Fluid, Electrolyte, and Acid-Base Balance

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metabolic alkalosis - nursing interventions

monitor I&O, vital signs, resp, LOC; IV fluids; tx underlying problem

hypercalcemia

high calcium
> 5.5
>10.5 total

nursing interventions - Hyperkalemia

monitor K+ levels, avoid foods high in K+

Respiratory Alkalosis - clinical manifestations

seizures; deep,rapid, breathing; hyperventilation; tachycadia; decrease or normal BP; hypokalemia; numbness and tingling of extremities; lethargy, confusion; nausea, vomiting; circumoral parethesias (numbness, tingling, loss of sensation around mouth)

Increase ADH

decrease urine output
- increase in solutes in blood ----> secrete ADH ---> increase reabsorption of water into blood ----> decrease urine output
- water dilutes body fluids

increase osmolarity

fluid volume deficit

Overhydration

hypo-osmolar gain of only water
low sodium levels

Nursing Interventions - Hypernatremia

assess, sx, monitor behavior changes, monitor I&O, monitor labs, encourage fluids

hypercalcemia - nursing interventions

increase movement and exercise, increase oral intake, limit food/fluids high in Ca+, increase fiber foods, protect confused pt, encourage intake of cranberry or prune juice

High pH, Low PCO2

respiratory alkalosis

Atrial Natriuretic system (ANF)

- released from atrial wall of heart
- promotes sodium wasting - diuretic
- inhibits thirst, reducing fluid intake

pH > 7.45

high pH

ALKALINIC

Respiratory Alkalosis - risk factors

Hyperventilation (anxiety, fear), mechanical ventilation, elevated body temp, hypoxia, brainstem injury, fever, increased BMR

increase Hct

dehydration

Thirst Mechanism

primary regulator of fluid intake, located in hypothalamus

pH < 7.35

low pH

ACIDIC

Total Serum Calcium Level

8.5 - 10.5

Edema

excess interstitial fluid

dehydration

hyperosmolar loss of water
excess sodium

Fluid Volume Excess

Isotonic gain of water and electrolytes

* hypervolemia

clincal manifestations of Hypernatermia

thirst; dry sticky mucous memb; red, dry, swollen tongue
severe: fatigue, restlessness, behavior change, decrease LOC, disorientation, convulsions

Respiratory Alkalosis

state of excessive loss of CO2
hyperventilation - increased CO2 exhaled - pH rises

urine pH

determines if kidneys are responding appropriately to acid base imbalances

Normal PaO2 Level

80 -100

hypcalcemia

low calcium
< 4.5
< 8.5 total

Sodium

* Most abundant in ECF
* Regulates H20
* nerve impulses
* acidd base balance

clinical manifestations - Hyperkalemia

HEART
CARDIAC DYSRHYTHMIAS OR ARREST
DECREASE HR, IRREGULAR PULSE
ECG CHANGES
GI hyperactivity, irritablity, apathy, confusion, parestheis, numbness in extremities

Metabolic Acidosis- risk factors

increase nonvolatile acids in blood (renal falilure, diabetes, starvation); decrease bicarbonate (severe diarrhea); increase NaCl IV fluids; excessive ingestion of acids; cardiac arrest

Metabolic Acidosis - nursing interventions

monitor ABGs,I&O, LOC; administer IV sodium bicarbonate; tx underlying problem

Potassium

* Most abundant in ICF
* Nerve impulses
* Cardiac Conduction
* Skeletal, cardiac, and smooth muscle activity

uine specific gravity

urine concetration
high = fluid volume deficit
low = fluid volume excess

hypernatremia

high sodium
> 145

Clinical Manifestations - Hypokalemia

HEART
CARDIAC DYSRHYTHMIAS
WEAK IRREGULAR PULSES
- muscle weakness, leg cramps, fatigue, lethargy, anorexia, decrease bowel sounds, decrease deep tendon reflexes

high pH , high HCO3

metabolic alkalosis

Filtration

fluid and solutes move together across membrane from are of HIGH pressure ----> LOW pressure

Major Buffers

HCO3- (bicarbonate) and H2CO3 (carbonic acid)

hematocrit

% of volume of blood composed of RBCs

Clinical Manifestations of Hypoatremia

NEUROLOGICAL CHANGES
personality change, lethargy, confusion, muscle twitching, abdominal cramps, anorexia, nausea, vomiting, headaches, seizures, coma

Risk Factors for Fluid Volume Deficit

* Loss of water and electrolytes from:
-vomitting, diarrhea, excessive sweating, polyuria, fever, nasogastric suction, abnormaldrainage or wound losses
* Insufficient intake due to:
- anorexia, nausea, inability to access fluids, impaired swallowing, confusion, depression
* abnormal losses thru skin, GI tract, kidneys; decreased fluid intake; bleeding; movement of fluid into third space

clinical manifestations - Hypocalcemia

NEUROMUSCULAR
numbness, tingling, muscle tremors, severe cramps, tetany, cardiac dysrhythmias, abnormal ECG, positive trousseau's and chvosteks, confusion, anxiety, psychoses, hyperactive deep tendon reflexes

Nursing Interventions for fluid volume deficit

assess clinical manifestations, monitor wt & vital signs, assess skin turgor, monitor I & O, monitor labs, administer oral and IV fluids, provide mouth care, implement measures to prevent skin breakdown, provide for safety

Respiratory Acidosis - risk factors

acute lung conditions, chronic lung disease, overdose of narcotics or sedatives, brain injury, airway obstruction
COPD, pnuemonia, anesthesia

Bicarbonate

- primary function is regulating acid-base balance as an essentioan component of body's buffering system
- present in ICF and ECF
- regulated by kidneys
- must be consumed in diet, produced thru metabolic processes

Metabolic Alkalosis

excess bicarbonate, high pH

Normal Serum Bicarbonate (HCO3) Level

22-26

risk factors for fluid volume excess

excess intake of sodium-containing IV fluids, excess ingestion of sodium in diet or meds (antacids)
impaired fluid balance r/t: heart failure, renal failure, cirrhosis of liver

Factors affecting body fluid, electrolyte, and acid base balance

age, decrease in thirst sensation, impaired kidneys or renal function, decrease in total body water, decrease in hormones, use of diuretics, medications, decrease food and water intake, gender, high body fat, increase temperature, strenous exercise, fever, lifestyle, alcohol consumption

Risk Factors for Hypoatremia

* Loss of Sodium: GI, renal, skin
* Inappropriate ADH: head injury, AIDS, malignant tumors
* Gain of Water: hypotonic tube feeding, excess H2O intake, excessive IV administration of D5W

risk factors - Hypocalcemia

**sx removal of parathyroid gland
* conditions: hypoparathyroidism, acute pancreatitis, hyperphophatemia, thyroid carcinoma
* inadequate vitamin D intake: malabsorption, hypomagnesemia, alkalosis, sepsis, ETOH abuse

Active Transport

movement of solutes across cell membrane from LESS concentration -------> MORE concentration

Respiratory Alkalosis - nursing interventions

monitor vital signs and ABGs; assist to breathe more slowly; help breathe in paper bag or apply mask

Metabolic Alkalosis - clinical manifestations

restlessness followed by lethargy; dysrhytmias, tachycardia; compensatory hypoventilation; confusion; nausea, vomitting, diarrhea; tremors, muscle cramps, tingling in fingers and toes; hypokalemia

Hypoatremia

low sodium
< 135

Hypokalemia - risk factors

vomiting, gastric suction, diarrhea, heavy perspiration, use of K+ wasting drugs (diuretics), poor K+ intake, hyperaldosteronism

ADH

Antidiuretic hormone - regulates water excretion from kidneys

low pH, High PCO2

respiratory acidosis

Renin-angiotensin-aldosterone system

contributes to fluid balance; responds to changes in renal perfusion; net effect is to increase blood volume through sodium and renal retention

Osmosis

water moves across cell membrane from LOW ------> HIGH

osmolarity lab

solute concentration in blood

Buffers

- prevent excessive changes in pH
- HCO3- and H2CO3, plasma proteins, hemoglobin, phosphates

decrease Hct

overhydration

Regulates Body Fluids

Kidneys
Hormones
- ADH
- Renin-angiotensin-aldosterone system
- ANF

Hypercalcemia - clinical manifestations

lethargy, weakness, decrease tendon reflex, bone pain, anorexia, constipation, polyuria, hypercalcuria, flank pain, dysrhytmias

Daily Fluid Intake

2500 ml/day
* 1500 - oral fluids
* 1000 - food

Respiratory Acidosis - nursing intervention

frequently assess resp. status and sounds, monitor airway and ventilation, administer pulmonary therapy, monitor I&O, vital signs, blood gases; narcotic antagonist as indicated; maintain adequate hydration

Normal pH level

7.35 - 7.45

decrease ADH

increase urine output
- decrease in solutes in blood -----> ADH suppressed -----> decrease in kidney permeability ---> decrease reabsorption of water into blood ----> increase urine output
- excrete excess water

Calcium

* vital in regulating neuromuscular function
* bone and teeth
* parathyroid
* nerve impulses
* muscle contraction

Fluid Output

Urine (1400-1500 ml/day)
Feces (100-200 ml/day)
Insensible loss (skin and lungs)

arterial blood gases (ABGs)

evaluate acid base balance and O2

Nursing Interventions of Excess Fluid Volume

assess clinical manifestations; monitor wt and vital signs; assess edema; assess breath sounds; monitor fluid I & O; monitor lab findings; place in fowler's position; administer diuretics; restrict fluid intake as needed; restrict dietary sodium; implement measures to prevent skin breakdown

risk factors - Hypernatremia

- loss of water: hypervent, fever, diarrhea, water deprivation
- gain of sodium: iv, tube feedings, excess table salt
- diabetes insipidus, heat stroke

fluid volume deficit

isotonic loss of water and electrolytes

* hypovolemia

Respiratory acidosis

* state of excess CO2 in the body
* CO2 retention due to hypoventilation or impaired lung function = low pH

Normal PaCO2 level

35 -45

Metabolic Acidosis - clinical manifestations

HA; decreased BP; Hyperkalemia (high K+); muscle twitching; warm, flushed, skin; nausea, vomiting, diarrhea; changes in LOC; kussmaul respirations

Metabolic Alkalosis - risk factors

severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3, excessive use of K+ losing diuretics, excessive adrenal corticoid hormone, cushings sydndrome, hyperaldosteronism, antacids, parenteral NaHCO3

hyperkalemia

high potassium
> 5

Normal Serum Sodium Level

135 - 145

Hyperkalemia - risk factors

* decreased K+ excretion: renal failure, hypoaldosteronism, K+ conserving diuretics
* high K+ intake: excessive use of salt substitutes, rapid/excessive IV K+ infusion, K+ shif out of cells into plasma

hypokalemia

low potassium
< 3.5

Normal Serum Potassium Level

3.5 - 5

Hypokalemia - nursing interventions

monitor HR & rhythm, administer oral K+ with food, administer IV K+ slowly, teach client about food hihg in K+, teach preventive measures

low pH, low HCO3

metabolic acidosis

Primary Regulator of Body Fluids

Kidneys

decrease osmolarity

fluid volume excess

how lungs regulate acid-base

- eliminating or retaining CO2
* alters rate/depth of respirations
~ faster rate/ more depth = get rid of CO2 & Increase pH
~ slower rate / less depth = retain CO2 & decrease pH

Normal Serum Calcium

4.5-5.5

Hypercalcemia - risk factors

prolonged immobilization, hyperparathyroidism, malignancy of bone, paget's disease

Hypocalcemia - nursing interrventions

protect confused pt, monitor respiratory and cardiac status, administer oral and iv ca+, teach about risk of osteoporosis

Respiratory Acidosis - clinical manifestations

hypoventilation; rapid, shallow respirations; shortness of breath - dyspnea; can't catch breath; headache, hyperkalemia, dysrhythmias (increase K+), drowsy, dizzy, disoriented, muscle weakness

Complete Blood Count

basic screening - hct, rbc, wbc, etc

Third Space Syndrome

fluid shifts from vascular space to area where it is not readily accessible as ECF

Clinical Manifestations of Excess Fluid Volume

wt gain ( >2%); fluid intake > output; full, bounding pulse; tachycardia; increased BP; distended neck veins, moist crackles (rales) in lungs; dyspnea; shortness of breath; mental confusion

Clinical Manifestations of fluid volume deficit

weakness, thirst, weight loss (>2%), fluid intake less than output, decreased skin turgor, dry mucous membranes, sunken eyeballs, decreased tearing, subnormal temp, weak pulse, tachycardia, decreased BP, orthostatic hypotension, decreased cap refill, decreased urine volume, increased specific gravity of urine, increased hematocrit, increased BUN

Nursing Interventions - Hyponatremia

assess sx, monitor I&O, monitor labs, encourage intake in food high in Na+, limit water intake

Diffusion

2 solutes of different concentrations seperated by semipermeable membrane; move from HIGH -----> LOW

Metabolic Acidosis

low bicarbonate levels, low pH

How kidneys regulate acid-base

selectively excreting or conserving HCO3- and H+

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