Fluids and Electrolytes

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  • Hi i was wondering if you can send me a hard copy of the fluids and electrolytes and the nursing diagnosis/ process. It will be very helpful and i will highly appreciate it. Thank you, :) castillo.e09@hotmail.com
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  • Hi i was wondering if you can send me a hard copy of the fluids and electrolytes and the nursing diagnosis/ process. It will be very helpful and i will highly appreciate it. Thank you, :) my email is castillo.e09@hotmail.com
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Fluids and Electrolytes

  1. 1. FluidsFluids andand ElectrolytesElectrolytes Ma. Tosca Cybil A. Torres, RN
  2. 2. OBJECTIVESOBJECTIVES After this lecture/discussion, the learner should be able to:After this lecture/discussion, the learner should be able to: 1.1. Describe the mechanisms that maintain fluid, electrolyteDescribe the mechanisms that maintain fluid, electrolyte andand acid-base balance.acid-base balance. 2.2. Compare the mechanisms and effects of fluid deficit andCompare the mechanisms and effects of fluid deficit and excess.excess. 3.3. Discuss the mechanisms and effects of deficits and excess.Discuss the mechanisms and effects of deficits and excess. 4.4. Describe the mechanisms that maintain acid-base balance.Describe the mechanisms that maintain acid-base balance. 5.5. Differentiate between metabolic and respiratory acidosis andDifferentiate between metabolic and respiratory acidosis and alkalosis.alkalosis. 6.6. Apply the pathophysiologic principles of acid-base balance toApply the pathophysiologic principles of acid-base balance to the interpretation of ABG measurements.the interpretation of ABG measurements. 7.7. Analyze the components of ABGs to identify the type of acid-Analyze the components of ABGs to identify the type of acid- base balance.base balance. 8.8. Describe the causes and effects of each type of acid-baseDescribe the causes and effects of each type of acid-base balance.balance. 9.9. Use ABG findings in formulating the care of the patient with anUse ABG findings in formulating the care of the patient with an acid-base imbalance.acid-base imbalance. 10.10. Describe the management of patients with a fluid, electrolyte, orDescribe the management of patients with a fluid, electrolyte, or acid-base imbalance.acid-base imbalance.
  3. 3. Fluids
  4. 4. HOW IMPORTANT IS WATER?HOW IMPORTANT IS WATER? • Between 50% and 60% of the humanBetween 50% and 60% of the human body by weight is waterbody by weight is water • Water provides a medium forWater provides a medium for transporting nutrients to cells and wastestransporting nutrients to cells and wastes from cells and for transportingfrom cells and for transporting substances such as hormones, enzymes,substances such as hormones, enzymes, blood platelets, and red and white bloodblood platelets, and red and white blood cellscells • Water facilitates cellular metabolism andWater facilitates cellular metabolism and proper cellular chemical functioningproper cellular chemical functioning • Water acts as a solvent for electrolytesWater acts as a solvent for electrolytes and nonelectrolytesand nonelectrolytes • Helps maintain normal body temperatureHelps maintain normal body temperature • Facilitates digestion and promotesFacilitates digestion and promotes eliminationelimination • Acts as a tissue lubricantActs as a tissue lubricant
  5. 5. VARIATIONS IN FLUID CONTENTVARIATIONS IN FLUID CONTENT BODY FATBODY FAT Because fat cells contain littleBecause fat cells contain little water and lean tissue is rich inwater and lean tissue is rich in water, the more obese thewater, the more obese the person, the smaller theperson, the smaller the percentage of total body waterpercentage of total body water compared with body weight.compared with body weight. This is also true between sexesThis is also true between sexes because females tend to havebecause females tend to have proportionally more body fatproportionally more body fat than males.than males. There is also an increase in fatThere is also an increase in fat cells in older peoplecells in older people
  6. 6. VARIATIONS IN FLUID CONTENTVARIATIONS IN FLUID CONTENT AGEAGE
  7. 7. AVENUES BY WHICH WATERAVENUES BY WHICH WATER ENTERS AND LEAVES THE BODYENTERS AND LEAVES THE BODY
  8. 8. ↓Blood volume or ↓BP Volume receptor Atria and great veins Hypothalamus ↓ Posterior pituitary gland Osmoreceptors in hypothalamus ↑Osmolarity ↑ADH Kidney tubules ↑H2O reabsorption ↑vascular volume and ↓osmolarity Narcotics, Stress, Anesthetic agents, Heat, Nicotine, Antineoplastic agents, Surgery ANTIDIURETIC HORMONE REGULATION MECHANISMSANTIDIURETIC HORMONE REGULATION MECHANISMS
  9. 9. Juxtaglomerular cells-kidney ↓Serum Sodium ↓Blood volume Angiotensin I Kidney tubules Angiotensin II Adrenal Cortex ↑Sodium resorption (H2O resorbed with sodium); ↑ Blood volume Angiotensinogen in plasma RENIN Angiotensin-Angiotensin- convertingconverting enzymeenzyme ALDOSTERONE Intestine, sweat glands, Salivary glands Via vasoconstriction of arterial smooth muscle ALDOSTERONE-RENIN-ANGIOTENSIN SYSTEMALDOSTERONE-RENIN-ANGIOTENSIN SYSTEM
  10. 10. Fluid Types • Fluids in the body generally aren’t found in pure forms • Isotonic, hypotonic, and hypertonic types • Defined in terms of the amount of solute or dissolve substances in the solution • Balancing these fluids involves the shifting of fluid not the solute involved
  11. 11. Isotonic Solutions • No net fluid shifts occur between isotonic solutions because the solution are equally concentrated • Ex. NSS or 0.9SS
  12. 12. Hypotonic Solutions • Has a lower solute concentration than another solution • Fluid from the hypotonic solution would shift into the second solution until the two solutions had equal concentrations • Ex. Half normal or 0.45%SS
  13. 13. Hypertonic Solutions • Has a higher solute concentration than another solution • Fluid from the second solution would shift into the hypertonic solution until the two solutions had equal concentrations • Ex. D5NSS
  14. 14. Fluid Movements • Fluids and solutes constantly move within the body, which allows the body to maintain homeostasis • Fluids along with nutrients and waste products constantly shift within the body’s compartments from the cell to the interstitial spaces, to the blood vessels and back again
  15. 15. Fluid Movements • Types of Transport –A. Active transport –B. Passive transport • Diffusion • Osmosis • Filtration
  16. 16. Assessment• CLINICAL MEASUREMENT – Daily weights • Each kg = 1 L of fluid • To gain accuracy: – Balance the scale before each use and weigh the client; » At same time each day before breakfast after the first void » Wear the same or similar clothing » On the same scale – Vital signs • Tachycardia – first sign of hypovolemia – Fluid I & O • Oral fluids • Ice chips • Foods that tend to become fluid at room temperature • Tube feedings • Parenteral fluids • IV meds • Catheter or tube irrigant • Urinary output – if with diaper, 1 g = 1 mL • Vomitus or liquid feces • Diaphoresis • Tube drainage • Wound dressing or wound fistula
  17. 17. LABORATORY TESTS FOR EVALUATING FLUID STATUS • Osmolality – measures the solute concentration per kilogram in blood and urine. • Osmolarity – concentration of solution per liter. • BUN – (10-20 mg/dL)made up of urea, an end product of protein metabolism by the liver. • Creatinine (0.7 to 1.5 mg/dL)- end product of muscle metabolism • Serum electrolytes • CBC
  18. 18. Diagnosis • Fluid volume deficit • High risk for Fluid volume deficit • Fluid volume excess • Altered oral mucous membrane
  19. 19. FLUID BALANCEFLUID BALANCE • The desirable amount of fluid intake and loss in adults ranges from 1500 to 3500 mL each 24 hours. Ave= 2500 mL • Normally INTAKE = OUTPUT FLUID IMBALANCEFLUID IMBALANCE • Changes in ECF volume = alterations in sodium balance • Change in sodium/water ratio = either hypoosmolarity or hyperosmolarity • Fluid excess or deficit = loss of fluid balance • As with all clinical problems, the same pathophysiologic change is not of equal significance to all people • For example, consider two persons who have the same viral syndrome with associated nausea and vomiting
  20. 20. FLUID DEFICIT/HYPOVOLEMIAFLUID DEFICIT/HYPOVOLEMIA • May occur as a result of:May occur as a result of: – Reduced fluid intakeReduced fluid intake – Loss of body fluidsLoss of body fluids – Sequestration (compartmentalizing) of body fluidsSequestration (compartmentalizing) of body fluids Pathophysiology and Clinical ManifestationsPathophysiology and Clinical Manifestations DECREASED FLUID VOLUMEDECREASED FLUID VOLUME Stimulation of thirstStimulation of thirst center in hypothalamuscenter in hypothalamus Person complains of thirstPerson complains of thirst ↑↑ ADH SecretionADH Secretion ↑↑ Water resorptionWater resorption ↓↓ Urine OutputUrine Output Renin-Angiotensin-Renin-Angiotensin- Aldosterone SystemAldosterone System ActivationActivation ↑↑ Sodium andSodium and Water ResorptionWater Resorption ↑↑ Urine specific gravityUrine specific gravity
  21. 21. Pathophysiology and Clinical ManifestationsPathophysiology and Clinical Manifestations UNTREATED FLUID VOLUME DEFICITUNTREATED FLUID VOLUME DEFICIT Depletion of fluids availableDepletion of fluids available ↑↑ BODY TEMPERATUREBODY TEMPERATURE Dry mucous membranesDry mucous membranes Difficulty with speechDifficulty with speech Cells become unable to continueCells become unable to continue providing water to replace ECFproviding water to replace ECF losseslosses Signs of circulatory collapseSigns of circulatory collapse ↓↓ blood pressureblood pressure ↑↑ heart rateheart rate ↑↑ respiratory raterespiratory rate Restlessness and ApprehensionRestlessness and Apprehension
  22. 22. Hypovolemia • Nursing Intervention – Monitor fluid intake and output – Checked daily weight (a 1lb(0.45kg) weight loss equals a 500 ml fluid loss) – Monitor hemodynamic values such as CVP – Monitor results of laboratory studies – Assess level of consciousness – Administer and monitor I.V. fluids – Apply and adjust oxygen therapy as ordered – If patient is bleeding, apply direct continuous pressure to the area and elevate it if possible – Assess skin turgor – Assess oral mucous membranes – Turn the patient at least every 2 hours to prevent skin breakdown – Encourage oral fluids
  23. 23. Hypovolemia • Warning Signs – Cool pale skin over the arms and legs – Decreased central venous pressure – Delayed capillary refill – Deterioration in mental status flat jugular veins – Orthostatic hypotension – Tachycardia – Urine output initially more than 30ml/min, then dropping below 10ml/hour – Weak or absent peripheral pulses – Weight loss
  24. 24. Collaborative Care ManagementCollaborative Care Management Identification of vulnerable patients and risk factors:Identification of vulnerable patients and risk factors: * Compromised mental state* Compromised mental state * Physical limitations* Physical limitations * Disease states* Disease states * Limited access to adequate food and fluids* Limited access to adequate food and fluids Development of a plan of careDevelopment of a plan of care Family members shouldFamily members should be educated about thebe educated about the importance of fluid andimportance of fluid and nutrition intakenutrition intake Collaboration with theCollaboration with the nurse, patient, familynurse, patient, family members, and othermembers, and other health care providershealth care providers for continuedfor continued assessment andassessment and treatment of problemstreatment of problems Ongoing assessment andOngoing assessment and detailed action plan ofdetailed action plan of fluid and serumfluid and serum electrolyte balance.electrolyte balance. Factors such asFactors such as medications (particularlymedications (particularly diuretics),diuretics), hyperventilation, fever,hyperventilation, fever, burns, diarrhea, andburns, diarrhea, and diabetes withdiabetes with appropriate referralappropriate referral
  25. 25. Collaborative Care Key PointsCollaborative Care Key Points • 1 Liter of water = 1 kg of water by weight1 Liter of water = 1 kg of water by weight • Fluid replacement are calculated according to this ratio plus 1.5 L toFluid replacement are calculated according to this ratio plus 1.5 L to fulfill the current daily needsfulfill the current daily needs • For example, JUAN, a one-year-old, lost 1 kg of water from diarrhea asFor example, JUAN, a one-year-old, lost 1 kg of water from diarrhea as weighed from his diaper over the last 24 hours. Therefore, since 1weighed from his diaper over the last 24 hours. Therefore, since 1 kg=1 L, fluid replacement therapy for him will involve 1 L of fluids +kg=1 L, fluid replacement therapy for him will involve 1 L of fluids + 1500 L.1500 L. • Oral fluid resuscitation is preferable but if the patient is unable toOral fluid resuscitation is preferable but if the patient is unable to tolerate fluids, IV Therapy may be orderedtolerate fluids, IV Therapy may be ordered • Vital signs should be assessed regularlyVital signs should be assessed regularly • Postural hypotension is common for postural persons with fluidPostural hypotension is common for postural persons with fluid volume deficit. How do we assess this?volume deficit. How do we assess this? • For example, in the care of LOIDA, a 31 year old with severe DHN, youFor example, in the care of LOIDA, a 31 year old with severe DHN, you take her blood pressure (130/80) and pulse (75) while she’s lyingtake her blood pressure (130/80) and pulse (75) while she’s lying down. Then you ask her to sit at the edge of bed. When you take herdown. Then you ask her to sit at the edge of bed. When you take her blood pressure again, you get 115/80 and when you take her pulse,blood pressure again, you get 115/80 and when you take her pulse, you get 80. This is consistent with intravascular volume depletion.you get 80. This is consistent with intravascular volume depletion. • Daily weighing is also useful to monitor fluid and electrolyte balanceDaily weighing is also useful to monitor fluid and electrolyte balance • Laboratory results should be reviewed for various fluid and electrolyteLaboratory results should be reviewed for various fluid and electrolyte disturbances so that appropriate adjustments to therapy can bedisturbances so that appropriate adjustments to therapy can be initiatedinitiated
  26. 26. Fluid Replacement Therapy • Aimed at restoring and maintaining homeostasis • Methods: – Oral and gastric feeding – Parenteral therapy • Choice of therapy affected by several factors – Type and severity of imbalance – Patient’s overall health status, age, renal and cardiovascular status – Usual maintenance requirements
  27. 27. Fluid Replacement Therapy Advantages – Provides the patient with life-sustaining fluids, electrolytes, and drugs – Immediate and predictable therapeutic effects – Preferred for administering fluids, electrolytes, and drugs in emergency situations – Allows fluid intake when a patient has GI malabsorption – Permits accurate dosage titration for analgesics and other drugs
  28. 28. Fluid Replacement Therapy Disadvantages – Solution incompatibility – Adverse reactions – Infection
  29. 29. Fluid Replacement Therapy Administration routes – Oral route : oral ingestion of fluids and electrolytes as liquids or solids administered directly into the GI tract – Nasogastric route: instillation of fluids and electrolytes through feeding tubes, such as NG, gastrostomy and jejunostomy tubes – I.V. route: administration of fluids and electrolytes directly into the bloodstream using continuous infusion, bolus, or I.V. push injection through peripheral or central venous site
  30. 30. Which among the following IV solutions contains the highest potassium content? A. D5 IMB B. Lactated Ringer's Solution C. D5 LRS D. D5 0.3 NaCl
  31. 31. Composition of Different Intravenous Solution IVF Dextrose (g/L) Na (meq/L) Cl (meq/L) K (meq/L) Lactate (meq/L) D5 0.9% NaCl 50 154 154 D5 0.15% NaCl 50 25 25 D5 0.3% NaCl 50 51 51 D5 0.45% NaCl 50 77 77 D5 IMB 50 25 22 20 23 LRS 0 130 109 4 28 NSS 0 154 154 D5LRS 50 130 109 4 28
  32. 32. Fluid Replacement Therapy ISOTONIC SOLUTION FactsFacts ExamplesExamples UsesUses -same osmolality as plasma-same osmolality as plasma (app. 275 to 295 mOsm/kg)(app. 275 to 295 mOsm/kg) -vascular space osmolality not-vascular space osmolality not altered by infusionaltered by infusion -expand intracellular and-expand intracellular and extracellular space equally;extracellular space equally; degree of expansion correlatesdegree of expansion correlates with amount of fluid infusedwith amount of fluid infused -no solution-related shifting-no solution-related shifting between ICF and ECF spacesbetween ICF and ECF spaces -cells neither shrink nor swell-cells neither shrink nor swell with fluid movementwith fluid movement Dextrose 5% inDextrose 5% in water,water, Normal SalineNormal Saline Solution,Solution, Lactated RingersLactated Ringers SolutionSolution -Fluid loss andFluid loss and dehydrationdehydration -HypernatremiaHypernatremia -Blood transfusion,Blood transfusion, fluid challenges,fluid challenges, resuscitation, shock,resuscitation, shock, metabolic alkalosis,metabolic alkalosis, hypercalcemia,hypercalcemia, hyponatremiahyponatremia -Acute blood loss,Acute blood loss, burns, dehydration,burns, dehydration, hypovolemiahypovolemia
  33. 33. Fluid Replacement Therapy HYPOTONIC SOLUTION
  34. 34. Fluid Replacement Therapy HYPERTONIC SOLUTION
  35. 35. FLUID EXCESS/HYPERVOLEMIAFLUID EXCESS/HYPERVOLEMIA PsychiatricPsychiatric Disorders, SIADH,Disorders, SIADH, Certain head injuriesCertain head injuries Dietary SodiumDietary Sodium IndiscretionIndiscretion Renal and endocrineRenal and endocrine disturbances,disturbances, malignancies, adenomasmalignancies, adenomas OverhydrationOverhydration Excessive SodiumExcessive Sodium IntakeIntake Failure of renal orFailure of renal or hormonal regulatoryhormonal regulatory functionsfunctions FLUID VOLUME EXCESS/HYPERVOLEMIAFLUID VOLUME EXCESS/HYPERVOLEMIA
  36. 36. • Since ECF becomes hypoosmolar, fluid moves into the cells to equalizeSince ECF becomes hypoosmolar, fluid moves into the cells to equalize the concentration on both sides of the cell membranethe concentration on both sides of the cell membrane • Thus there, is an increase in intracellular fluidThus there, is an increase in intracellular fluid • The brain cells are particularly sensitive to the increase ofThe brain cells are particularly sensitive to the increase of intracellular water, the most common signs of hypoosmolarintracellular water, the most common signs of hypoosmolar overhydration are changes in mental status. Confusion, ataxia, andoverhydration are changes in mental status. Confusion, ataxia, and convulsions may also occur.convulsions may also occur. • Other clinical manifestations include: hyperventilation, sudden weightOther clinical manifestations include: hyperventilation, sudden weight gain, warm, moist skin, increased ICP: slow bounding pulse with angain, warm, moist skin, increased ICP: slow bounding pulse with an increase in systolic and decrease in diastolic pressue and peripheralincrease in systolic and decrease in diastolic pressue and peripheral edema, usually not markededema, usually not marked
  37. 37. Hypervolemia • Evaluating pitting edema – Press your fingertip firmly into the patients skin over a bony surface for a few seconds. Then note the depth of the imprint your finger leaves on the skin • A slight imprint indicates +1 pitting edema • A deep imprint, with the skin slow to return to its original contour, indicates a +4 pitting edema • When the skin resists pressure and appears distended, the condition is called brawny edema, which causes the skin to swell so much that fluid cant be displaced
  38. 38. Hypervolemia • Diagnostic Findings: – Decreased hematocrit resulting from hemodilution – Normal serum Na level – Low serum K and BUN levels • either due to hemodilution or higher levels may indicate renal failure – Low oxygen level – Abnormal chest x-ray • Indicates fluid accumulation • May reveal pulmonary edema or pleural effusions
  39. 39. Hypervolemia • Treatment – Na and fluid intake restriction – Diuretics to promote excess fluid excretion – Morphine and nitroglycerin (Nitro-Dur) for pulmonary edema • Dilate blood vessels • Reduce pulmonary congestion and amount of blood returning to the heart – Digoxin for heart failure • Strengthens cardiac contractions
  40. 40. Hypervolemia • Treatment – Supportive measures • Oxygen administration • Bed rest – Hemodialysis or continuous renal replacement therapy for renal dysfunction
  41. 41. Hypervolemia • Nursing Interventions – Monitor fluid intake and output – Monitor daily weight – Monitor cardiopulmonary status – Auscultate breathe sounds – Assess for complaints of dyspnea – Monitor chest x-ray results – Monitor arterial blood gas values – Assess for peripheral edema – Inspect the patient for sacral edema – Monitor infusion of I.V. solutions – Monitor the effects of prescribed medications
  42. 42. BURN
  43. 43. General Information • Involve destruction of the epidermis, dermis, or subcutaneous layers of the skin • Can be permanently disfiguring and incapacitating and possibly life-threatening
  44. 44. General Information • Associated imbalances result from alterations in skin integrity and internal body membranes, and from effect of heat on body water and solute loss that may result from cellular destruction
  45. 45. General Information • Type and severity of imbalance depends on burn type and depth, percentage body surface area involved and burn phase
  46. 46. Pathophysiology • Burn Phase: – Refer to stages that describe physiologic changes occurring after a burn Burn phase Fluid- accumulation phase Fluid- remobilization phase Convalescent phase
  47. 47. Pathophysiology  Fluid-accumulation phase: Last fro 36 to 48 hours after a burn injury Fluid shifts from vascular compartment to interstitial space – third-space shift Edema caused by shifted fluid, which typically reaches maximum within 8 hours after injury Circulation possibly compromised and pulses diminished from severe edema Burn phase Fluid- accumulation phase Fluid- remobilization phase Convalescent phase
  48. 48. Pathophysiology • Several reasons for fluid imbalances during fluid- accumulation phase – Damage to capillaries causing altered vessel permeability – Diminished kidney perfusion – Production and release of stress hormones such as aldosterone and ADH Burn phase Fluid- accumulation phase Fluid- remobilization phase Convalescent phase
  49. 49. Pathophysiology  Respiratory problems  Muscle and tissue injuries  GI problems  Electrolyte imbalances: Common during fluid accumulation phase due to body’s hypermetabolic needs and priority that fluid replacement takes over nutritional needs during emergency phase Burn phase Fluid- accumulation phase Fluid- remobilization phase Convalescent phase
  50. 50. Pathophysiology  Fluid- remobilization phase : Also known as diuresis stage Starts about 48 hours after initial burn Fluid shifted back to vascular compartment Edema at burn site decreased, blood flow to kidneys increased, increased urine output Fluid and electrolyte imbalances can still occur Burn phase Fluid- accumulation phase Fluid- remobilization phase Convalescent phase
  51. 51. Pathophysiology  Convalescent phase: Begins after first two phases has been resolved Characterized by healing or reconstruction of burn wound Major fluid shifts now resolved but possible further fluid and electrolyte imbalances exist as a result of inadequate dietary intake Anemia is common – severe burns typically destroy red blood cells Burn phase Fluid- accumulation phase Fluid- remobilization phase Convalescent phase
  52. 52. Characteristics 1. Minor Burns a. Partial thickness burns are no greater than 15% of the TBSA in the adult b. Full thickness burns are < 2% of the TBSA in the adult c. Burn areas do not involve the eyes, ears, hands, face, feet, or perineum d. There are no electrical burns or inhalation injuries e. The client is an adult younger than 60 y.o. f. The client has no preexisting medical condition at the time of the burn injury g. No other injury occurred with the burn
  53. 53. Characteristics 2. Moderate Burns a. Partial thickness burns are deep and are 15% to 25% of the TBSA in the adult b. Full thickness burns are 2% to 10% of the TBSA in the adult c. Burn areas do not involve the eyes, ears, hands, face, feet, or perineum d. There are no electrical burns or inhalation injuries e. The client is an adult younger than 60 y.o. f. The client has no chronic cardiac, pulmonary, or endocrine disorder at the time of the burn injury g. No other complicated injury occurred with the burn
  54. 54. Characteristics 3. Major Burns a. Partial thickness burns are > 25% of the TBSA in the adult b. Full thickness burns are > 10% of the TBSA c. Burn areas involve the eyes, ears, hands, face, feet, or perineum d. The burn injury was an electrical or inhalation injury e. The client is older than 60 y.o. f. The client has a chronic cardiac, pulmonary, or metabolic disorder at the time of the burn injury g. Burns are accompanied by other injuries
  55. 55. Assessment of Burn Injury Takes several weeks to heal. Scarring may occur. Takes several weeks to heal. Scarring may occur. Superficial: Pink or red; blisters form (vesicles); weeping, edematous, elastic. Superficial layers of skin are destroyed; wound moist and painful. Deep dermal: Mottled white and red: edematous reddened areas blanch on pressure. May be yellowish but soft and elastic – may or may not be sensitive to touch; sensitive to cold air. Hair does not pull out easily Second degree In about 5 days, epidermis peels, heals spontaneously. Itching and pink skin persist for about a week. No scarring. Heals spont. If it does not become infected w/in 10 days - 2 weeks. Pink to red: slight edema, which subsides quickly. Pain may last up to 48 hours. Relieved by cooling. Sunburn is a typical example. First Degree Reparative ProcessAssessment of ExtentExtent / Degree
  56. 56. Eschar must be removed. Granulation tissue forms to nearest epithelium from wound margins or support graft. For areas larger than 3-5 cm, grafting is required. Expect scarring and loss of skin function. Area requires debridement, formation of granulation tissue, and grafting. Destruction of epithelial cells – epidermis and dermis destroyed Reddened areas do not blanch with pressure. Not painful; inelastic; coloration varies from waxy white to brown; leathery devitalized tissue is called eschar. Destruction of epithelium, fat, muscles, and bone. Third degree Reparative ProcessAssessment of ExtentExtent / Degree Assessment of Burn Injury
  57. 57. 59 Burn:Classification Superficial (1° burns) • Involve only the epidermal layer of the skin. • sunburns are commonly first-degree burns.
  58. 58. 60 1° burn 2° burn
  59. 59. 61 Superficial burn (1° burn)
  60. 60. 62 • Present of blisters indicates superficial partial-thickness injury. • Blister may ↑size because continuous exudation and collection of tissue fluid. • Healing phase of partial thickness, itching and dryness because ↑vascularization of sebaceous glands, ↓reduction of secretions and ↑perspiration. Partial thickness (2°burn)
  61. 61. 63 2° burn
  62. 62. 64 Partial thickness (2°burn)
  63. 63. 65 Burn:Classification 3.Full thickness (third-degree burn) • Destruction of the epidermis and the entire dermis, subcutaneous layer, muscle and bone. • Nerve ending are destroyed-painless wound. • Eschar may be formed due to surface dehydration. • Black networks of coagulate capillaries may be seen. • Need skin grafting because the destroyed tissue is unable to epithelialize. • Deep partial-thickness burn may convert to a full-thickness burn because of infection, trauma or ↓blood supply.
  64. 64. 66 3° burn
  65. 65. 67 Eschar:composed of denatured protein
  66. 66. 68 Full thickness (3°burn)
  67. 67. 69 Extent of surface area burned • Rule of nines-An estimated of the TBSA involved as a result of a burn. • The rule of nines measures the percentage of the body burned by dividing the body into multiples of nine. • The initial evaluation is made upon arrival at the hospital.
  68. 68. 70 Lund and Browder • More precise method of estimating • Recognizes that the percentage of BSA of various anatomic parts. • By dividing the body into very small areas and providing an estimate of proportion of BSA accounted for by such body parts • Includes, a table indicating the adjustment for different ages • Head and trunk represent larger proportions of body surface in children.
  69. 69. 71
  70. 70. 72 Age in yearsAge in years 00 11 55 1010 1515 AdultAdult A-head (back orA-head (back or front)front) 9½9½ 88 ½½ 6½6½ 5½5½ 4½4½ 3½3½ B-1 thigh (back orB-1 thigh (back or front)front) 2¾2¾ 33 ¼¼ 44 4¼4¼ 4½4½ 4¾4¾ C-1 leg (back orC-1 leg (back or front)front) 2½2½ 22 ½½ 2¾2¾ 33 3¼3¼ 3½3½ Lund and Browder chart
  71. 71. TYPES OF BURNS Thermal Burns: caused by exposure to flames, hot liquids, steam or hot objects Chemical Burns: Caused by tissue contact with strong alkali, or organic compounds Systemic toxicity from cutaneous absorption can occur Radiation Burns: caused by exposure to UV light, x-rays, or radioactive source
  72. 72. TYPES OF BURNS Electrical Burns: Caused by heat generated by electrical energy as it passes through the body Results in internal tissue damage Cutaneous burns cause muscle and soft tissue damage that may be extensive, particularly in high voltage electrical injuries Alternating current is more dangerous than direct current because it is associated with CP arrest, ventricular fibrillation, tetanic muscle contractions, and long bone or vertebral fractures
  73. 73. Potential Imbalance  Hypovolemia Approximately 10% of plasma volume lost into tissue soon after a severe burn Occurs because of the third space shift causes multiple effects: With burn’s damage to the skin surface, decrease in skins ability to prevent water loss; patient can lose up to 8L of fluid per day (400ml/hour) Potential for blood loss, adding to fluid volume losses
  74. 74. Potential Imbalance • Hypervolemia – Usually develops 3 to 5 days after a major burn injury – Occurs during the fluid remobilization phase, as fluid shifts from the interstitial space back to the vascular compartment – May be exacerbated by excessive administration of I.V. fluids
  75. 75. Potential Imbalance • Hyperkalemia / Hypokalemia • Hypocalcemia • Hyponatremia / Hypernatremia • Metabolic acidosis • Respiratory acidosis
  76. 76. Burns NURSING PRIORITY: The client with burn injury is often awake, mentally alert, and cooperative at first. The level of consciousness may change as respiratory status change or as the fluid shift occurs, precipitating hypovolemia. If the client is unconscious or confused, assess him or her for the possibility of a head injury.
  77. 77. Burns • Assess for – Patent airway – Presence of adequate breath sounds – Symptoms of hypoxia – Pulmonary damage • Burns around the face, neck, mouth or in the oral mucosal area – Circulatory status • Tachycardia and hypotension occur early • Elevate UO
  78. 78. Burns • Assess for – GI function – check last time client ate – Fluid status • UO (30 ml/hr) • Hypotension (< 90/60) • Confusion / disorientation – Circulatory status of the extremities
  79. 79. Burns  Treatment  Respiratory status takes priority over the treatment of the burn injury  If burn area is small  cold compress or immerse in cool water (not icenot ice) to ↓ heat  May have ointment on the burn area  Analgesics IV, IM, SQ. oral forms may not be absorbed effectively
  80. 80. Burns • Nursing intervention – Maintain patent airway; prevent hypoxia – Evaluate fluid status; determine circulatory status – Prevent of decrease infection – Maintain nutrition – Prevent contractures and scarring – Promote acceptance and adaptation to alterations in body image
  81. 81. Burns Formula name Electrolyte- Containing solution Colloid-Containing Solution Dextrose in Water Evans NSS 1 ml/kg/%burn NSS 1 ml/kg/%burn 2000 ml Brooke LR 1.5 ml/kg/%burn 0.5 ml/kg/%burn 2000 ml Modified Brooke LR 2 ml/kg/%burn None None Parkland LR 4 ml/kg/%burn None None Hypertonic Saline Fluid containing 250 mEq of Na/L to maintain hourly urine output of 70 ml in adults None None First 24 hours
  82. 82. Burns Formula name Electrolyte- Containing solution Colloid-Containing Solution Dextrose in Water Evans ½ of first 24-hr requirement ½ of first 24-hr requirement 2000 ml Brooke ½ - ¾ of first 24-hr requirement ½ - ¾ of first 24-hr requirement 2000 ml Modified Brooke None 0.3-0.5 ml/kg/%burn Titrate to maintain urine output Parkland None 0.3-0.5 ml/kg/%burn Titrate to maintain urine output Hypertonic Saline Same solution to maintain hourly urine output of 30 ml in adults None None Second 24 hours
  83. 83. Considerations  AGE AND GENERAL HEALTH • Mortality rates are higher for children < 4 y.o, particularly those < 1 y.o., and for clients over the age of 60 years. • Debilitating disorders, such as cardiac, respiratory, endocrine, and renal d/o, negatively influence the client’s response to injury and treatment. • Mortality rate is higher when the client has a pre- existing disorder at the time of the burn injury
  84. 84. Electrolytes
  85. 85. Which one is not a cation? A. Calcium B. Magnesium C. Phosphorous D. Sodium
  86. 86. Anions and Cations • Anions • Cations Bicarbonate Chloride Phosphorous Calcium Magnesium Potassium Sodium
  87. 87. WHAT DO ELECTROLYTES DO?WHAT DO ELECTROLYTES DO?
  88. 88. • Controls and regulates volume of body fluidsControls and regulates volume of body fluids • Its concentration is the major determinant of ECF volumeIts concentration is the major determinant of ECF volume • Is the chief electrolyte of ECFIs the chief electrolyte of ECF • Influence ICF VolumeInfluence ICF Volume •Participates in the generation and transmission of nerve impulsesParticipates in the generation and transmission of nerve impulses • Is an essential electrolyte in the sodium-potassium pumpIs an essential electrolyte in the sodium-potassium pump • RDA: not known precisely. 500 mgRDA: not known precisely. 500 mg • Eliminated primarily by the kidneys, smaller in feces and perspirationEliminated primarily by the kidneys, smaller in feces and perspiration • Salt intake affects sodium concentrationsSalt intake affects sodium concentrations • Sodium is conserved through reabsorption in the kidneys, a processSodium is conserved through reabsorption in the kidneys, a process stimulated by aldosteronestimulated by aldosterone • Normal value: 135-145 mEq/LNormal value: 135-145 mEq/L
  89. 89. HYPONATREMIAHYPONATREMIA • Refers to the serum sodium concentration less than 135 mEq/L • Common with thiazide diuretic use, but may also be seen with loop and potassium-sparing diuretics as well • Occurs with marked sodium restriction, vomiting and diarrhea, SIADH, etc. The etiology may be mulfactorial • May also occur postop due to temporary alteration in hypothalamic function, loss of GI fluids by vomiting or suction, or hydration with nonelectrolyte solutions • Postoperative hyponatremia is a more serious complication in premenopausal women. The reasons behind this is unknown • Therefore monitoring serum levels is critical and careful assessment for symptoms of hyponatremia is important for all postoperative patients
  90. 90. PATHOPHYSIOLOGY OF HYPONATREMIAPATHOPHYSIOLOGY OF HYPONATREMIA Sodium loss from the intravascular compartmentSodium loss from the intravascular compartment Diffusion of water into the interstitial spacesDiffusion of water into the interstitial spaces Sodium in the interstitial space is dilutedSodium in the interstitial space is diluted Decreased osmolarity of ECFDecreased osmolarity of ECF Water moves into the cell as a result of sodium lossWater moves into the cell as a result of sodium loss Extracellular compartment is depleted of waterExtracellular compartment is depleted of water CLINICAL SYMPTOMSCLINICAL SYMPTOMS
  91. 91. CLINICAL MANIFESTATIONS OF HYPONATREMIACLINICAL MANIFESTATIONS OF HYPONATREMIA Muscle Weakness APATHY Postural hypotension Nausea and Abdominal Cramps Weight Loss In severe hyponatremia: mental confusion, delirium, shock and comaIn severe hyponatremia: mental confusion, delirium, shock and coma
  92. 92. COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT • General goal: correct sodium imbalance and restore normal fluid andGeneral goal: correct sodium imbalance and restore normal fluid and electrolyte homeostasiselectrolyte homeostasis • Recognition of people at risk for hyponatremia is essential for itsRecognition of people at risk for hyponatremia is essential for its prevention: athletes, persons working in hot environmentsprevention: athletes, persons working in hot environments • Salt is always replaced along with waterSalt is always replaced along with water • Management includes educating vulnerable people to recognize signsManagement includes educating vulnerable people to recognize signs and symptoms of sodium depletion and maintaining sufficient sodiumand symptoms of sodium depletion and maintaining sufficient sodium and water intake to replace skin and insensible fluid lossand water intake to replace skin and insensible fluid loss • Generally, an increased sodium and water intake provides adequateGenerally, an increased sodium and water intake provides adequate treatmenttreatment • Education as the importance of sodium and fluid balance and theEducation as the importance of sodium and fluid balance and the rationale for prescription medications to ensure compliancerationale for prescription medications to ensure compliance • Daily weight. MIODaily weight. MIO • Monitoring of sodium levels to determine extent of replacementMonitoring of sodium levels to determine extent of replacement • Generally, PNSS or PLRS is prescribedGenerally, PNSS or PLRS is prescribed • Too rapid restoration of sodium balance, hypertonic sodium solutionsToo rapid restoration of sodium balance, hypertonic sodium solutions may provoke brain injurymay provoke brain injury
  93. 93. HYPERNATREMIAHYPERNATREMIA • A serum sodium level above 145 mEq/L is termed hypernatremiaA serum sodium level above 145 mEq/L is termed hypernatremia • May occur as a result of fluid deficit or sodium excessMay occur as a result of fluid deficit or sodium excess • Frequently occurs with fluid imbalanceFrequently occurs with fluid imbalance • Develops when an excess of sodium occurs without a proportionalDevelops when an excess of sodium occurs without a proportional increase in body fluid or when water loss occurs withoutincrease in body fluid or when water loss occurs without proportional loss of sodiumproportional loss of sodium • Risk Factors: excess dietary or parenteral sodium intake, wateryRisk Factors: excess dietary or parenteral sodium intake, watery diarrhea, diabetes insipidus, damage to thirst center, those withdiarrhea, diabetes insipidus, damage to thirst center, those with physical or mental status compromise, and people withphysical or mental status compromise, and people with hypothalamic dysfunctionhypothalamic dysfunction
  94. 94. PATHOPHYSIOLOGY OF HYPERNATREMIAPATHOPHYSIOLOGY OF HYPERNATREMIA Increased Sodium concentration in ECFIncreased Sodium concentration in ECF Osmolarity risesOsmolarity rises Water leaves the cell by osmosis and entersWater leaves the cell by osmosis and enters the the extracellular compartmentsthe the extracellular compartments Dilution of fluids in ECFDilution of fluids in ECF Cells are water depletedCells are water depleted Suppression of aldosteroneSuppression of aldosterone secretionsecretion Sodium is exreted in theSodium is exreted in the urineurine CLINICAL SYMPTOMSCLINICAL SYMPTOMS
  95. 95. CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS Dry, sticky mucousDry, sticky mucous membranesmembranes Firm, rubberyFirm, rubbery tissue turgortissue turgor Manic excitementManic excitement TachycardiaTachycardia DEATHDEATH
  96. 96. COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT • Recognition of risk factors: bedridden and debilitated patients,Recognition of risk factors: bedridden and debilitated patients, diabetes insipidus, fluid deprivation, the elderly and the verydiabetes insipidus, fluid deprivation, the elderly and the very youngyoung • A careful and accurate record of MIO permits quick recognitionA careful and accurate record of MIO permits quick recognition of negative fluid balanceof negative fluid balance • People with kidney failure, CHF, or increased aldosteronePeople with kidney failure, CHF, or increased aldosterone production may require dietary sodium intake restrictionproduction may require dietary sodium intake restriction • Usually, osmolar balance can be restored with oral fluids. IfUsually, osmolar balance can be restored with oral fluids. If not, the parenteral route may be necessarynot, the parenteral route may be necessary • Fluid resuscitation must be undertaken with particular cautionFluid resuscitation must be undertaken with particular caution in patients with compromised cardiac or renal functionin patients with compromised cardiac or renal function • The nurse should closely monitor the patient’s response toThe nurse should closely monitor the patient’s response to fluids and be alert to symptoms of fluid overloadfluids and be alert to symptoms of fluid overload
  97. 97. • Major cation of the ICF. Chief regulator of cellular enzyme activity andMajor cation of the ICF. Chief regulator of cellular enzyme activity and cellular water contentcellular water content • The more K, the less Na. The less K, the more NaThe more K, the less Na. The less K, the more Na • Plays a vital role in such processes such as transmission of electricalPlays a vital role in such processes such as transmission of electrical impulses, particularly in nerve, heart, skeletal, intestinal and lung tissue;impulses, particularly in nerve, heart, skeletal, intestinal and lung tissue; CHON and CHO metabolism; and cellular building; and maintenance ofCHON and CHO metabolism; and cellular building; and maintenance of cellular metabolism and excitationcellular metabolism and excitation • Assists in regulation of acid-base balance by cellular exchange with HAssists in regulation of acid-base balance by cellular exchange with H • RDA: not known precisely. 50-100 mEqRDA: not known precisely. 50-100 mEq • Sources: bananas, peaches, kiwi, figs, dates, apricots, oranges,Sources: bananas, peaches, kiwi, figs, dates, apricots, oranges, prunes, melons, raisins, broccoli, and potatoes, meat, dairy productsprunes, melons, raisins, broccoli, and potatoes, meat, dairy products • Excreted primarily by the kidneys. No effective conserving mechanismExcreted primarily by the kidneys. No effective conserving mechanism • Conserved by sodium pump and kidneys when levels are lowConserved by sodium pump and kidneys when levels are low • Aldosterone triggers K excretion in urineAldosterone triggers K excretion in urine • Normal value: 3.5 – 5 mEq/LNormal value: 3.5 – 5 mEq/L
  98. 98. CAUSES AND EFFECTS OF HYPOKALEMIACAUSES AND EFFECTS OF HYPOKALEMIA • Known as a low level of serum potassium, less than 3.5 mEq/LKnown as a low level of serum potassium, less than 3.5 mEq/L Decreased IntakeDecreased Intake ↓ Food and Fluids as in starvation Failure to replace GI losses Increased LossIncreased Loss ↑↑ AldosteroneAldosterone Gastrointestinal lossesGastrointestinal losses Potassium-losing diureticsPotassium-losing diuretics Loss from cells as in trauma,Loss from cells as in trauma, burnsburns Shift of PotassiumShift of Potassium into Cellsinto Cells (No change in total(No change in total body potassium)body potassium) HYPOKALEMIAHYPOKALEMIA GI TractGI Tract Anorexia N&V Abdominal distention CNSCNS Lethargy, Diminished deep-tendon reflexes, Confusion, Mental depression MusclesMuscles Weakness, Flaccid paralysis, Weakness of respiratory muscles, Respiratory arrest CV SystemCV System Decrease in standing BP, Dysrhythmias, ECG changes, Myocardial damage, Cardiac arrest KidneysKidneys ↓Capacity to concentrate waste, water loss, thirst, kidney damage
  99. 99. PATHOPHYSIOLOGY OF HYPOKALEMIAPATHOPHYSIOLOGY OF HYPOKALEMIA = Action Potential= Action Potential Nerve and Muscle ActivityNerve and Muscle Activity LowLow ExtracellularExtracellular K+K+ Increase inIncrease in restingresting membranemembrane potentialpotential The cellThe cell becomesbecomes lessless excitableexcitable
  100. 100. Sodium is retained in the body through resorption bySodium is retained in the body through resorption by the kidney tubulesthe kidney tubules Potassium is excretedPotassium is excreted Aldosterone is secretedAldosterone is secreted Use of certain diuretics such as thiazides and furosemide, andUse of certain diuretics such as thiazides and furosemide, and corticosteroidscorticosteroids Increased urinary outputIncreased urinary output Loss of potassium in urineLoss of potassium in urine
  101. 101. COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT • Being alert to the conditions that cause potassium depletion such as vomiting, diarrhea and diuretics, by monitoring the patient for early warning signs • No more than 3 enemas without consulting a physician • Education about the importance of adequate dietary intake of potassium • In severe hypokalemia, a patient may die unless potassium is administered promptly • The safest way to administer K is orally. When K is given IV, the rate of flow must be monitored closely and should be diluted. Should not exceed 20 mEq/hr • If PO, taken with at least ½ glass of water • Cardiac monitoring is useful • Potassium sparing diuretics such as triamterene, spironolactone, etc • Symptoms of K depletion: muscle weakness, anorexia, nausea and vomiting = appropriate referral
  102. 102. CAUSES AND EFFECTS OF HYPERKALEMIACAUSES AND EFFECTS OF HYPERKALEMIA • Serum potassium level greater than 5.5 mEq/LSerum potassium level greater than 5.5 mEq/L Excess IntakeExcess Intake Dietary intake of excess of kidney’s ability to excrete; Excess parenteral administration Decreased LossDecreased Loss Potassium-sparing diuretics;Potassium-sparing diuretics; Renal failure; AdrenalRenal failure; Adrenal insufficiencyinsufficiency Shift of PotassiumShift of Potassium out of the Cellsout of the Cells Extensive injuries,Extensive injuries, crushing injuries,crushing injuries, metabolic acidosismetabolic acidosis HYPERKALEMIAHYPERKALEMIA GI TractGI Tract N&V Diarrhea, Colic CNSCNS Numbness, paresthesias MusclesMuscles Early: irritability Late: weakness leading to flaccid paralysis CV SystemCV System Conduction disturbance, ventricular fibrillation, Cardiac Arrest KidneysKidneys Oliguria leading to anuria
  103. 103. COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT • Patients at risk should be identified: impaired renal function toPatients at risk should be identified: impaired renal function to avoid OTC, esp. NSAIDS which provoke hyperkalemia; and saltavoid OTC, esp. NSAIDS which provoke hyperkalemia; and salt substitutes that are high in potassiumsubstitutes that are high in potassium • Severity guides therapySeverity guides therapy – Mild: Withholding provoking agent (i.e., K supp)Mild: Withholding provoking agent (i.e., K supp) – Severe (>6 mEq/L: cation-exchange resin such asSevere (>6 mEq/L: cation-exchange resin such as Kayexalate (act by exchanging the cations in the resin forKayexalate (act by exchanging the cations in the resin for the potassium in the intestinethe potassium in the intestine  potassium is then excretedpotassium is then excreted in the stool; Continuous cardiac monitoringin the stool; Continuous cardiac monitoring • Bowel function must be maintained if Kayexelate therapy is toBowel function must be maintained if Kayexelate therapy is to be effectivebe effective • Potassium-wasting diuretics may be prescribed to promotePotassium-wasting diuretics may be prescribed to promote further potassium loss. Dialysis for patients with renal failure tofurther potassium loss. Dialysis for patients with renal failure to eliminate excess potassiumeliminate excess potassium • Intravenous Ca Gluconate may be prescribed to counteract theIntravenous Ca Gluconate may be prescribed to counteract the cardiac effects of hyperkalemiacardiac effects of hyperkalemia • Insulin infusions and IV NaCO3 may be used to promoteInsulin infusions and IV NaCO3 may be used to promote intracellular uptake of Kintracellular uptake of K
  104. 104. • Most abundant electrolyte in the body. 99% in bones and teethMost abundant electrolyte in the body. 99% in bones and teeth • Close link between calcium and phosphorus. High PO4, Low CaClose link between calcium and phosphorus. High PO4, Low Ca • Necessary for nerve impulse transmission and blood clotting and isNecessary for nerve impulse transmission and blood clotting and is also a catalyst for muscle contraction and other cellular activitiesalso a catalyst for muscle contraction and other cellular activities • Needed for Vitamin B12 absorption and useNeeded for Vitamin B12 absorption and use • Necessary for strong bones and teeth and thickness and strength ofNecessary for strong bones and teeth and thickness and strength of cell membranescell membranes • RDA: 1g for adults. Higher for children and pregnant and lactatingRDA: 1g for adults. Higher for children and pregnant and lactating women according to body weight, older people, esp. post-menopausalwomen according to body weight, older people, esp. post-menopausal • Found in milk, cheese, and dried beans; some in meat and vegetablesFound in milk, cheese, and dried beans; some in meat and vegetables • Use is stimulated by Vitamin D. Excreted in urine, feces, bile, digestiveUse is stimulated by Vitamin D. Excreted in urine, feces, bile, digestive secretions, and perspirationsecretions, and perspiration • Normal value 8.5 – 10.5 mg/dlNormal value 8.5 – 10.5 mg/dl
  105. 105. CAUSES AND EFFECTS OF HYPOCALCEMIACAUSES AND EFFECTS OF HYPOCALCEMIA DecreasedDecreased Ionized CaIonized Ca Large tranfusion with citrated blood Excess LossExcess Loss Kidney DiseaseKidney Disease Decrease in GI TractDecrease in GI Tract and Bone Absorptionand Bone Absorption ↑↑MagnesiumMagnesium ↑↑CalcitoninCalcitonin ↓Vitamin D ↓Parathyroid Hormone HYPOCALCEMIAHYPOCALCEMIA BonesBones Osteoporosis leading to Fractures CNSCNS Tingling ↓ convulsions OtherOther Abnormal deposits of calcium in body tissues MusclesMuscles Muscle spasm ↓ Tetany CardiovascularCardiovascular SystemSystem Dysrhythmias ↓ Cardiac arrest InadequateInadequate IntakeIntake Dietary DeficitDietary Deficit
  106. 106. PATHOPHYSIOLOGY OF HYPOCALCEMIAPATHOPHYSIOLOGY OF HYPOCALCEMIA •Calcium ions are thought to line the pores of cell membranes, especially neurons •Calcium and Sodium repel each other •When serum calcium levels are low, this blocking effect is minimized •When Sodium moves more easily into the cell, depolarization takes place more easily •This results in increased excitability of the nervous system leading to muscle spasm, tingling sensations, and if severe, convulsions and tetany •Skeletal, smooth, and cardiac muscle functions are all affected by overstimulation Sodium Calcium
  107. 107. CLINICAL MANIFESTATIONS OF HYPOCALCEMIACLINICAL MANIFESTATIONS OF HYPOCALCEMIA COMPLAINT OF NUMBNESS AND TINGLING OF EARS, NOSE,COMPLAINT OF NUMBNESS AND TINGLING OF EARS, NOSE, FINGERTIPS OR TOESFINGERTIPS OR TOES TREATMENTTREATMENT PAINFUL MUSCULAR SPASMS (TETANY)PAINFUL MUSCULAR SPASMS (TETANY) ESPECIALLY OF FEET AND HANDSESPECIALLY OF FEET AND HANDS (CARPOPEDAL SPASMS), MUSCLE TWITCHING(CARPOPEDAL SPASMS), MUSCLE TWITCHING AND CONVULSIONS MAY FOLLOWAND CONVULSIONS MAY FOLLOW
  108. 108. TESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCYTESTS USED TO ELICIT SIGNS OF CALCIUM DEFICIENCY
  109. 109. COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT • Identify risk factors: Inadequate calcium intake, excess calcium loss,Identify risk factors: Inadequate calcium intake, excess calcium loss, Vitamin D deficiency, patients with poor dietsVitamin D deficiency, patients with poor diets • Education about the importance of adequate calcium and Vitamin DEducation about the importance of adequate calcium and Vitamin D intakeintake • Patients undergoing thyroid, parathyroid, and radical neck surgery arePatients undergoing thyroid, parathyroid, and radical neck surgery are particularly vulnerable to hypocalcemia secondary to parathyroidparticularly vulnerable to hypocalcemia secondary to parathyroid hormone deficithormone deficit • Monitoring of serum calcium levels and correction of deficitsMonitoring of serum calcium levels and correction of deficits • Citrate is added to store blood to prevent coagulation.Citrate is added to store blood to prevent coagulation. • Citrate + Transfusion = Citrate+CalciumCitrate + Transfusion = Citrate+Calcium • Normally, Liver + Citrate = Quick metabolismNormally, Liver + Citrate = Quick metabolism • Preexisting calcium deficit/hepatic dysfunction/large amounts of BTPreexisting calcium deficit/hepatic dysfunction/large amounts of BT very rapidly = hypocalcemiavery rapidly = hypocalcemia • With acute hypocalcemia, Ca Gluconate is used + Continuous cardiacWith acute hypocalcemia, Ca Gluconate is used + Continuous cardiac monitoringmonitoring • Mild Hypocalcemia: High calcium diet or oral calcium saltsMild Hypocalcemia: High calcium diet or oral calcium salts • If PTH or Vit D Deficiency is the cause: aluminum hydroxide gel isIf PTH or Vit D Deficiency is the cause: aluminum hydroxide gel is used because when serum phosphate level rises, calcium level fallsused because when serum phosphate level rises, calcium level falls • Complication: Bone demineralizationComplication: Bone demineralization • Therefore, careful ambulation should be encouraged to minimize boneTherefore, careful ambulation should be encouraged to minimize bone resorptionresorption
  110. 110. HYPERCALCEMIA: Serum concentration > 10mg/dLHYPERCALCEMIA: Serum concentration > 10mg/dL Causes and EffectsCauses and Effects Loss from bonesLoss from bones Immobilization, Carcinoma with bone metastases, Multiple myeloma Excess IntakeExcess Intake ↑↑ Calcium diet (esp. milk)Calcium diet (esp. milk) Antacids containing calciumAntacids containing calcium Increase in factorsIncrease in factors Causing MobilizationCausing Mobilization from bonefrom bone ↑↑PTH, ↑PTH, ↑ Vitamin D, steroid therapy HYPERCALCEMIAHYPERCALCEMIA KidneysKidneys Stones ↓ Kidney Damage CNSCNS ↓Deep-tendon reflexes ↓ Lethargy ↓ Coma BonesBones Bone pain ↓ Osteoporosis ↓ Fractures MusclesMuscles Muscle fatigue, hypotonia ↓ ↓ GI motility CV SystemCV System Depressed activity ↓ Dysrhythmias ↓ Cardiac Arrest
  111. 111. HOW IT HAPPENSHOW IT HAPPENS HYPERCALCEMIAHYPERCALCEMIA DEPRESSED NERVEDEPRESSED NERVE AND MUSCLEAND MUSCLE ACTIVITYACTIVITY DEEP TENDONDEEP TENDON REFLEXES MAY BEREFLEXES MAY BE DECREASED ORDECREASED OR ABSENTABSENT MYOCARDIALMYOCARDIAL FUNCTION ISFUNCTION IS ALTEREDALTERED
  112. 112. CLINICAL MANIFESTATIONS OF HYPERCALCEMIACLINICAL MANIFESTATIONS OF HYPERCALCEMIA Decreased GIDecreased GI MotilityMotility Cardiac DysrhythmiasCardiac Dysrhythmias ConstipationConstipation NauseaNausea Mental status changes:Mental status changes: lethargy, confusion,lethargy, confusion, memory lossmemory loss
  113. 113. CLINICAL MANIFESTATIONS OF HYPERCALCEMIACLINICAL MANIFESTATIONS OF HYPERCALCEMIA ImmobilizationImmobilization BoneBone DemineralizationDemineralization CalciumCalcium accumulates inaccumulates in the ECF andthe ECF and passes throughpasses through the kidneysthe kidneys Ca PrecipitationCa PrecipitationCalcium StonesCalcium Stones
  114. 114. COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT • Mild hypercalcemia: hydration and education about avoiding foods high in calcium or medications that promote calcium elevation • Ambulation as appropriate; weight-bearing exercises as tolerated • Trapeze, resistance devices • Marked hypercalcemia: prevention of pathologic fractures, individualized plan of care • Prevention of renal calculi: encourage oral fluids to prevent concentrated urine: 3000 to 4000 mL/day unless contraindicated • Acid-ash fruit juices: cranberry juice and prune juice • Severe hypercalcemia: medical emergency: continuous cardiac monitoring, hydration, IV furosemide, Calcitonin and/or plicamycin (mithramycin), q2 serum and urinary electrolytes
  115. 115. • Mostly found within body cells: heart, bone, nerve, and muscle tissuesMostly found within body cells: heart, bone, nerve, and muscle tissues • Second most important cation in the ICF, 2Second most important cation in the ICF, 2ndnd to K+to K+ • Functions: Metabolism of CHO and CHON, protein and DNA synthesis,Functions: Metabolism of CHO and CHON, protein and DNA synthesis, DNA and RNA transcription, and translation of RNA, maintains normalDNA and RNA transcription, and translation of RNA, maintains normal intracellular levels of potassium, helps maintain electric activity inintracellular levels of potassium, helps maintain electric activity in nervous tissue membranes and muscle membranesnervous tissue membranes and muscle membranes • RDA: about 18-30 mEq; children require larger amountsRDA: about 18-30 mEq; children require larger amounts • Sources: vegetables, nuts, fish, whole grains, peas, and beansSources: vegetables, nuts, fish, whole grains, peas, and beans • Absorbed in the intestines and excreted by the kidneysAbsorbed in the intestines and excreted by the kidneys • Plasma concentrations of magnesium range from 1.5 – 2.5 mEq/L, withPlasma concentrations of magnesium range from 1.5 – 2.5 mEq/L, with about one third of that amount bound to plasma proteinsabout one third of that amount bound to plasma proteins
  116. 116. HYPOMAGNESEMIA: Serum level < 1.5 mEq/LHYPOMAGNESEMIA: Serum level < 1.5 mEq/L • Usually coexists with hypokalemia and less often with hypocalcemia Decreased IntakeDecreased Intake Prolonged malnutrition, Starvation Impaired absorption from GI TractImpaired absorption from GI Tract Malabsorption syndrome, Alcohol WithdrawalMalabsorption syndrome, Alcohol Withdrawal Syndrome, Hypercalcemia, Diarrhea,Syndrome, Hypercalcemia, Diarrhea, Draining gastrointestinal fistulaDraining gastrointestinal fistula ExcessiveExcessive ExcretionExcretion ↑↑Aldosterone,Aldosterone, ConditionsConditions causing largecausing large losses of urinelosses of urine HYPOMAGNESEMIAHYPOMAGNESEMIA Mental ChangesMental Changes Agitation, Depression, Confusion CNSCNS Convulsions, Paresthesias, Tremor, Ataxia MusclesMuscles Cramps, Spasticity, Tetany CV SystemCV System Tachycardia, Hypotension, Dysrhythmias HYPOKALEMIAHYPOKALEMIA
  117. 117. PATHOPHYSIOLOGY OF HYPOMAGNESEMIAPATHOPHYSIOLOGY OF HYPOMAGNESEMIA Low serum magnesium levelLow serum magnesium level Increased acetylcholine releaseIncreased acetylcholine release Increased neuromuscular irritabilityIncreased neuromuscular irritability Increased sensitivity to acetylcholine at the myoneural junctionIncreased sensitivity to acetylcholine at the myoneural junction Diminished threshold ofDiminished threshold of excitation for the motorexcitation for the motor nervenerve Enhancement of myofibrilEnhancement of myofibril contractioncontraction
  118. 118. PATHOPHYSIOLOGY OF HYPOMAGNESEMIAPATHOPHYSIOLOGY OF HYPOMAGNESEMIA High Serum CalciumHigh Serum Calcium Increased acetylcholine releaseIncreased acetylcholine release Increased neuromuscular irritabilityIncreased neuromuscular irritability Increased sensitivity to acetylcholine at the myoneural junctionIncreased sensitivity to acetylcholine at the myoneural junction Diminished threshold ofDiminished threshold of excitation for the motorexcitation for the motor nervenerve Enhancement of myofibrilEnhancement of myofibril contractioncontraction High Serum CalciumHigh Serum Calcium Excretion of MagnesiumExcretion of Magnesium By the GI tractBy the GI tract
  119. 119. PATHOPHYSIOLOGY OF HYPOMAGNESEMIAPATHOPHYSIOLOGY OF HYPOMAGNESEMIA MAGNESIUMMAGNESIUM INHIBITS TRANSPORT OF PTHINHIBITS TRANSPORT OF PTH DECREASE IN THE AMOUNT OF CALCIUM BEING RELEASEDDECREASE IN THE AMOUNT OF CALCIUM BEING RELEASED FROM THE BONEFROM THE BONE POSSIBLE CALCIUM DEFICITPOSSIBLE CALCIUM DEFICIT
  120. 120. CLINICAL MANIFESTATIONS OF HYPOMAGNESEMIACLINICAL MANIFESTATIONS OF HYPOMAGNESEMIA CONFUSIONCONFUSION DEPRESSIONDEPRESSION CRAMPSCRAMPS TETANYTETANY CONVULSIONSCONVULSIONS
  121. 121. COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT • Recognition of people at risk: people taking loop diuretics andRecognition of people at risk: people taking loop diuretics and digoxin should be encouraged to eat foods rich in magnesium,digoxin should be encouraged to eat foods rich in magnesium, such as fruits, vegetables, cereals, and milksuch as fruits, vegetables, cereals, and milk • Recognition of signs and symptoms of magnesium deficiencyRecognition of signs and symptoms of magnesium deficiency • Magnesium is essential for potassium resorption, so ifMagnesium is essential for potassium resorption, so if hypokalemia does not respond to potassium replacement,hypokalemia does not respond to potassium replacement, hypomagnesemia should be suspectedhypomagnesemia should be suspected • Treatment of the underlying cause is the first consideration inTreatment of the underlying cause is the first consideration in hypomagnesemiahypomagnesemia • Severe: parenteral magnesium replacement is indicatedSevere: parenteral magnesium replacement is indicated • IV therapy: continuous cardiac monitoringIV therapy: continuous cardiac monitoring • Safety measures for patients with mental status changesSafety measures for patients with mental status changes
  122. 122. HYPERMAGNESEMIA: Serum Mg level 2.5 mEq/LHYPERMAGNESEMIA: Serum Mg level 2.5 mEq/L • Seldom develops in the presence of normal renal functionSeldom develops in the presence of normal renal function • May occur as a result of Mg replacementMay occur as a result of Mg replacement • May occur when MgSO4 is administered to prevent seizuresMay occur when MgSO4 is administered to prevent seizures resulting from eclampsiaresulting from eclampsia • Careful monitoring is imperativeCareful monitoring is imperative
  123. 123. PATHOPHYSIOLOGYPATHOPHYSIOLOGY Renal failure, Excessive IV infusion ofRenal failure, Excessive IV infusion of magnesium, Decreased GI eliminationmagnesium, Decreased GI elimination and/or absorption, etc.and/or absorption, etc. Accummulation of Mg in the bodyAccummulation of Mg in the body Diminishing of reflexes, drowsiness, lethargyDiminishing of reflexes, drowsiness, lethargy Mg Level RisesMg Level Rises Severe Respiratory DepressionSevere Respiratory Depression RESPIRATORY ARREST may occurRESPIRATORY ARREST may occur Altered Electrical ConductionAltered Electrical Conduction Slowed heartSlowed heart rate and AVrate and AV BlockBlock PeripheralPeripheral vasodilationvasodilation Hypotension, flushing, andHypotension, flushing, and increased skin warmthincreased skin warmth
  124. 124. COLLABORATIVE CARE MANAGEMENTCOLLABORATIVE CARE MANAGEMENT • Identification of patients at risk: those with impaired renalIdentification of patients at risk: those with impaired renal function to avoid OTC that contain magnesium such as Milk offunction to avoid OTC that contain magnesium such as Milk of Magnesia and some Mg-containing antacidsMagnesia and some Mg-containing antacids • Any patient receiving parenteral magnesium therapy should beAny patient receiving parenteral magnesium therapy should be assessed frequently for signs of hypermagnesemiaassessed frequently for signs of hypermagnesemia • Mild hypermagnesemia: withholding magnesium-containingMild hypermagnesemia: withholding magnesium-containing medications may sufficemedications may suffice • Renal failure: dialysisRenal failure: dialysis • Severe: may require treatment with calcium gluconate (10-20Severe: may require treatment with calcium gluconate (10-20 mL of 10% Ca Gluconate administered over 10 minutes)mL of 10% Ca Gluconate administered over 10 minutes) • If cardiorespiratory collapse is imminent, the patient mayIf cardiorespiratory collapse is imminent, the patient may require temporary pacemaker and ventilator supportrequire temporary pacemaker and ventilator support
  125. 125. NURSING MANAGEMENT OFNURSING MANAGEMENT OF PATIENT WITH FLUID ANDPATIENT WITH FLUID AND ELECTROLYTE IMBALANCESELECTROLYTE IMBALANCES
  126. 126. Parameter_____Fluid Excess___Parameter_____Fluid Excess___ Fluid Loss/Electrolyte Imbalance____Fluid Loss/Electrolyte Imbalance____ Behavior Tires easily; Change in behavior, confusion, apathy Head, neck Facial edema, distended neck Headache, thirst, dry mucous membranes veins Upper GI Anorexia, nausea, vomiting Skin Warm, moist, taut, cool feeling Dry, decreased turgor where edematous Respiration Dyspnea, orthopnea, productive Changes in rate and depth of respiration cough, moist breath sounds Circulation Loss of sensation in edematous Pulse rate changes, dysrhythmia, postural areas, pallor, bounding pulse, increased blood pressure hypotension Abdomen Increased girth, fluid wave Distention, abdominal cramps Elimination Constipation Diarrhea, constipation Extremities Dependent edema, “pitting” Muscle weakness, tingling, tetany , discomfort from weight of bedclothes
  127. 127. Pitting edemaPitting edema Dependent edemaDependent edema Refractory EdemaRefractory Edema
  128. 128. LABORATORY VALUESLABORATORY VALUES FLUID DEFICITFLUID DEFICIT FLUID EXCESSFLUID EXCESS HemoconcentrationHemoconcentration HemodilutionHemodilution ↑↑ Hct, BUN, E+ levelsHct, BUN, E+ levels ↓↓ Hct, BUN, E+ levelsHct, BUN, E+ levels ↑↑ Urine Specific GravityUrine Specific Gravity ↓ Urine Specific Gravity↓ Urine Specific Gravity
  129. 129. Determined from analysis of patient dataDetermined from analysis of patient data Diagnostic TitleDiagnostic Title Possible Etiologic FactorsPossible Etiologic Factors 11 Deficient fluid volumeDeficient fluid volume Active fluid volume lossActive fluid volume loss (hemorrhage, diarrhea, gastric(hemorrhage, diarrhea, gastric intubation, wounds, diaphoresis),intubation, wounds, diaphoresis), inadequate fluid intake, failure ofinadequate fluid intake, failure of regulatory mechanisms,regulatory mechanisms, sequestration of body fluidssequestration of body fluids 22 Excess Fluid VolumeExcess Fluid Volume Excess fluid intake, excess sodiumExcess fluid intake, excess sodium intake, compromised regulatoryintake, compromised regulatory processesprocesses
  130. 130. EXPECTED PATIENT OUTCOMESEXPECTED PATIENT OUTCOMES 1.1. Will maintain functional fluid volume as evidenced byWill maintain functional fluid volume as evidenced by adequate urinary output, stable weight, normal vitaladequate urinary output, stable weight, normal vital signs, normal urine specific gravity, moist mucussigns, normal urine specific gravity, moist mucus membranes, balanced intake and output, elastic skin turgor,membranes, balanced intake and output, elastic skin turgor, prompt capillary refill, and absence of edemaprompt capillary refill, and absence of edema 2.2. Will verbalize understanding of treatment plan andWill verbalize understanding of treatment plan and causative factors that led to the imbalancecausative factors that led to the imbalance
  131. 131. 1,21,2Intake and Output MonitoringIntake and Output Monitoring - Type and amount of fluid the patient has received and the- Type and amount of fluid the patient has received and the route by which they were administeredroute by which they were administered -- Record of solid food intake. Gelatin or Popsicles areRecord of solid food intake. Gelatin or Popsicles are recorded as fluidsrecorded as fluids -- Ice chips are recorded by dividing the amount of chipsIce chips are recorded by dividing the amount of chips by ½ (60 mL of chips = 30 mL water)by ½ (60 mL of chips = 30 mL water) -- Accurate output record and described by color, content,Accurate output record and described by color, content, and odor (Normally, gastric contents are watery and paleand odor (Normally, gastric contents are watery and pale yellow-green; they usually have a sour odor)yellow-green; they usually have a sour odor) -- With acid-base balance upset, gastric secretions mayWith acid-base balance upset, gastric secretions may have a fruity odor because of ketone bodieshave a fruity odor because of ketone bodies -- Bile: thicker than gastric juice, dark green to brown,Bile: thicker than gastric juice, dark green to brown, acrid odor, bitter taste when vomitingacrid odor, bitter taste when vomiting -- NGT irrigation added to intakeNGT irrigation added to intake -- Stools: difficult to estimate amount; consistency, color,Stools: difficult to estimate amount; consistency, color, and number of stools provide a reasonable estimateand number of stools provide a reasonable estimate -- Peritoneal or pleural fluid drainage is recorded as outputPeritoneal or pleural fluid drainage is recorded as output as with its amount, color, and clarityas with its amount, color, and clarity -- Character and volume of urine. Place signs andCharacter and volume of urine. Place signs and materials somaterials so that an accurate record of UO is maintainedthat an accurate record of UO is maintained
  132. 132. 1,21,2 Intake and Output MonitoringIntake and Output Monitoring - Evaluate and refer urine specific gravity as appropriate- Evaluate and refer urine specific gravity as appropriate (normal value is 1.003 – 1.030). The implications are:(normal value is 1.003 – 1.030). The implications are: HighHigh DehydrationDehydration LowLow SIADH, overhydrationSIADH, overhydration -- Drainage, fluid aspirated from any body cavity must beDrainage, fluid aspirated from any body cavity must be measured. With dressings, fluid loss is the differencemeasured. With dressings, fluid loss is the difference between the wet dressings and the dry weight of thebetween the wet dressings and the dry weight of the dressingdressing -- Accurate recording of the temperature to help theAccurate recording of the temperature to help the physician determine how much fluid should be replacedphysician determine how much fluid should be replaced 1,21,2 Daily WeightDaily Weight -- Evaluate trends in weight (An increase in 1kg in weightEvaluate trends in weight (An increase in 1kg in weight is equal to the retention of 1L of fluid in an edematousis equal to the retention of 1L of fluid in an edematous patient)patient) Considerations:Considerations: -- Daily weights early in the morning after voidingDaily weights early in the morning after voiding but before he or she has eaten or defecatedbut before he or she has eaten or defecated
  133. 133. 11 Replacement of Fluid and ElectrolytesReplacement of Fluid and Electrolytes General Principles:General Principles: -- Either by oral intake (healthiest way), tube feeding,Either by oral intake (healthiest way), tube feeding, intravenous infusion, and/or total parenteral nutritionintravenous infusion, and/or total parenteral nutrition -- Normal saline solution and plain water should also beNormal saline solution and plain water should also be given by slow drip to replace daily fluid lossgiven by slow drip to replace daily fluid loss -- IV administration per doctor’s ordersIV administration per doctor’s orders -- Fluid replacement considerations:Fluid replacement considerations: ** Most effective when apportioned over 24 hr periodMost effective when apportioned over 24 hr period (Better regulation,(Better regulation, ↓potential for calculi formation and↓potential for calculi formation and subsequent renal damage, ↓potential for circulatorysubsequent renal damage, ↓potential for circulatory overload which may cause in fluid and electrolyteoverload which may cause in fluid and electrolyte shifts)shifts) ** Administer concentrated solutions of Na, Glucose orAdminister concentrated solutions of Na, Glucose or protein because they require body fluids for dilutionprotein because they require body fluids for dilution ** Consider the size of the patient (small adult has lessConsider the size of the patient (small adult has less fluid in each compartment, especially in thefluid in each compartment, especially in the intravascular compartment)intravascular compartment) -- Promote oral intake as appropriatePromote oral intake as appropriate ** Caution with coffee, tea, and some colasCaution with coffee, tea, and some colas
  134. 134. ** small amount at frequent intervals is more useful than asmall amount at frequent intervals is more useful than a large amount presented less oftenlarge amount presented less often ** Always give consideration to cultural and aestheticAlways give consideration to cultural and aesthetic aspects of eatingaspects of eating -- Give mouth care to a dehydrated patient before and afterGive mouth care to a dehydrated patient before and after mealsmeals and before bedtime (Xerostomia may lead toand before bedtime (Xerostomia may lead to disruption of tissues indisruption of tissues in the oral cavity)the oral cavity) -- Avoid irritating foodsAvoid irritating foods -- Stimulation of saliva may be aided by hard candy or chewingStimulation of saliva may be aided by hard candy or chewing gum or carboxymethylcellulose (artificial saliva)gum or carboxymethylcellulose (artificial saliva) -- Keep lips moist and well lubricatedKeep lips moist and well lubricated -- Give salty broth or soda crackers for sodium replacementGive salty broth or soda crackers for sodium replacement andand tea or orange juice for potassium replacement astea or orange juice for potassium replacement as appropriate.appropriate. Bananas, citrus fruits and juices, some freshBananas, citrus fruits and juices, some fresh vegetables, coffee, andvegetables, coffee, and tea are relatively high in potassiumtea are relatively high in potassium and low in sodium. Milk, meat,and low in sodium. Milk, meat, eggs, and nuts are high ineggs, and nuts are high in protein, sodium and potassium.protein, sodium and potassium. -- Offer milk for patients with draining fistulas from any portionOffer milk for patients with draining fistulas from any portion of theof the GI tract. Lactose intolerance is not necessarily aGI tract. Lactose intolerance is not necessarily a contraindication (Lactase enzyme preparations are available)contraindication (Lactase enzyme preparations are available) -- Increase usual daily requirement of foods when losses mustIncrease usual daily requirement of foods when losses must bebe restored, as toleratedrestored, as tolerated
  135. 135. ** Patients with cardiac and renal impairments arePatients with cardiac and renal impairments are instructed to avoid foods containing high levelsinstructed to avoid foods containing high levels of sodium, potassium and bicarbonateof sodium, potassium and bicarbonate -- Administer replacement solutions through tube feeding as isAdminister replacement solutions through tube feeding as is ** Either water, physiologic solution of NaCl, high proteinEither water, physiologic solution of NaCl, high protein liquids, or a regular diet can be blended, diluted andliquids, or a regular diet can be blended, diluted and given by gavagegiven by gavage ** The water content in the tube feeding needs to beThe water content in the tube feeding needs to be increased if:increased if: 11 the patient complains of thirstthe patient complains of thirst 22 the protein or electrolyte content of the tubethe protein or electrolyte content of the tube feeding is highfeeding is high 33 the patient has fever or disease causing anthe patient has fever or disease causing an increased metabolic rateincreased metabolic rate 44 UO is concentratedUO is concentrated 55 signs of water deficit developsigns of water deficit develop -- Administer parenteral fluids as necessaryAdminister parenteral fluids as necessary
  136. 136. ** Types of solutionsTypes of solutions -- D5W (hypotonic) is given short-term for hyponatremiaD5W (hypotonic) is given short-term for hyponatremia -- D5NSS may be given depending on the serum levels ofD5NSS may be given depending on the serum levels of sodium and vascular volume + KCl to meet normalsodium and vascular volume + KCl to meet normal intake needs and replace losses for hyponatremiaintake needs and replace losses for hyponatremia -- Dextrose 5% in 0.2% normal saline is generally used asDextrose 5% in 0.2% normal saline is generally used as a maintenance fluida maintenance fluid -- Dextrose 5% in ½ normal saline is generally used as aDextrose 5% in ½ normal saline is generally used as a replacement solution for losses caused byreplacement solution for losses caused by gastrointestinal drainagegastrointestinal drainage -- PNSS is given primarily when large amounts of sodiumPNSS is given primarily when large amounts of sodium have been lost and for patients with hyponatremiahave been lost and for patients with hyponatremia -- LRS is also isotonic because it remains in theLRS is also isotonic because it remains in the extracellular spaceextracellular space -- Fructose or 10-20% glucose in distilled water areFructose or 10-20% glucose in distilled water are hypertonic solutions and may partially meet bodyhypertonic solutions and may partially meet body needs for CHOsneeds for CHOs -- Dextran (commonly-used plasma expander) increasesDextran (commonly-used plasma expander) increases plasma volume by increasing oncotic pressure. Mayplasma volume by increasing oncotic pressure. May cause prolonged bleeding time and is CI in patientscause prolonged bleeding time and is CI in patients with renal failure, bleeding disorders, or severe CHFwith renal failure, bleeding disorders, or severe CHF
  137. 137. ** AdministrationAdministration -- The rate should be regulated according to the patient’sThe rate should be regulated according to the patient’s needs and condition per doctor’s ordersneeds and condition per doctor’s orders -- Monitor UO carefully. Refer marked decreases!Monitor UO carefully. Refer marked decreases! -- Verify orders for potassium administration in patientsVerify orders for potassium administration in patients with renal failure and untreated adrenal insufficiencywith renal failure and untreated adrenal insufficiency -- Usual rate for fluid loss replacement: 3ml/minUsual rate for fluid loss replacement: 3ml/min -- Recognize signs of pulmonary edema (bounding pulse,Recognize signs of pulmonary edema (bounding pulse, engorged peripheral veins, hoarseness, dyspnea,engorged peripheral veins, hoarseness, dyspnea, cough, and rales) that can result fromcough, and rales) that can result from ↑IV rate↑IV rate -- If infiltration occurs, the infusion should be stoppedIf infiltration occurs, the infusion should be stopped immediately and relocated. Peripheral IV sites areimmediately and relocated. Peripheral IV sites are generally rotated every 72 hoursgenerally rotated every 72 hours -- For dextran and other plasma expanders, observe forFor dextran and other plasma expanders, observe for anaphylactic reaction (apprehension, dyspnea,anaphylactic reaction (apprehension, dyspnea, wheezing, tightness of chest, angioedema,wheezing, tightness of chest, angioedema, itching, hives and hypotension). If this happens,itching, hives and hypotension). If this happens, switch infusion to nonprotein solution and run at KVOswitch infusion to nonprotein solution and run at KVO rate, notify physician and monitor VSrate, notify physician and monitor VS -- Pronounced and continued thirst despite administrationPronounced and continued thirst despite administration of fluids is not normal and should be reported (mayof fluids is not normal and should be reported (may indicate DM or hypercalcemia)indicate DM or hypercalcemia)
  138. 138. ** Patient/Family EducationPatient/Family Education -- Include the signs and symptoms of water excess inInclude the signs and symptoms of water excess in discharge instructionsdischarge instructions -- With drug therapy, instruct patient and family regardingWith drug therapy, instruct patient and family regarding correct method of administration, correct dose, andcorrect method of administration, correct dose, and therapeutic and adverse effectstherapeutic and adverse effects -- Instruct to read labels for nutritional contentInstruct to read labels for nutritional content * For K restriction: avoid organ meats, fresh and dried* For K restriction: avoid organ meats, fresh and dried fruits, and salt substitutesfruits, and salt substitutes -- Skin assessment and care, positioning techniques forSkin assessment and care, positioning techniques for patients with mobility restrictionspatients with mobility restrictions
  139. 139. ** Achievement of outcomes is successful in disturbances in fluidAchievement of outcomes is successful in disturbances in fluid and electrolyte balance:and electrolyte balance: 11 Maintains functional fluid volume level with adequate UO,Maintains functional fluid volume level with adequate UO, VS within the patient’s normal limits, sp gr of urineVS within the patient’s normal limits, sp gr of urine within 1.003-1.035, moist mucous membranes, stablewithin 1.003-1.035, moist mucous membranes, stable weight, Intake=output, elastic skin turgor, and no edemaweight, Intake=output, elastic skin turgor, and no edema 22 States possible causes of imbalance and plan to preventStates possible causes of imbalance and plan to prevent recurrence of imbalancesrecurrence of imbalances 33 Reports a decrease or absence of symptoms causingReports a decrease or absence of symptoms causing discomfortdiscomfort
  140. 140. Fluids and Electrolytes Acid-base balance
  141. 141. DRAWING ARTERIAL BLOOD GASESDRAWING ARTERIAL BLOOD GASES ALLEN’S TESTALLEN’S TESTARTERIAL PUNCTUREARTERIAL PUNCTURE
  142. 142. NORMAL ACID-BASE BALANCENORMAL ACID-BASE BALANCE Estimated HCO3 concentration after fullyEstimated HCO3 concentration after fully oxygenated arterial blood has beenoxygenated arterial blood has been equilibrated with CO2 at a PCO2 of 40equilibrated with CO2 at a PCO2 of 40 mmHg at 38C; eliminates the influence ofmmHg at 38C; eliminates the influence of respiration on the plasma HCO3respiration on the plasma HCO3 concentrationconcentration 22-2622-26 mEq/LmEq/LStandard HCO3Standard HCO3 Partial pressure of CO2 in the arterialPartial pressure of CO2 in the arterial blood:blood: PCO2<35 mmHg = respiratory alkalosisPCO2<35 mmHg = respiratory alkalosis PCO2>45 mmHg = respiratory acidosisPCO2>45 mmHg = respiratory acidosis 35-45 mmHg35-45 mmHgPaCO2PaCO2 Identifies whether there is acidemia orIdentifies whether there is acidemia or alkalemia:alkalemia: pH<7.35 = acidosis; pH>7.45 = alkalosispH<7.35 = acidosis; pH>7.45 = alkalosis 7.35-7.457.35-7.45pHpH Partial pressure of oxygen in arterialPartial pressure of oxygen in arterial blood (decreases with age)blood (decreases with age) In adults < 60 years:In adults < 60 years: 60-80 mmHg = mild hypoxemia60-80 mmHg = mild hypoxemia 40-60 mmHg = moderate hypoxemia40-60 mmHg = moderate hypoxemia < 40 mmHg = severe hypoxemia< 40 mmHg = severe hypoxemia 80-100 Hg80-100 HgPaO2PaO2 Definition and ImplicationsDefinition and ImplicationsNormal ValueNormal ValueParameterParameter
  143. 143. BASIC REGULATION OF ACID-BASE BALANCEBASIC REGULATION OF ACID-BASE BALANCE CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3 The lungs help control acid-base balance by blowing off orThe lungs help control acid-base balance by blowing off or retaining CO2. The kidneys help regulate acid-base balance byretaining CO2. The kidneys help regulate acid-base balance by excreting or retaining HCO3excreting or retaining HCO3
  144. 144. TYPES OF ACID-BASE DISTURBANCESTYPES OF ACID-BASE DISTURBANCES Depression of the centralDepression of the central nervous system, asnervous system, as evidenced by disorientationevidenced by disorientation followed by comafollowed by coma Overexcitability of theOverexcitability of the nervous system; musclesnervous system; muscles may go into a state of tetanymay go into a state of tetany and convulsioonsand convulsioons
  145. 145. EXPECTED DIRECTIONAL CHANGES WITH ACID-BASE IMBALANCESEXPECTED DIRECTIONAL CHANGES WITH ACID-BASE IMBALANCES ↑ ↑ ↑ ↓ ↓ ↓ Normal ↓ ↓ Normal ↑ ↑ HCO3HCO3 Normal ↑ ↑ ↑ ↑ Normal Metabolic Alkalosis Uncompensated Partly Compensated Compensated Normal ↓ ↓ ↓ ↓ Normal Metabolic Acidosis Uncompensated Partly Compensated Compensated ↓ ↓ ↓ ↑ ↑ Normal Respiratory Alkalosis Uncompensated Partly Compensated Compensated ↑ ↑ ↑ ↓ ↓ Normal Respiratory Acidosis Uncompensated Partly Compensated Compensated PCO2PCO2pHpHCONDITIONCONDITION
  146. 146. Compensation
  147. 147. RESPIRATORY ACIDOSIS: CARBONIC ACID EXCESSRESPIRATORY ACIDOSIS: CARBONIC ACID EXCESS Damage to the respiratory center in the medulla, drug or narcotic use, obstructionDamage to the respiratory center in the medulla, drug or narcotic use, obstruction of respiratory passages, respiratory and respiratory muscle disordersof respiratory passages, respiratory and respiratory muscle disorders Decrease in the rate of pulmonary ventilationDecrease in the rate of pulmonary ventilation Increase in the concentration of CO2, carbonic acid,Increase in the concentration of CO2, carbonic acid, and hydrogen ionsand hydrogen ions RESPIRATORY ACIDOSISRESPIRATORY ACIDOSIS Potassium moves out of the cellsPotassium moves out of the cells HYPERKALEMIAHYPERKALEMIA VENTRICULAR FIBRILLATIONVENTRICULAR FIBRILLATION
  148. 148. NURSING MANAGEMENT OF RESPIRATORY ACIDOSISNURSING MANAGEMENT OF RESPIRATORY ACIDOSIS ASSESSMENTASSESSMENT ** Health Hx: complaints of headache, confusion, lethargy,Health Hx: complaints of headache, confusion, lethargy, nausea, irritability, nausea, irritability, anxiety, dyspnea, andnausea, irritability, nausea, irritability, anxiety, dyspnea, and blurred vision, preexisting conditionsblurred vision, preexisting conditions ** Physical Examination: lethargy to stupor to coma, tachycardia,Physical Examination: lethargy to stupor to coma, tachycardia, hypertension, cardiac dysrhythmias, airway patencyhypertension, cardiac dysrhythmias, airway patency NURSING DIAGNOSES include but are not limited to:NURSING DIAGNOSES include but are not limited to: Diagnostic TitleDiagnostic Title Possible Etiologic FactorsPossible Etiologic Factors 11 Impaired gas exchangeImpaired gas exchange HypoventilationHypoventilation 22 Disturbed thought processesDisturbed thought processes Central nervous system depressionCentral nervous system depression 33 AnxietyAnxiety Hypoxia, hospitalizationHypoxia, hospitalization 44 Risk for ineffective familyRisk for ineffective family Illness of a family memberIllness of a family member copingcoping 55 Ineffective airway clearanceIneffective airway clearance Hypoventilation, secretionsHypoventilation, secretions 66 Ineffective breathing patternIneffective breathing pattern Hypoventilation, dyspneaHypoventilation, dyspnea
  149. 149. NURSING MANAGEMENT OF RESPIRATORY ACIDOSISNURSING MANAGEMENT OF RESPIRATORY ACIDOSIS EXPECTED PATIENT OUTCOMES include but are not limited to:EXPECTED PATIENT OUTCOMES include but are not limited to: 11 Will maintain airway patency and adequate breathing rate andWill maintain airway patency and adequate breathing rate and rhythm will return of ABGs to patient’s normal levelrhythm will return of ABGs to patient’s normal level 22 Will be alert and oriented to time, place, and person, or to hisWill be alert and oriented to time, place, and person, or to his or her normal baseline level of consciousnessor her normal baseline level of consciousness 33 Will cope with anxietyWill cope with anxiety 44 Will exhibit effective coping and awareness of effectiveWill exhibit effective coping and awareness of effective support systemssupport systems 55 Will have secretions that are normal for self in amount and canWill have secretions that are normal for self in amount and can be raisedbe raised 66 Will maintain adequate rate and depth of respirations usingWill maintain adequate rate and depth of respirations using pursed lip and other breathing techniques when necessary (aspursed lip and other breathing techniques when necessary (as inin the patient with COPD)the patient with COPD)
  150. 150. NURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSISNURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSIS INTERVENTIONSINTERVENTIONS 11 Supporting effective gas exchangeSupporting effective gas exchange -- Provide a position of comfort to allow ease of respirationProvide a position of comfort to allow ease of respiration -- Obtain and monitor ABG results and VS. Refer accordinglyObtain and monitor ABG results and VS. Refer accordingly -- Provide and monitor supplemental oxygen as orderedProvide and monitor supplemental oxygen as ordered -- Turn the patient q2 and PRNTurn the patient q2 and PRN -- Provide pulmonary hygiene PRNProvide pulmonary hygiene PRN -- Maintain adequate hydrationMaintain adequate hydration -- Provide comfort measures such as mouth careProvide comfort measures such as mouth care -- Assist with ADLsAssist with ADLs -- Instruct patient regarding coughing and deep breathing andInstruct patient regarding coughing and deep breathing and management of disease condition, especially COPDmanagement of disease condition, especially COPD 22 Coping with disturbed thought processesCoping with disturbed thought processes -- Do frequent neurologic assessmentsDo frequent neurologic assessments -- Monitor and document person’s baseline LOC frequentlyMonitor and document person’s baseline LOC frequently
  151. 151. NURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSISNURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSIS -- Reorient as necessary by providing calendars, clocks, etc.Reorient as necessary by providing calendars, clocks, etc. 33 Relieving anxietyRelieving anxiety -- Provide a calm, relaxed environmentProvide a calm, relaxed environment -- Give clear, concise explanations of treatment plansGive clear, concise explanations of treatment plans -- Encourage expression of feelingsEncourage expression of feelings -- Provide support and information to patient and familyProvide support and information to patient and family -- Teach relaxation techniquesTeach relaxation techniques -- Assist the patient to identify coping mechanisms to deal withAssist the patient to identify coping mechanisms to deal with anxiety and stressanxiety and stress 44 Enhancing coping mechanismsEnhancing coping mechanisms -- Provide support and information to family members about theProvide support and information to family members about the patient’s ongoing conditionpatient’s ongoing condition -- Reassure them that there is a physiologic cause for theReassure them that there is a physiologic cause for the patient’s behaviorpatient’s behavior
  152. 152. NURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSISNURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSIS -- Encourage questions and open communicationEncourage questions and open communication 55 Promote airway clearancePromote airway clearance -- Implement regular breathing and coughing exercisesImplement regular breathing and coughing exercises -- Do suctioning as necessaryDo suctioning as necessary -- Maintain good hydrationMaintain good hydration -- Do chest physiotherapy as appropriateDo chest physiotherapy as appropriate 66 Promoting an effective breathing patternPromoting an effective breathing pattern -- Maintain alveolar ventilationMaintain alveolar ventilation -- Teach the patient proper breathing techniques as well asTeach the patient proper breathing techniques as well as panicpanic control breathingcontrol breathing
  153. 153. NURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSISNURSING MANAGEMENT OF PATIENT WITH RESPIRATORY ACIDOSIS EVALUATION. Achievement of outcomes is successful when the patient:EVALUATION. Achievement of outcomes is successful when the patient: 1a.1a. Demonstrates improved ventilation and oxygenationDemonstrates improved ventilation and oxygenation 1b1b Has vital signs, ABGs, and cardiac rhythm within own normalHas vital signs, ABGs, and cardiac rhythm within own normal rangerange 22 Returns to baseline LOCReturns to baseline LOC 33 Reports reduced anxietyReports reduced anxiety 44 Family uses adequate coping mechanismsFamily uses adequate coping mechanisms 55 Is able to raise secretions on ownIs able to raise secretions on own 66 Demonstrate effective breathing techniquesDemonstrate effective breathing techniques
  154. 154. RESPIRATORY ALKALOSIS: CARBONIC ACID DEFICITRESPIRATORY ALKALOSIS: CARBONIC ACID DEFICIT Anxiety, hysteria, fever, hypoxia, pain, pulmonary disorders, lesionsAnxiety, hysteria, fever, hypoxia, pain, pulmonary disorders, lesions affecting the respiratory center in the medulla, brain tumor,affecting the respiratory center in the medulla, brain tumor, encephalitis, meningitis, hyperthyroidism, gram-negative sepsisencephalitis, meningitis, hyperthyroidism, gram-negative sepsis Hyperventilation: Excessive pulmonary ventilationHyperventilation: Excessive pulmonary ventilation Decrease in hydrogen ion concentrationDecrease in hydrogen ion concentration RESPIRATORY ALKALOSISRESPIRATORY ALKALOSIS
  155. 155. NURSING MANAGEMENT OF RESPIRATORY ALKALOSISNURSING MANAGEMENT OF RESPIRATORY ALKALOSIS ASSESSMENTASSESSMENT ** Health Hx: anxiety, shortness of breath, muscle cramps orHealth Hx: anxiety, shortness of breath, muscle cramps or weakness, palpitations, panic, dyspneaweakness, palpitations, panic, dyspnea ** Physical Examination: light-headedness, confusion as a result ofPhysical Examination: light-headedness, confusion as a result of cerebral hypoxia, hyperventilation, tachycardia or arrhythmia,cerebral hypoxia, hyperventilation, tachycardia or arrhythmia, muscle weakness, (+) Chvostek’s sign or Trousseau’s signmuscle weakness, (+) Chvostek’s sign or Trousseau’s sign indicating a low ionized serum calcium level secondary toindicating a low ionized serum calcium level secondary to hyperventilation and alkalosis, hyperactive deep tendon reflexes,hyperventilation and alkalosis, hyperactive deep tendon reflexes, unsteady gait, muscle spasms to tetany, agitation, psychosis,unsteady gait, muscle spasms to tetany, agitation, psychosis, seizures in extreme cases, decreased potassium levelsseizures in extreme cases, decreased potassium levels NURSING DIAGNOSES include but are not limited to:NURSING DIAGNOSES include but are not limited to: Diagnostic TitleDiagnostic Title Possible Etiologic FactorsPossible Etiologic Factors 11 AnxietyAnxiety Stress, fearStress, fear 22 Ineffective breathing patternIneffective breathing pattern Hyperventilation, anxietyHyperventilation, anxiety 33 Disturbed thought processesDisturbed thought processes CNS excitability; irritabilityCNS excitability; irritability 44 Risk for injuryRisk for injury Change in LOC, and potential forChange in LOC, and potential for seizuresseizures
  156. 156. NURSING MANAGEMENT OF RESPIRATORY ALKALOSISNURSING MANAGEMENT OF RESPIRATORY ALKALOSIS EXPECTED PATIENT OUTCOMES include but are not limited to:EXPECTED PATIENT OUTCOMES include but are not limited to: 11 Will report decreased anxiety; verbalizes methods to copeWill report decreased anxiety; verbalizes methods to cope withwith anxietyanxiety 22 Will return to normal respiratory rate and rhythm or at leastWill return to normal respiratory rate and rhythm or at least decreased hyperventilation, with return to baseline ABGsdecreased hyperventilation, with return to baseline ABGs 33 Will exhibit reorientation to person, place, and time as perWill exhibit reorientation to person, place, and time as per patient’s baselinepatient’s baseline 44 Will be free from injuryWill be free from injury INTERVENTIONSINTERVENTIONS 11 Allay anxietyAllay anxiety -- Give antianxiety medications as orderedGive antianxiety medications as ordered -- Have patient breath into a paper bagHave patient breath into a paper bag -- Teach relaxation techniques when initial anxiety attack isTeach relaxation techniques when initial anxiety attack is overover

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