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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+