ul><ul><ul><li>hypercalcemia (> 5.8 mEq/L). </li></ul></ul></ul>
    84. 88. <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, increase 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>
    85. 89. a. HYPERCALCEMIA <ul><li>Serum calcium > 10.5 mg/dL </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>Overuse of calcium supplements and antacids, </li></ul></ul><ul><ul><li>excessive Vitamin A and D, </li></ul></ul><ul><ul><li>malignancy, </li></ul></ul><ul><ul><li>hyperparathyroidism, </li></ul></ul><ul><ul><li>prolonged immobilization, </li></ul></ul><ul><ul><li>thiazide diuretic </li></ul></ul><ul><li>s/sx: </li></ul><ul><ul><li>anorexia, </li></ul></ul><ul><ul><li>Nausea/vomiting, </li></ul></ul><ul><ul><li>polyuria, </li></ul></ul><ul><ul><li>muscle weakness, </li></ul></ul><ul><ul><li>fatigue, </li></ul></ul><ul><ul><li>lethargy </li></ul></ul><ul><li>Dx: </li></ul><ul><ul><li>inc serum Ca </li></ul></ul><ul><ul><li>ECG: </li></ul></ul><ul><ul><ul><li>Shortened QT interval, ST segments </li></ul></ul></ul><ul><ul><li>inc PTH levels </li></ul></ul><ul><ul><li>xrays - osteoporosis </li></ul></ul>
    86. 90. <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>
    87. 91. b. HYPOCALCEMIA <ul><li>Calcium < 8.5 mg/dL </li></ul><ul><li>Etiology: </li></ul><ul><ul><li>removal of parathyroid gland during thyroid surgery, </li></ul></ul><ul><ul><li>Vit. D and Mg deficiency, </li></ul></ul><ul><ul><li>Furosemide, </li></ul></ul><ul><ul><li>infusion of citrated blood, </li></ul></ul><ul><ul><li>inflammation of pancreas, </li></ul></ul><ul><ul><li>renal failure, </li></ul></ul><ul><ul><li>thyroid CA, </li></ul></ul><ul><ul><li>low albumin, </li></ul></ul><ul><ul><li>alkalosis, </li></ul></ul><ul><ul><li>alcohol abuse, </li></ul></ul><ul><ul><li>osteoporosis (total body Ca deficit) </li></ul></ul><ul><li>s/sx: </li></ul><ul><ul><li>Tetany, </li></ul></ul><ul><ul><li>(+) Chovstek’s </li></ul></ul><ul><ul><li>(+) Trousseaus’s, </li></ul></ul><ul><ul><li>seizures, </li></ul></ul><ul><ul><li>depression, </li></ul></ul><ul><ul><li>impaired memory, </li></ul></ul><ul><ul><li>confusion, </li></ul></ul><ul><ul><li>delirium, </li></ul></ul><ul><ul><li>hallucinations, </li></ul></ul><ul><ul><li>hypotension, </li></ul></ul><ul><ul><li>dysrythmia </li></ul></ul>
    88. 92. (+) Chovstek’s Trousseaus Sign
    89. 93. <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>
    90. 94. 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>
    91. 95. 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>
    92. 96. <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>
    93. 97. 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>
    94. 98. <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>
    95. 99. The Anions <ul><li>CHLORIDE </li></ul><ul><li>PHOSPHATES </li></ul><ul><li>BICARBONATES </li></ul>
    96. 100. 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>
    97. 101. <ul><li>Regulation of Cl – </li></ul><ul><li>No direct regulation </li></ul><ul><li>indirectly regulated as an effect of Na + homeostasis. As sodium is retained or excreted, Cl – passively follows. </li></ul><ul><li>Chloride Imbalance </li></ul><ul><ul><ul><li>hyperchloremia (> 105 mEq/L) </li></ul></ul></ul><ul><ul><ul><li>hypochloremia (< 95 mEq/L). </li></ul></ul></ul>
    98. 102. 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>
    99. 103. <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>
    100. 104. 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>
    101. 105. <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>
    102. 106. 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>
    103. 107. <ul><li>Phosphates </li></ul><ul><li>needed for the synthesis of: </li></ul><ul><ul><ul><li>ATP, GTP </li></ul></ul></ul><ul><ul><ul><li>DNA, RNA </li></ul></ul></ul><ul><ul><ul><li>phospholipids </li></ul></ul></ul>
    104. 108. <ul><li>Regulation of Phosphate </li></ul><ul><li>by parathyroid hormone </li></ul><ul><li>PTH </li></ul><ul><li> </li></ul><ul><li>increases renal excretion of phosphate </li></ul><ul><li> </li></ul><ul><li>decrease plasma phosphate </li></ul><ul><li>  </li></ul><ul><li>- no real phosphate imbalances </li></ul>PO 4 --- plasma PO 4 ---
    105. 109. 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>
    106. 110. <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>
    107. 111. 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>
    108. 112. <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>
    109. 113. ACID-BASE BALANCE
    110. 114. Acid An acid is any chemical that releases H + in solution. Base A base is any chemical that accepts H + .
    111. 115. pH is the negative logarithm of H + concentration, and an indicator of acidity.   pH = - log [H + ] Example: [H + ] = 0.1  M = 10 –7 M
    112. 116. Normal functions of proteins (especially enzymes) heavily depend on an optimal pH. pH7.35-pH7.45
    113. 117. Regulation of acid-base balance 1) Chemical Buffers 2) Respiratory Control of pH 3) Renal Control of pH
    114. 118. <ul><li>Buffer </li></ul><ul><li>is any mechanism that resists changes in pH. </li></ul><ul><li>substance that can accept or donate hydrogen </li></ul><ul><li>prevent excessive changes in pH </li></ul>
    115. 119. 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>Respiratory and renal system are active in regulation </li></ul>
    116. 120. 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>
    117. 121. 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>
    118. 122. 3) The Protein Buffer There are three major buffers in body fluid. 1) The Bicarbonate (HCO 3 - ) Buffer 2) The Phosphate Buffer Chemical Buffers
    119. 123. <ul><li>Properties of Chemical Buffers </li></ul><ul><ul><li>- respond to pH changes within a fraction of a second. </li></ul></ul><ul><ul><li>- Bind to H  but can not remove H  out of the body </li></ul></ul><ul><ul><li>- Limited ability to correct pH changes </li></ul></ul>
    120. 124. <ul><ul><li> pH </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>stimulate peripheral/central chemoreceptors </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li> pulmonary ventilation </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>removal of CO 2 and  pH </li></ul></ul>H 2 CO 3 H  + HCO 3 - H 2 O + CO 2
    121. 125. <ul><li>Limit to respiratory control of pH </li></ul><ul><ul><li>The respiratory regulatory mechanism cannot remove H + out of the body. Its efficiency depends on the availability of HCO 3 - . </li></ul></ul>H  + HCO 3 - H 2 CO 3 H 2 O + CO 2
    122. 126. <ul><li>Renal Control of pH </li></ul><ul><li>The kidneys can neutralize more acid or base than both the respiratory system and chemical buffers. </li></ul><ul><li>a. Renal tubules secrete hydrogen ions into the tubular fluid, where most of it combines with bicarbonate, ammonia, and phosphate buffers. </li></ul><ul><li>b. Bound and free H + are then excreted in urine. </li></ul>
    123. 127. <ul><li>The kidneys are the only organs that actually expel H + from the body. Other buffering systems only reduce its concentration by binding it to another chemical. </li></ul><ul><li>3. Tubular secretion of H + continues as long as a sufficient concentration gradient exists between the tubule cells and the tubular fluid. </li></ul>
    124. 128. <ul><li>Disorders of Acid-Base Balance </li></ul><ul><li>Acidosis : < pH 7.35 , Alkalosis : > pH 7.45 </li></ul><ul><ul><li>Mild acidosis </li></ul></ul><ul><ul><li>depresses CNS, causing </li></ul></ul><ul><ul><li>confusion , disorientation , and coma . </li></ul></ul><ul><ul><li>Mild alkalosis </li></ul></ul><ul><ul><li>CNS becomes hyperexcitable. </li></ul></ul><ul><ul><ul><li>Nerves fire spontaneously and overstimulate skeletal muscles. </li></ul></ul></ul><ul><ul><li>- Severe acidosis or alkalosis is lethal. </li></ul></ul>
    125. 129. <ul><li>Respiratory vs Metabolic Cause </li></ul><ul><li>Respiratory acidosis / alkalosis </li></ul><ul><ul><li>- caused by hypoventilation or hyperventilation </li></ul></ul>H  + HCO - H 2 CO 3 H 2 O + CO 2 Initial change Emphysema
    126. 130. <ul><li>Respiratory acidosis / alkalosis </li></ul><ul><ul><li>- caused by hypoventilation or hyperventilation </li></ul></ul><ul><ul><li>Metabolic acidosis or alkalosis </li></ul></ul><ul><ul><li>- result from any causes but respiratory problems </li></ul></ul>Diabetes   production of organic acids  metabolic acidosis Chronic vomiting  loss of stomach acid  metabolic alkalosis