fluid, electrolyte, and acid base balances Flashcards
poor skin turgor pale dry skin low BP increased HR and R and Temp confused, weight loss, lethargy. In child, dark circles under eyes, lifeless, sunken fontanel
dehydrated patient
weight gain
edema
high BP, increased R, SOB, JVD, cough, crackles
copious amounts of white frothy sputum which could be blood tinged. Patient in tripod position because of orthopnea. Needs O2. Low O2 sats.
Too much fluid/Hypervolemia
transports nutrients to cells and wastes from cells
transports hormones, enzymes, blood cells
facilitates cellular metabolism
acts as a solvent for electrolytes and nonelectrolytes
helps maintain normal body temp
facilitates digestion and promotes elimination
acts as a tissue lubricant
functions of water
found inside cells
2/3 of body fluid
40% of body weight
Most stable body fluid
Intracellular fluid
fluid outside cells
extracellular fluid
fluid that surrounds cells
reserve fluid
interstitial fluid
fluid in blood vessels (plasma)
least stable fluid
intravascular fluid
CSF, peritoneal, bile duct, biliary, synovial, intraocular, and pericardial fluids
transcellular
1/3 of body fluids is
extracellular fluid
60% of average healthy adult and 70-80% of healthy infants is
water
solvent
liquid
solute
any substance dissolved in solution
requires energy
movement of ions against osmotic pressure to an area of higher pressure
Active transport
passive movement of electrolytes or other particles down the concentration gradient
diffusion
movement from an area of lesser to an area of greater concentration
osmosis
movement across a membrane, under pressure, from higher to lower pressure
filtration
water passes from an area of lesser solute concentration to greater concentration until equilibrium is established
Major force in body fluid movement and IV therapy
water moves into and out of cells and capillaries
Osmosis
tendency of solutes to move freely throughout a solvent “downhill”
diffusion
requires energy for movement of substances through cell membrane from lesser solute concentration to higher solute concentration
active transport
passage of fluid through permeable membrane from area of higher to lower pressure
filtration
concentration of solute (particles) per kg of water
Osmolality
concentration of solute (particles) per liter of fluid (this does not have to be water)
Osmolarity
concentration of solute (particles) in the plasma
serum osmolality
275-295 milliosmoles/liter
Normal serum osmolality
If serum osmolality is high
the patient is dry
If serum osmolality is low
patient is wet
have the same osmolality as normal plasma
isotonic fluids
neither makes cell swell or shrink
I SO PERFECT ISOTONIC
no osmotic pressure difference is created so fluid remains in ECF
used to replace fluid volume quickly
given to trauma patients who are bleeding, shock, severe NVD
be careful with CHF patients
tonicity is similar to blood
Isotonic IV fluid
given for losses from burns and diarrhea
Normal saline 0.9%
(sodium and chloride in water) provides no calories or free water
sodium, chloride, calcium, potassium, and lactate
Provides no calories or free water
Most resembles electrolyte concentration of plasma
Lactated Ringer’s- LR
having lower osmolality than normal plasma
hypotonic
less than 290 mOsm\L
Hypotonic
pulls water out of blood vessels into cells
used to prevent and treat cellular dehydration
patients require frequent monitoring
hypotonic
CONTRAINDICATED in acute brain injuries, large burns, major trauma, liver disease. patients at risk for 3rd spacing, increased cranial pressure, CVA, stroke, brain surgery,
hypotonic intravenous fluid
fluid trapped in interstitial spaces (fluid around cell)
3rd spacing
5% dextrose in water
hypotonic IV fluid
isotonic in bag but quickly changes in body
free water shifts from vessels into cells
5% dextrose in water
Hypotonic IV fluid
provides free water to cells along with sodium and chloride
1/2 of each liter moves into cells and 1/2 stays in vascular space
1/2 NS- 0.45% Normal Saline
having a higher osmolality/tonicity than normal plasma
causes water to be pulled from cells into blood vessels
increases vascular volume
decreases cell water
can cause vascular overload
monitor patient closely
hypertonic IV fluids
increased BP
causes cells to shrink/dehydrate
helps stabilize BP, increased urine output, increased peripheral edema/3rd spacing/interstitial fluid around cells/can be damaging to veins
hypertonic IV fluids
excessive breakdown of fat often seen in diabetic patients
ketosis
provides water to cells
provides some calories, enough to prevent ketosis
D5 1/2 NS: 5% dextrose in a 0.45% Saline
provides free water and calories to cells
D5NS: 5% dextrose in 0.9% saline
used for patients with dangerously low serum sodium levels of 115 mg/dL or less
given via IV pump
requires frequent monitoring of vitals, neuro status, lung sounds, and urinary output
Pt can become fluid overloaded. 1st sign is neuro deficit and lungs start filling with fluid
3% and 5% Saline
Hypertonic IV fluid
used on a limited basis to treat hypoglycemia
given via IV push or IV pump
irritating to veins
10% or 50% Dextrose
Hypertonic IV fluids
Dextran, Plasma, Hetastarch, and Albumin (protein)
colloid volume expanders
decrease blood volume
used to treat 3rd spacing either alone or with crystalloids
pull fluids from tissues into vessels
volume expanders
a large particle that normally does not pass through cell and capillary membranes, do not readily dissolve into true solutions
colloid
increasing the number of colloids causes an increase in
osmolality
salt that dissolves readily
crystalloid
used to treat low blood volume in burn patients
albumin
8 primary organs of homeostasis
kidneys, cardiovascular system, lungs, adrenal glands, thyroid gland, parathyroid glands, GI tract, and nervous system
normally filter 135-180 L plasma, excrete 1.5 L of urine a day
kidneys
pumps and carries nutrients and water in the body
cardiovascular system
regulate oxygen and carbon dioxide levels of blood
lungs
help body conserve sodium, save chloride and water, and excrete potassium
adrenal glands
increases blood flow in body and increases renal circulation
thyroid gland
regulate the level of calcium in ECF
parathyroid glands
absorbs water and nutrients that enter body through this route
GI tract
acts as a switchboard to inhibit and stimulate fluid balance (thirst center and ADH storage)
Nervous system
most water absorption occurs in the
colon
causes water retention
ADH
prompts fluid retention
hormone that regulates electrolyte levels
aldosterone
body’s own natural steroids
glucocorticoids
promote retention of sodium and water
adrenal cortex makes
cortisol/glucocorticoids
released from cells in heart in response to excessive blood volume. promotes sodium wasting, causes fluid loss
ANP/atrial natriuretic peptide
found in brain tissue and stored in myocardium
blood test used to predict CHF of fluid volume excess
BNP/brain natriuretic peptide
fluid and solute are lost in proportional amounts
isotonic fluid loss/hypovolemia
normal serum osmolality
fluid losses are primarily in vascular space
isotonic fluid loss
hemorrhage, vomiting, GI suction, diarrhea, fever, excessive heat, burns, diuretics
causes of isotonic fluid loss/hypovolemia/dehydration
more water is lost than solute
hypertonic dehydration
Patient will be dry.
serum osmolality is increased, pulling fluid into the vessels from the cells
cells shrink and become dehydrated
hypertonic dehydration
inadequate fluid intake
severe isotonic fluid losses
diabetes insipidus
increased solute intake without proportional increase in water
causes of hypertonic dehydration
excessive thirst and urination
caused by inadequate ADH
Loss of 5-15 L/day
symptoms of hypertonic dehydration
extracellular body spaces that do not normally contain fluid
Physiologically useless
3rd spacing fluid
massive trauma
malnutrition
protein deficiency
crush injuries, burns, sepsis, cancer, intestinal obstruction, abdominal surgery, liver dysfunction, starvation, cirrhosis, chronic alcoholism, heart failure, renal failure
Causes of 3rd spacing
hypovolemia
Most common type of dehydration
Isotonic
dehydration due to N/V/D, hemorrhage, etc.
Isotonic
equal losses of fluid and particles (electrolytes)
Isotonic dehydration
greater losses of particles (electrolytes)
Can lead to seizures
hypotonic dehydration
greater losses of fluid than electrolytes
Can lead to brain swelling or cerebral edema
hypertonic dehydration
When dehydrated you lose electrolytes and potassium and water. potassium leaves cell and is in the vascular space. If rehydrated then potassium:
Moves from extracellular fluid into cells and serum potassium drops
thirst mental status changes concentrated urine and low urine output dark amber or dark brown urine dry skin decreased skin turgor and elasticity dry mucous membranes sunken eyeballs flat neck veins skin tenting poor skin turgor acute weight loss In baby, may have sunken fontanel, hypotension, decreased BP, increased HR, increased resp rate
assessment for dehydration
mental status changes
1st sign of dehydration in elderly and infants
in elderly you check skin turgor:
over chest
acute weight loss
most important sign in infants and young children of dehydration
Most accurate reflection of fluid balance
labs to check for dehydration
BUN, creatinine, serum electrolyte panel, urinalysis, and urine specific gravity
hemoconcentration
high hematocrit and BUN (false high)
diagnostic finding in dehydration
high urine specific gravity
dehydration
normal specific gravity value
1.0053-1.030
high serum osmolality greater than 300 mOsm/kg
high serum sodium greater than 150 mEq/L
hypertonic dehydration
Who is at risk for dehydration:
infants and young children
Elderly
People with acute or chronic illnesses
environmental causes (vigorous exercise, work outside)
diet and lifestyle (stroke, bulimia, etc.)
infants at risk for dehydration because of:
higher total body percentage of water 80%
kidneys are immature
larger BSA
higher metabolic rate
Watch closely because they get dehydrated quickly
Most at risk for dehydration:
acute and chronically ill patients
Why are elderly at risk for dehydration:
low amount of total body water
less muscle mass
kidneys lose function
diminished thirst mechanism
Who are people with acute illness that are at risk for dehydration:
surgery losses and drains
gastroenteritis
burns
cirrhosis
priority nursing diagnoses for dehydration:
deficient fluid volume acute confusion deficient knowledge regarding disease management risk for electrolyte imbalance risk for injury altered comfort risk for impaired skin integrity
What are nursing interventions that are appropriate for dehydration:
Oral fluid replacement: if mild patient can drink
commercial oral rehydration solutions. May only tolerate small sips at first.
AVOID FRUIT JUICE, SODA, AND SPORTS DRINKS
Parenteral fluid replacement/IV- isotonic fluids, may require bolus or TPN
daily weights, vitals, mental status and behavior, urinary output, IV infusion rate, I&0, Lung sounds.
assist with rehydration.
provide comfort measures
most frequently used oral replacement fluid
0.9% NS isotonic fluid
What should you avoid if dehydrated patient:
fruit juice, soda, and sports drinks
How do you weigh patient with dehydration or imbalance?
Same scale, same time of day, and same clothes or naked
standard urinary output
60 mL/hr
To measure adequacy of interventions for dehydrated patient:
adequate urinary output stable HR and BP skin with normal turgor mucous membranes moist and pink return to usual mental status HCT, BUN, serum osmolality, and electrolytes return to normal
To determine patient’s adequate urinary output range:
0.5 mL/hr x Wt in Kg of patient
excessive retention of water and sodium in ECF
hypervolemia
above normal amounts of water in extracellular spaces
overhydration
excessive ECF accumulates in tissue (interstitial) spaces
edema
movement of fluid from space surrounding cells to blood
interstitial-to-plasma shift
increased BP, bounding pulse, fast and shallow respirations, JVD, pale and cool skin, increased urinary output, rapid weight gain, edema, lung crackles, dyspnea, and ascites
signs and symptoms of hypervolemia
too much fluid in body veins
more fluid that particles (usually sodium)
serum osmolality falls, shifting fluid into cells (high and dry, low and wet)
hypotonic fluid excess-water intoxication
repeated plain water enemas
overuse of hypotonic fluids or too painful infusion
drinking too much water
SIADH (syndrome of inappropriate ADH)
excess ADH causes kidneys to retain water but not sodium
Psychogenic polydipsia
causes of hypotonic fluid excess-water intoxication
what causes hypotonic fluid excess in infants and young children:
improper mixing of formula
giving water bottles instead of pacifier
severe or prolonged isotonic fluid volume excess occurs in
patients with heart failure and renal failure
compulsive water drinker
psychogenic polydipsia
how does edema form:
caused by hypertension increased capillary hydrostatic pressure decreased capillary oncotic pressure lymphatic obstruction sodium excess
edema is caused by
injury, inflammation, malnutrition, liver disease
assessment of fluid overload
high central venous pressure JVD engorged hand veins gallop/S3 hepatomegaly and splenomegaly anasarca tense or bulging fontanel peripheral edema
generalized edema
anasarca
check for peripheral edema in ambulatory patients in:
legs, ankles and feet
check for edema in nonambulatory patients in:
sacrum and back
2 mm
slight indentation
normal contours
associated with interstitial fluid volume 30% above normal
1+ pitting edema
4 mm
deeper pit after pressing
lasts longer than 1+
fairly normal contour
2+ pitting edema
6 mm
skin swelling obvious by inspection
remains several seconds after pressing
deep pit
3+ pitting edema
deep pit
8mm
remains for prolonged time after pressing, possibly minutes
frank swelling
4+ pitting edema
will not pit skin taut, warm, shiny May see water leaking from pores fluid can no longer be displaced secondary to excessive interstitial fluid accumulation no pitting tissue palpates as firm or hard
Brawny edema
increased RR irritated dry hacky cough- early sign LIFE THREATENING Tachypnea, dyspnea, irritated cough Moist productive cough with white frothy sputum-late sign labored breathing crackles
Pulmonary edema
early sign of pulmonary edema
irritated dry hacky cough
late sign of pulmonary edema
moist productive cough with white frothy sputum
vital signs
normal heart rate, full or bounding pulse, increasing BP
third spacing
acute rapid weight gain
urinary output and concentration
polyuria in patients with normal heart and kidney function
decreased output in patients with heart or kidney disease
hypervolemia assessment
chest x-ray: pleural effusions
hemodilution: HCT low, BUN low
assessment of fluid excess
Who is at risk for fluid volume excess:
Elderly due to decreased heart and kidney function
infants up to 2 yrs due to immature kidneys
children 2-12 yrs less stable regulatory responses
acute illness stress response promotes
chronic illness cardiovascular and renal disease
medications long term glucocorticoids promote fluid retention
fluid volume excess
altered comfort
risk for impaired skin integrity
knowledgeable deficit
priority nursing diagnoses for fluid volume excess
restrict fluid intake as ordered
Monitor lung sounds
watch for signs and symptoms of pulmonary edema: tachypnea, SOB, cough-early signs
give meds as rx’d: LOOP and thiazide diuretics, potassium sparing diuretics
Monitor electrolytes during diuretic therapy
accurate intake and output counts
monitor weight
nursing interventions for fluid volume excess
most accurate way to measure fluid status
monitor weight: same scale, same time of day, same clothes or naked
early signs and symptoms of pulmonary edema
tachypnea, SOB, cough
Pt teaching for excess fluid overload
teach patients with peripheral edema to elevate legs
teach about sodium restricted diet
teach risk factors for fluid volume excess
teach patient to weigh daily at home
Notify PCP of weight gain of 2.2 lbs. in 24 hrs
controls and regulates volume of body fluids
sodium
chief regulator of cellular enzyme activity and water content
potassium
nerve impulse, blood clotting, muscle contraction, B12 absorption
calcium
metabolism of carbs and proteins, vital actions involving enzymes
magnesium
maintains osmotic pressure in blood, produces hydrochloric acid
chloride
body’s primary buffer system
bicarbonate
involved in important chemical reactions in body, cell division, and hereditary traits
phosphate
where sodium goes,
chloride goes too
the major cation of the ECF
sodium
normal sodium level
135-145 mEq\L
primary function is regulation of fluid volume
sodium
reabsorbed and secreted in kidneys
sodium
minimal loss through feces and perspiration
sodium
low levels can be caused by excessive water intake-heavy water drinkers
sodium
Adults need about 3.8 grams daily to replace daily losses and maintain blood levels
Intake should not exceed 5.8 grams daily
sodium
older adults, African Americans, people with chronic diseases like diabetes, hypertension, kidney disease
sodium restriction
dietary sources of sodium
table salt NaCl-also good source of iodine
soy sauce, cured pork, canned foods, processed foods, salty seasonings, processed cheeses
drink every fluid they can find, even toilet water and bird baths
psychogenic polydipsia
sodium less than 135 mEq/L
hyponatremia
common causes of hyponatremia
diuretics, GI fluid losses, hormonal disturbance
anorexia, nausea, vomiting
weakness, lethargy, confusion
muscle cramps, muscle twitching, seizures
signs and symptoms of hyponatremia
increase oral sodium intake
if severe, IV saline infusion
treatment for hyponatremia
sodium greater than 145 mEq/L
hypernatremia
excessive sodium intake, water deprivation, increased water loss through sweating, heat stroke
causes of hypernatremia
thirst, elevated temp, dry mouth, sticky mucous membranes
signs and symptoms of hypernatremia
hallucinations, irritability, lethargy, seizures
severe hypernatremia
sodium restriction, increase water intake
treatment for hypernatremia
found in ECF
functions with sodium to regulate serum osmolality and blood volume
chloride
normal level is 95-108 mEq/L
chloride
found in gastric juice
involved in regulating acid/base balance
buffer in gas exchange in RBCs
found in the same foods as sodium
chloride
chloride greater than 108 mEq/L
hyperchloremia
chloride less than 95 mEq/L
hypochloremia
usually associated with hyponatremia
hypokalemia, or metabolic alkalosis
chloride problem
major cation of ICF
potassium
normal levels are 3.5-5.0 mEq/L
potassium
key electrolyte in cellular metabolism
potassium
regulates conduction of cardiac rhythm
potassium
excreted and absorbed through kidneys
losses through vomiting and diarrhea, potassium wasting diuretics
potassium
dietary recommendation of at least 4.7 grams/day
potassium
potassium restriction in
chronic kidney disease
common food sources of potassium:
bananas, oranges, apricots, dates, tomatoes, spinach, dairy products, and meats
chief regulator of all electrolytes
potassium
common causes of hypokalemia
potassium wasting diuretics, GI losses,steroids, anorexia, or bulemia
fatigue, anorexia, N/V, dysrhythmias, parasthesias
signs and symptoms of hypokalemia
numbness/tingling
parasthesias
potassium supplementation-diet, medications
IV potassium must be DILUTED
treatment for hypokalemia
potassium less than 3.5 mEq/L
hypokalemia
potassium greater than 5.0 mEq/L
hyperkalemia
common cause of hyperkalemia
potassium sparing diuretics and renal failure
signs and symptoms of hyperkalemia
muscle weakness, dysrhythmia
Kayexalate
binds potassium in gut to treat hyperkalemia
Insulin
drives potassium back into cells to treat hyperkalemia
glucose
encourage potassium back in cells to treat hyperkalemia
treatment for hyperkalemia
meds such as kayexalate, insulin, and glucose if severe, dialysis
dietary measures-caution against intake
treatment of hypokalemia
order EKG to check heart function and rhythm
M.U.R.D.E.R. M-muscle weakness U- urine, oliguria, anuria R- respiratory distress D-decreased cardiac contractility E- ECG changes R- reflexes, hyperreflexia or areflexia (flaccid)
signs and symptoms of increased potassium levels
M- Medications- Ace inhibitors, NSAIDs A- Acidosis- metabolic and respiratory C- Cellular destruction - burns, traumatic injury H- Hypoaldosteronism, hemolysis I- Intake - excessive N- Nephrons, renal failure E- Excretion - impaired
causes of increased potassium
responsible for bone health, neuromuscular, and cardiac function
calcium
Normal level is 8.5-10.5 mg/dL
calcium
essential factor in blood clotting
calcium
99% located in bone and teeth, 1% in circulating blood
calcium
serum losses lead to bone losses
calcium
adults and adolescents need dietary intake of calcium of
1200-1500 mg/day
dietary sources of calcium
milk, milk products, daily green leafy vegetables, salmon
sign of hypocalcemia
If you inflate BP cuff on arm above normal systolic BP, patient’s hand will flex
Chvostek’s sign- tap face below zygoma and you will see unilateral twitch if positive sign
calcium less than 8.5 mg/dL
hypocalcemia
common causes of hypocalcemia
malabsorption, hypoparathyroidism
signs and symptoms of hypocalcemia
diarrhea, numbness and tingling in extremities, muscle cramps,tetany, convulsions (seizures), positive trousseau’s sign and chvostek’s sign
treatment for hypocalcemia
encourage increased calcium intake
if severe, monitor airway and place on seizure precautions
parenteral calcium infusion
common causes of hypercalcemia
malignant bone disease
hyperparathyroidism
calcium level of 10.5 mg/dL or more
hypercalcemia
muscle weakness, polyuria, polydipsia, bizarre behavior
signs and symptoms of hypercalcemia
treatment for hypercalcemia
eliminate calcium supplements
limit calcium rich foods
dialysis
normal phosphorus level
2.5-4.5 mg/dL
found in ICF, bone, skeletal muscle, nerve tissue
phosphorus
helps metabolize proteins, fats, and carbs
phosphorus
essential for functioning of muscles, nerves, and RBCs
phosphorus
can be associated with elevated calcium levels
complication of refeeding after severe malnourishment
administering TPN without adequate phosphorus
prolonged use of aluminum and magnesium based antacids
severe vomiting and diarrhea
prolonged gastric suction
increased calcium, low phosphate
hypophophatemia
phosphate less than 2.6 mg/dL
hypophosphatemia
phosphate greater than 4.5 mg/dL
hyperphosphatemia
hypocalcemia excessive intake vitamin D excess massive blood transfusions large milk intake rhabdomyolysis (break down of striated/skeletal muscle)
hyperphosphatemia symptoms
rhabdomyolysis happens in
people who do extreme physical exercise. Patients in one position for too long.
used in more than 300 chemical reactions
magnesium
normal levels 1.5-2.5 mEq/L
magnesium
necessary for protein and DNA synthesis
magnesium
only 1% found in circulating blood, 99% in ICF and bone
magnesium
deficiency is rare- occurs mostly in alcoholics and those with absorption disorders (pancreatitis, burns)
magnesium
dietary recommendation of 18-30 mEq/day
magnesium
dietary sources of magnesium
most foods
green vegetables, cereal grains, nuts
common causes of hypomagnesemia
chronic alcoholism
excessive loss of fluids from GI tract (NG suction)
Symptoms of hypomagnesemia
tremors, increased reflexes, positive Chvostek’s and Trousseau’s signs
treatment of hypomagnesemia
carefully administer magnesium salts as ordered
place patient on seizure precautions
encourage patient to eat magnesium rich foods
magnesium of less than 1.5 mEq/L
hypomagnesemia
common causes of hypermagnesemia
renal failure
adrenal insufficiency
excessive intake of magnesium-containing antacids
signs and symptoms of hypermagnesemia
vasodilation and flushing
nausea and vomiting
depressed DTR’s
treatment for hypermagnesemia
notify PCP
dialysis
the amount of acid or base in a solution
pH
substance containing hydrogen ions that an be liberated or released
acid
substance that can trap hydrogen ions
base
normal arterial blood and body tissue pH is
735-7.45
the lower the pH the ________ the acid
stronger
the higher the pH the __________ the base
stronger
pH below __________ or above _____ is usually FATAL
6.9 or 7.8
pH requires
TIGHT control
homeostatic regulators of hydrogen ions
respiratory mechanisms and renal mechanisms
work rapidly to restore homeostasis. regulate acid-base balance by either eliminating or retaining carbon dioxide
respiratory mechanisms
if pH is low respirations
increase (rapid and deep) causes a drop in carbon dioxide
If hyperventilating you get
alkalotic; respiratory alkalosis
any clinical condition that increases respiratory rate and depth can cause lungs to eliminate CO2 and cause decreased PACO2 and increased pH causing
RESPIRATORY ALKALOSIS
pH increases respirations decrease, body retains CO2, increased carbonic acid level retention, increased acid leads to
respiratory acidosis
if pH is high respirations _________________ causing body to retain carbon dioxide which increases the carbonic acid level
decrease (slow and shallow)
effective but slow if pH is high will excrete bicarb, this can take up to 3 days to normalize pH level
, renal mechanism/kidneys
disturbance alters the carbonic acid portion of the buffering system
respiratory
disturbance alters the bicarbonate portion of the buffering system
metabolic
normal PCO2 range is
35-45 mmHg
normal HCO3 level is
22-26 mEq/L
ROME
Respiratory opposite metabolic equal
occur when carbonic acid or bicarbonate levels become disproportionate
acid base imbalances
primary excess of carbonic acid in ECF (PCO2 greater than45 and pH less than 7.35)
respiratory acidosis
primary deficit of carbonic acid in ECF (PCO2 less than 35 and pH greater than 7.45)
respiratory alkalosis
proportionate deficit of bicarbonate in ECF (HCO3 less than 22 and pH less than 7.35)
metabolic acidosis
primary excess of bicarbonate in ECF (HCO3 greater than 26 and pH greater than 7.45
metabolic alkalosis
causes of respiratory acidosis
acute and chronic respiratory disease CNS depression neuromuscular disease retention of PCO2 common in patients with chronic respiratory diseases
signs and symptoms of respiratory acidosis
acute: increased pulse and respirations, decreased LOC
chronic: weakness, HA
example pH 7.30 PCO2 47
Interventions for respiratory acidosis
O2, adequate hydration
causes of respiratory alkalosis
hyperventilation, extreme anxiety
high fever, early sepsis
signs and symptoms of respiratory alkalosis
confusion, difficulty concentrating, lightheadedness, palpitations, sweating
interventions for respiratory alkalosis
encourage slow, deep breaths (paper bag)
sedatives
Morphine or Ativan may be given to decrease respiratory rate
causes of metabolic acidosis
uncontrolled DM
excessive GI fluid losses
signs and symptoms of metabolic acidosis
N/V
Increased respiratory rate, peripheral vasodilation, hyperkalemia
interventions for metabolic acidosis
correction of underlying problem
bicarbonate IV
causes of metabolic alkalosis
excessive acid loss- vomiting or gastric suctioning
hypokalemia
signs and symptoms of metabolic alkalosis
dizziness, tingling of extremities, hypertonic muscles
interventions for metabolic alkalosis
give salt p.o. or sodium rich foods
reduces transfusion reactions
typing and cross matching
A person with group A blood can donate blood to
A and AB
A person with group A blood can receive blood from
A & O
A person with group B blood can give blood to
B & AB
A person with group B blood can receive blood from
B & O
A person with group AB blood can donate blood to
AB only
A person with group AB blood can receive from
all: A, B, AB, and O
A person with type O blood can give blood to
all: A, B, AB, and O
A person with type O blood can receive blood from
O only
identifies major antigens
helps reduce risk of transfusion reactions
RBCs from donor blood is mixed with plasma from recipient, a reagent is added, observed for clumping and if no clumping should be safe to give blood
crossmatching
blood products include:
whole blood RBCs or PRBCs Plasma WBCs plasma derivatives- albumin autologous transfusion-
helps with oxygen transport
PRBCs
patient can receive their own blood- prior to surgery donate and it is given back postop
autologous transfusion
given to neutropenic patients
WBCs
stay with patient for __________ of transfusion
first 5 minutes
when monitoring tranfusions:
verify doctor's orders baseline vitals inspect IV site 18 gauge preferred, no less than 20 gauge IV catheter verify blood by 2 RN's vitals q 15 min x 4 then 30 min until completed flush with hanging saline after infusion blood must infuse in 4 hours or less
the longer blood hangs the more likely
it is to grow bacteria
some patients may receive __________ between transfusions, especially if heart failure patient
diuretics
types of transfusion reactions:
Allergic, bacterial febrile, hemolytic, circulatory overload
flushing, itching, rash, urticaria, hives, anaphylaxis
Allergic reaction to transfusion
fever, increased BP, and chills
bacterial reaction to transfusion
fever, chills, and flushing
febrile reaction to transfusion
RBCs destruction, fever, chills, SOB, chest pain, back pain. caused by infusing incompatible blood
hemolytic transfusion reaction
One of the most serious types of transfusion reactions
hemolytic
hypervolemia, cough, crackles, increased BP
circulatory overload
transfusion reaction nursing interventions:
immediately stop the transfusion
disconnect the tubing from the patient
Infuse 0.9% NS
Vital signs, cardiac and respiratory assessment
Notify physician
Send the blood back to the blood bank, call the lab to come draw a blood sample and take a urine specimen (sometimes ordered) according to policy
IV insertion and maintenance
Choose the right site: site that meets patient’s need for fluids, in hand or lower arm, In trauma or cardiac arrest use antecubital fossa (bend of arm), use nondominant limb if possible, avoid using veins that lie over joints, avoid veins in feet of patients with diabetes or circulatory problems, avoid limbs with injuries, loss of sensation.
Know why IV is placed
A lot of facilities require physician’s orders for IV placed in lower extremities
complications of IV therapy:
infiltration infection phlebitis, thrombophlebitis extravasation severed catheter allergic reaction air embolism speed shock fluid overload
fluid leaks into tissue outside of vein
infiltration
purulent drainage and redness
infection
red, inflammation of vein, red streak up arm
phlebitis
inflammation of vein
thrombophlebitis
similar to infiltration with tissue damage
red, hot
extravasation
part of catheter shears off and causes an embolus
requires calling PCP
severed catheter
itching at site, redness, anaphylaxis, laryngeal edema, runny nose
allergic reaction
obstruction of blood vessel caused by air bubble
air embolism
sudden physiologic reaction to IV med or fluids given too quickly
speed shock
LOC, cardiac arrest, dyspnea, SOB, crackles, tachypnea
fluid overload
the worst type of complication of IV therapy
extravasation
documentation of IV therapy
how patient tolerated
date, time, type of catheter
Label actual site with date, time, and gauge size, and your initials
# of attempts
insertion site and its appearance
the type and amount of fluid being infused and the rate
any patient teaching
There once was a tekkie named Chvos, whose calcium was so low it was lost! He'd tap on his face on the facial nerve space Till his face twitched and his eyes almost crossed.
Chvostek’s sign
There once was a bride named Eve Snow, Whose groom's parathyroid was low. His calcium decked And both arms were so flexed that poor Eve carried her own trousseau.
Trousseau’s sign
Normal thirst or may refuse some fluids
A moist mouth and tongue
Normal to slightly decreased urine output, normal specific gravity, and serum osmolality
less than 3% weight gain
normal HR, P, breathing, and warm extremities
cap refill less than 2 seconds
instant recoil on skin turgor test
eyes not sunken (and/or fontanel in baby)
this can be managed at home with oral hydration
mild dehydration
dry mouth and tongue
tired, restlessness, irritability, increased thirst
decreased urine output to slightly elevated urine specific gravity and serum osmolality
3-9% weight loss
normal to increased HR and P, normal to fast breathing, and cool extremities
cap refill greater than 2 seconds
recoil on skin turgor test in less than 2 seconds
slightly sunken eyes (and/of fontanel in baby)
may or may not be treatable at home, more aggressive approach may be needed
an IV bolus of fluid may or may not be given
marked or moderate dehydration
Poor drinking or may be unable to drink
lethargy, parched mouth and tongue
Minimal to no urine output, elevated urine specific gravity and serum osmolality
greater than 9% weight loss
increased HR, weak pulses, deep breathing, and cool mottled extremities
cap refill that is very prolonged or minimal
recoil on skin turgor test is more than 2 seconds
deeply sunken eyes (and/or fontanel in baby)
Considered MEDICAL EMERGENCY!!!
Patient is at risk for shock and death!!!
requires aggressive IV rehydration
severe dehydration
