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Introductory Medical-Surgical Nursing I- Fluid, Electrolyte, and Acid Base Balance
Terms in this set (82)
Largest portion of body weight
Affected by age, sex, fat, decreases with age, Females lower than males.
Obese lower due to increased fat cells.
"Water goes where sodium is"
Most abundant electrolyte; in extracellular fluid.
Major role in regulating fluid volumes, muscular activity, nerve impulse conduction, and acid-base balance.
Mainly in intracellular fluid; the major intracellular cation.
Maintaining fluid osmolarity and volume within cell.
Critical in transmitting nerve impulses.
Usually bound to other ions, especially Na. Regulates osmotic pressure between fluid compartments.
Usually combined with phosphorus to form the mineral salts, Bones and Teeth.
99% concentrated in bones/ teeth; 1% in extracellular fluid.
Ingested through diet and absorbed through intestine.
Promotes transmission of nerve impulses; helps regulate muscle contraction and relaxation.
Ca and Phos. relationship
One falls then the other rises.
Cation found in bone (50-60%, intracellular (39-49%), and extracellular (1%).
Role in metabolism of carbs and protein. Important in heart, nerve, and muscle function.
Other substances dissolved in body fluids .
Do not carry an electrical charge.
Measured in milligrams per deciliter.( mg/dl)
Main regulators of fluid balance.
Control extracellular fluid by adjusting the concentration of specific electrolytes, osmolality of body fluids, the volume of extracellular fluid, blood volume, and pH
Secreted by kidneys.
Hormone secreted when blood volume or blood pressure falls.
Causes the release of aldosterone with subsequent sodium and water retention.
Secreted by the adrenal glands.
Acts on kidney tubules to increase reabsorption of sodium and decrease reabsorption of potassium, acts as a volume regulator.
Antidiuretic hormone (ADH)
Produced by the hypothalamus.
Causes capillaries to reabsorb more water, so urine is more concentrated and less volume is excreted
Atrial natriuretic factor (ANF)
Hormone released atria in response to stretching by increased blood volume. Stimulates excretion of sodium and water by the kidneys, decreased synthesis of renin, decreased release of aldosterone, and vasodilation.
Reduces blood volume and lowers blood pressure
Regulates fluid intake.
Increased plasma osmolality stimulates osmoreceptors in the hypothalamus to trigger the sensation of thirst.
More sodium and less water make a person thirsty.
Gains and Losses In a healthy adult
24-hour fluid intake and output approximately equal.
Fluids are gained by drinking and eating and are lost through the kidneys, skin, lungs, and gastrointestinal tract.
Kidneys, water loss varies largely with the amount of solute excreted and with the level of antidiuretic hormone.
Skin occurs by sweating.
Lungs by evaporation at 300 to 400 ml/day.
GI tract, the usual loss of fluid is about 100 to 200 ml/day.
urine volume is between 1 and 2 L/day, or 1 ml/kg of body weight PER HR.
Age-Related Changes Affecting Fluid Balance Aging
Reduced sense of thirst.
Greatest loss from the intracellular fluid compartment.
Limited reserves to maintain fluid balance. Antihypertensives, diuretics, and antacids can also contribute to imbalances.
Fluid requirements based on ideal body weight, are 30 ml/kg for ages 55 to 65, and 25 ml/kg for 65 years and older.
Infants and toddlers
Increased BSA (body surface area), Increased Metabolic Rate Immature kidney function
Assessment of Fluid and Electrolyte Balance Vital signs
Pulse, respiration, temperature, and blood pressure can indicate changes in fluid and electrolyte balance. Temperature variations can be associated with fluid volume excess or deficit. Pulse rate and quality may change in response to blood volume alterations; electrolyte changes can affect heart rate and rhythm. Blood pressure is directly related to blood volume. Respirations are minimally affected by electrolyte changes.
Assessment of Fluid and Electrolyte Balance Intake and output
Accurate records are essential to determine whether the patient's intake is equal to output All fluids entering or leaving the body should be noted A changing urine output may reflect attempts by the kidneys to maintain or restore balance, or it may reflect a problem that causes fluid disturbances Urine characteristics also give clues to fluid balance Clear, pale urine in a healthy person suggests the excretion of excess water, whereas darker, concentrated urine indicates the kidneys are retaining water
Assessment of Fluid and Electrolyte Balance Body Weight
Good indicator of fluid loss or retention1 liter of fluid weights 2.2 lbs. Patients can accumulate up to 10 lbs. of fluid before pitting edema is evident Weigh daily on the same scale at the same time of day and wearing the same type of clothing
Assessment of Fluid and Electrolyte Balance Skin Characteristics
Moisture, turgor, and temperature reflect fluid balance. Dry, flushed skin—dehydration. Pale, cool, clammy skin—severe fluid volume deficit that occurs with shock. Moist, edematous tissue seen with excess fluid volume.
Assessment of Fluid and Electrolyte Balance
Facial characteristics Severely dehydrated patient has a pinched, drawn facial expression. Soft eyeballs and sunken eyes indicate severely deficient fluid volume. Puffy eyelids and fuller cheeks suggest excess fluid volume
Assessment of Fluid and Electrolyte Balance Skin turgor
Measured by pinching the skin over the sternum, the inner aspects of the thighs, or the forehead In patients who are dehydrated, skin flattens more slowly after the pinch is released Older people - slower to return to normal; inappropriate assessment
Assessment of Fluid and Electrolyte Balance Edema
Reflects water and sodium retention, which can result from excessive reabsorption or inadequate secretion of sodium, as may occur with kidney failure. Pitting depression remains in the tissue after pressure is applied with a fingertip. Test over tibia, fibula, sacrum or sternum. Hard edematous tissue is called brawny edema
Assessment of Fluid and Electrolyte Balance Mucous membranes
Tongue turgor In well person, tongue has one longitudinal furrow. Fluid volume deficit causes additional longitudinal furrows, and the tongue is smaller. Sodium excess causes the tongue to appear red and swollen. Moisture of the oral cavity A dry mouth may be the result of deficient fluid volume or mouth breathing. Can be the side effect of medications
Assessment of Fluid and Electrolyte Balance Veins
Appearance of the jugular veins in the neck and the veins in the hands can suggest either a fluid volume deficit or excess.
Occurs when too much fluid moves from the intravascular space (blood vessels) Into the interstitial or "third" space- the nonfunctional area between cells. This can cause potentially serious problems such as edema, reduced cardiac output, and hypotension.
Diagnostic Tests and Procedures Diagnostic Tests and Procedures Urine pH
( normal 7.0) Determines if kidneys are responding appropriately to metabolic acid-base imbalances Urine
Diagnostic Tests and Procedures specific gravity
(normal1.000 - 1.030) A measure of urine concentration A good indicator of fluid balance
Diagnostic Tests and Procedures Osmolality
(normal 50 -1200 mOsm/kg) Measures the number of dissolved particles in a solution Provides more precise measurement of kidneys' ability to concentrate urine
Diagnostic Tests and Procedures Urine creatinine clearance
Detects glomerular damage in the kidney . A 24-hour specimen is required 14 to 26 mg per kg of body mass per day for men, 11 to 20 mg per kg of body mass per day for women
Diagnostic Tests and Procedures Urine sodium
Sodium intake and fluid volume status 40 to 220 mEq/L/day
Diagnostic Tests and Procedures Urine potassium
A measure of renal tubular function 25 -125 mEq/L/day
Diagnostic Tests and Procedures Serum hematocrit
Percentage of blood volume composed of red blood cells Normal range: Men: 40-50% , Women: 38-47%
Diagnostic Tests and Procedures Serum creatinine
A metabolic waste product Indicator of renal function Normal range: 0.6-1.5 mg/dl
Diagnostic Tests and Procedures Blood urea nitrogen (BUN)
A measure of renal function Normal range: 8 - 20 mg/dl
Diagnostic Tests and Procedures Serum albumin
A plasma protein that helps maintain blood volume by creating colloid osmotic pressure (a form of osmotic pressure exerted by proteins, notably albumin, in a blood vessel's plasma (blood/liquid) that usually tends to pull water into the circulatory system). Normal range: 3.5 - 5.5 g/dl
Diagnostic Tests and Procedures Serum electrolytes
Sodium, potassium, chloride, phosphorus, Magnesium and calcium
Deficient fluid volume Less water than normal in the body Decreased intake, abnormal fluid losses, or both Examples: loss of water from excessive bleeding, severe vomiting/diarrhea, severe burns
Fluid Imbalances Excess fluid volume
An increase in body water From renal or cardiac failure with retention of fluid, increased production of antidiuretic hormone or aldosterone, overload with isotonic IV fluids, or administration of dextrose 5% in water (D5W) after surgery or trauma
Lower than normal sodium in the blood serum Can be actual deficiency of sodium or increase in body water that dilutes the sodium excessively.
Hyponatremia Assessment, Symptoms:
Headache, muscle weakness, fatigue, apathy, confusion, abdominal cramps, and orthostatic hypotension Take blood pressures with the patient lying or sitting and then standing to determine if a significant drop (20 mm/Hg or more)
Hyponatremia Medical treatment
The usual treatment is restriction of fluids while the kidneys excrete excess water Diuretic: furosemide (Lasix) Sodium replacement therapy
Hyponatremia Nursing care
Administer prescribed medications and IV fluids Measure fluid intake and output and assess mental status
Higher than normal concentration of sodium in the blood. Very serious imbalance; can lead to death if not corrected. Occurs when excessive loss of water or excessive retention of sodium
Hypernatremia Signs and symptoms
Thirst, flushed skin, dry mucous membranes, low urine output, restlessness, increased heart rate, convulsions, and postural hypotension
Hypernatremia Medical treatment
Oral or IV replacement of water to restore balance (slowly) A low-sodium diet often prescribed
Hypernatremia Nursing care
Encourage patients with hypernatremia to drink water Closely monitor the infusion of IV fluids. Teach patient to track daily intake and output and to recognize the signs and symptoms of fluid retention or depletion
Low serum potassium May result in gastrointestinal, renal, cardiovascular, and neurologic disturbances Can cause abnormal, potentially fatal, heart rhythm
Hypokalemia Signs and symptoms
Anorexia, abdominal distention, vomiting, diarrhea, muscle cramps, weakness, dysrhythmias (abnormal cardiac rhythms), postural hypotension, dyspnea, shallow respirations, confusion, depression, polyuria (excessive urination), and nocturia
Hypokalemia Medical treatment
Potassium replacement by the IV or oral route
Hypokalemia Nursing care
Monitoring at-risk patients for decreased bowel sounds, a weak and irregular pulse, decreased reflexes, and decreased muscle tone Cardiac monitors may be used to detect dysrhythmias Administer oral or IV potassium Urine output should be no less than 30 ml/hr Encourage pt. to eat foods high in potassium
High serum potassium
Hyperkalemia, Signs and symptoms
Explosive diarrhea and vomiting; muscle cramps and weakness, paresthesia, irritability, anxiety, abdominal cramps, and decreased urine output.
Hyperkalemia Medical treatment
Correct the underlying cause. Restrict potassium intake. Polystyrene sulfonate (Kayexalate) Intravenous calcium gluconate
Hyperkalemia Nursing care
Patients with low urine output or those taking potassium-sparing diuretics must be monitored carefully for signs and symptoms Carefully monitor flow rate of IV fluids, which should not exceed 10 mEq/hr through peripheral veins Screen the results of laboratory studies; > 5 mEq/L can cause cardiac arrest.
Usually bound to other electrolytes; therefore, chloride imbalances accompany other electrolyte imbalance May be caused by vomiting and uncontrolled diabetes.
Usually associated with metabolic acidosis
Usually occurs when sodium is lost because chloride most frequently bound with sodium
Regulated by the parathyroid glands
Results from diarrhea, inadequate dietary intake of calcium or vitamin D, and multiple blood transfusions (banked blood contains citrates that bind to calcium), in addition to some diseases, including hypoparathyroidism
results from a high calcium or vitamin D intake, hyperparathyroidism, and immobility that causes stores of calcium in the bones to enter the bloodstream
decreased gastrointestinal absorption or excessive gastrointestinal loss, usually from vomiting and diarrhea, or increased urinary loss
occurs most often with excessive use of magnesium-containing medications or intravenous solutions in patients with renal failure or preeclampsia of pregnancy
Respiratory system fails to eliminate the appropriate amount of carbon dioxide to maintain the normal acid-base balance Caused by pneumonia, drug overdose, head injury, chest wall injury, obesity, asphyxiation, drowning, or acute respiratory failure Medical treatment Improve ventilation, which restores partial pressure of carbon dioxide in arterial blood (Paco2) to normal
Respiratory Acidosis Nursing care
Assess PaCO2 in arterial blood Observe for signs of respiratory distress: restlessness, anxiety, confusion, tachycardia
Respiratory Acidosis Intervention
Encourage fluid intake Position patients with head elevated 30 degrees Oxygen therapy
pH = <7.35, PaCO2 = >45, HCO3 = 22-26
Low Paco2 with a resultant rise in pH Most common cause of respiratory alkalosis is hyperventilation
Respiratory Alkalosis Medical treatment
Major goal of therapy: treat underlying cause of condition; sedation may be ordered for the anxious patient
Respiratory Alkalosis Nursing care
In addition to giving sedatives as ordered, reassure the patient to relieve anxiety Encourage patient to breathe slowly, which will retain carbon dioxide in the body
Respiratory Alkalosis pH =
>7.45, PaCO2 = <35, HCO3 = 22-26
Body retains too many hydrogen ions or loses too many bicarbonate ions; with too much acid and too little base, blood pH falls Causes are starvation, dehydration, diarrhea, shock, renal failure, and diabetic ketoacidosis Signs and symptoms: changing levels of consciousness, headache, vomiting and diarrhea, anorexia, muscle weakness, cardiac dysrhythmias Medical treatment: the underlying disorder
Metabolic Acidosis Nursing care
Assessment of the patient in metabolic acidosis should focus on vital signs, mental status, and neurologic status Emergency measures to restore acid-base balance. Administer drugs and intravenous fluids as prescribed. Reassure and orient confused patients
Metabolic Acidosis pH =
<7.35, PaCO2 = 35-45, HCO3 = <22
Increase in bicarbonate levels or a loss of hydrogen ions Loss of hydrogen ions may be from prolonged nasogastric suctioning, excessive vomiting, diuretics, and electrolyte disturbances Signs and symptoms: headache; irritability; lethargy; changes in level of consciousness; confusion; changes in heart rate; slow, shallow respirations with periods of apnea; nausea and vomiting; hyperactive reflexes; and numbness of the extremities
Metabolic Alkalosis pH =
>7.45, PaCO2 = 35-45, HCO3 = >26
Metabolic Alkalosis Medical treatment
Depends on the underlying cause and severity of the condition
Metabolic Alkalosis Nursing care
Assessment Take vital signs and daily weight; monitor heart rate, respirations, and fluid gains and losses Keep accurate intake and output records, including the amount of fluid removed by suction Assess motor function and sensation in the extremities; monitor laboratory values, especially pH and serum bicarbonate levels
Metabolic Alkalosis Assessment of Fluid and Electrolyte Balance
To prevent metabolic alkalosis, use isotonic saline solutions rather than water for irrigating nasogastric tubes because the use of water for irrigation can result in a loss of electrolytes Provide reassurance and comfort measures to promote safety and well-being
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