Fluid _electrolytes_in_the_surgical_cli


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Fluid _electrolytes_in_the_surgical_cli

  1. 1. Paulette Hamner RN,MSN NUR 1213 Fluid & Electrolytes in the Surgical Client
  2. 2. F&E Outline/Surgical Client <ul><li>At great risk for F&E imbalances </li></ul><ul><li>Can be prevented or minimized by appropriate intervention </li></ul><ul><li>Assessment and management begins in preoperative period </li></ul><ul><li>Continues into postoperative period </li></ul>
  3. 3. Preoperative Period: <ul><li>Review history and assessment for potential problems </li></ul><ul><li>Review lab data </li></ul><ul><li>In the Outpatient setting various methods used </li></ul><ul><li>Hypokalemia most frequent cause of cancellation of elective surgery </li></ul>
  4. 4. Hypokalemia <ul><li>Manifestations </li></ul><ul><ul><li>Most serious are cardiac </li></ul></ul><ul><ul><li>Skeletal muscle weakness </li></ul></ul><ul><ul><li>Weakness of respiratory muscles </li></ul></ul><ul><ul><li>Decreased gastrointestinal motility </li></ul></ul>
  5. 5. Preop. Cont. <ul><li>If hypokalemia is caused by diuretics have a magnesium level checked. </li></ul><ul><li>Replace only after adequate urine output is established </li></ul><ul><li>Fluid Restriction </li></ul><ul><ul><li>NPO after midnight </li></ul></ul><ul><ul><li>Permission for unrestricted intake of cl. Liq. Up to 3 hrs. preop. </li></ul></ul><ul><ul><li>Oral meds with 30ml of H2O 1 hr. preop. </li></ul></ul>
  6. 6. Preop. Cont. <ul><ul><li>Use of H2 blockers if have increased risk of regurgitation and aspiration of gastric contents. </li></ul></ul><ul><li>If client has predisposing factors such as chronic illness </li></ul><ul><li>If on chronic corticosteroid therapy </li></ul>
  7. 7. Postoperative Period: <ul><li>Neuroendocrine response stimulated by many anesthetic agents </li></ul><ul><li>Surgical stress by secreting ACTH and cortisol. </li></ul><ul><li>Many changes happen </li></ul><ul><li>Circulatory instability </li></ul><ul><ul><li>R/T fluid loss during surgery or trauma that produces decreased renal perfusion. </li></ul></ul><ul><ul><li>This stimulates production of renin, angiotensis, and aldosterone </li></ul></ul>
  8. 8. Postop cont. <ul><ul><li>Causes vasoconstriction and Na and H2O conservation </li></ul></ul><ul><ul><li>In humans- Isotonic fluid loss (blood)- most potent stimuli to aldosterone and ADH secretion. </li></ul></ul><ul><ul><li>Surgery and trauma can cause the release of aldosterone and ADH </li></ul></ul><ul><ul><li>May last for 12-24 hrs. post-op </li></ul></ul><ul><ul><li>Reduced vol. of conc. Urine early post-op </li></ul></ul>
  9. 9. Postoperative Period cont.: <ul><ul><li>Decreased urine is due to hormonal changes </li></ul></ul><ul><ul><li>Increases the chance of hypokalemia if K+ is inadequate </li></ul></ul><ul><ul><li>In elderly-Neuroendocrine response-increased morbidity especially cardiovascular surgery. </li></ul></ul><ul><ul><li>Have a prolonged inadequate secretion of ADH-dilutional hyponatremia or </li></ul></ul><ul><ul><li>Suppression of ADH-lg. amt. of diluted urine </li></ul></ul><ul><ul><li>Extreme thirst, dehydration, hypernatremia </li></ul></ul>
  10. 10. Postop cont.: <ul><li>Metabolic Changes: </li></ul><ul><ul><li>First hours post-op=increased blood glucose levels </li></ul></ul><ul><ul><li>This may result from secretion of growth hormone and glucagon and suppression of insulin release. </li></ul></ul><ul><li>Hemodynamic Alterations: </li></ul><ul><ul><li>Increasing catecholamines (epi, norepi) </li></ul></ul><ul><ul><li>Have marked effect on CNS and CVS </li></ul></ul>
  11. 12. Postop: Fluid and Electrolyte Imbalance <ul><ul><li>Most common imbalance is extracellular third spacing-Fluid Volume Deficit </li></ul></ul><ul><ul><li>“ fluid loss” from the vascular space pools in another part of the body-surgical site or bowel from an ileus. </li></ul></ul><ul><ul><li>Factors-GI fluid loss, cont. fluid shifts, fever, too many blood samples, hyperventilation, diuretics. </li></ul></ul><ul><ul><li>If FVD is due to third spacing there is no decrease in body weight. </li></ul></ul>
  12. 13. Fluid Volume Deficit (FVD) <ul><ul><li>Decreased U.O. <30ml/hr </li></ul></ul><ul><ul><li>Postural hypotension </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Diminished skin turgor </li></ul></ul><ul><ul><li>Decreased capillary refill time </li></ul></ul><ul><ul><li>Inc. BUN out of proportion to creatinine </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Depends on type of fluid lost </li></ul></ul><ul><ul><li>Usually can be done with Isotonic solutions- NS or LR </li></ul></ul>
  13. 14. F&E Imbalances Postop cont: <ul><li>Fluid Volume Excess (FVE): </li></ul><ul><ul><li>Due to seepage of lg volumes of fluid from the vascular space into a third space. </li></ul></ul><ul><ul><li>As fluids are administered to correct vascular losses=added fluid load. </li></ul></ul><ul><ul><li>Most common causes are: </li></ul></ul><ul><ul><ul><li>Overcorrection of a previous FVD </li></ul></ul></ul><ul><ul><ul><li>Poorly guarded IV line </li></ul></ul></ul><ul><ul><ul><li>Treating pain with Morphine </li></ul></ul></ul><ul><ul><ul><li>Can occur anytime but usually immediately post-op </li></ul></ul></ul>
  14. 15. F&E Imbalances post-op cont. <ul><li>Hyponatremia R/T: </li></ul><ul><ul><li>Excessive temporary ADH secretion </li></ul></ul><ul><ul><li>Nausea without vomitin </li></ul></ul><ul><ul><li>Elevated ADH plasma levels </li></ul></ul><ul><ul><ul><li>Avoid using hypotonic solutions </li></ul></ul></ul><ul><ul><ul><li>Avoid excessive use of electrolyte free solutions during the first 2-4 post-op days </li></ul></ul></ul><ul><ul><ul><li>Serum Na+ should be kept between 130-135 mEq/ml </li></ul></ul></ul>
  15. 16. F&E Imbalances post-op cont: <ul><li>Hypokalemia </li></ul><ul><ul><li>Most common K+ imbalance post-op </li></ul></ul><ul><ul><li>May be lost through urine or GI </li></ul></ul><ul><ul><li>Usually not present in the first 24 hrs. post-op </li></ul></ul><ul><ul><li>Replacement may be needed after the initial 24 hour period </li></ul></ul><ul><ul><li>Daily supplement may be 60-100 mEq QD. </li></ul></ul>
  16. 17. F&E Imbalances post-op cont. <ul><li>Hyperkalemia </li></ul><ul><ul><li>Rare except for the client with acute renal failure, tissue necrosis, or hemolysis </li></ul></ul><ul><ul><li>If occurs at anytime during the post-op period, renal function should be assessed. </li></ul></ul><ul><ul><li>Release of cellular K+ by crush injuries, electrical injuries or acute renal failure can lead to lethal hyperkalemia within hours. </li></ul></ul>
  17. 18. F&E Imbalances post-op cont. <ul><li>Hypocalcemia: </li></ul><ul><ul><li>May be due to a parathyroidectomy, thyroidectomy, or radical neck dissection </li></ul></ul><ul><ul><li>May occur immediately or 1-2 days post-op </li></ul></ul><ul><ul><li>Lasts less than 5 days </li></ul></ul><ul><ul><li>Most client remain asymptomatic </li></ul></ul><ul><ul><li>Some develop paesthesias, laryngeal spasms or tetany. </li></ul></ul>
  18. 19. Acid-Base Disorders post-op <ul><li>Resp. Acidosis from shallow respirations </li></ul><ul><li>Resp. Alkalosis due to pain, hypoxia, CNS injury, and mechanical ventilation </li></ul><ul><li>Metabolic Alkalosis usually from NG drainage or vomiting or K+ wasting diuretics. </li></ul>
  19. 20. Outpatient Surgery Considerations <ul><li>Seldom have F&E imbalances but do require assessment and nursing interventions if occurs </li></ul><ul><li>Oral intake is encouraged when gag reflex returns, no nausea, client is sufficiently alert </li></ul><ul><li>Assessment of urine output and bladder distention </li></ul><ul><li>Thorough post-op instructions </li></ul><ul><li>Follow-up call the day after surgery </li></ul>