Fluid & Electrolytes and Acid Base Balance

Fluids and ElectrolytesFluids and ElectrolytesAcid Base BalanceAcid Base Balance

Prepared by :Prepared by :Dr. Malyn Basbas-UyDr. Malyn Basbas-Uy

Fluid volume deficit Fluid volume deficit (dehydration):(dehydration):

mechanism that influences fluid balance mechanism that influences fluid balance and sodium levels; and sodium levels;

decreased quantities of fluid and decreased quantities of fluid and electrolytes may be caused by deficient electrolytes may be caused by deficient intake (poor dietary habits, anorexia, and intake (poor dietary habits, anorexia, and nausea), nausea),

excessive output (vomiting, nasogastric excessive output (vomiting, nasogastric suction, and prolonged diarrhea), orsuction, and prolonged diarrhea), or

failure of regulatory mechanism that failure of regulatory mechanism that influences fluid balance and sodium levelsinfluences fluid balance and sodium levels..

Fluid volume deficit (dehydration):Fluid volume deficit (dehydration):

A.A. Pathophysiology: Pathophysiology:

Water moves out of the cells to Water moves out of the cells to replace a significant water loss; replace a significant water loss; cells eventually become unable to cells eventually become unable to compensate for the lost fluid, and compensate for the lost fluid, and cellular dehydration begins, cellular dehydration begins, leading to circulatory collapse.leading to circulatory collapse.


B. Risk factors: B. Risk factors:

1. No fluids available.1. No fluids available.

2. Available fluids not drinkable.2. Available fluids not drinkable.

3. Inability to take fluids 3. Inability to take fluids independently.independently.

4. No response to thirst; does not 4. No response to thirst; does not recognize the need for fluids.recognize the need for fluids.

5. Inability to communicate need; 5. Inability to communicate need; does not speak same language.does not speak same language.

6. Aphasia.6. Aphasia.

Fluid volume deficit (dehydration):Fluid volume deficit (dehydration): cont.cont.7. Weakness, comatose.7. Weakness, comatose.

8. Inability to swallow.8. Inability to swallow.

9. Psychological alterations.9. Psychological alterations.

10. Overuse of diuretics.10. Overuse of diuretics.

11. Increased vomiting.11. Increased vomiting.

12. Fever.12. Fever.

13. Wounds, burns.13. Wounds, burns.

14. Blood loss.14. Blood loss.

15. Endocrine abnormalities15. Endocrine abnormalities


C. Assessment: C. Assessment:

1. Subjective data1. Subjective data

a. Thirst.a. Thirst.

b. Behavioral changes: apprehension, b. Behavioral changes: apprehension, apathy, lethargy, confusion, apathy, lethargy, confusion, restlessness.restlessness.

c. Dizziness.c. Dizziness.

d. Numbness and tingling of hands and d. Numbness and tingling of hands and feet.feet.

e. Anorexia and nausea.e. Anorexia and nausea.

f. Abdominal cramps.f. Abdominal cramps.


2. Objective data2. Objective data

a. Sudden weight loss of 5%.a. Sudden weight loss of 5%.

b. Vital signs:b. Vital signs:

1. Decreased BP; postural 1. Decreased BP; postural changes.changes.

2. Increased temperature.2. Increased temperature.

3. Irregular, weak, rapid pulse.3. Irregular, weak, rapid pulse.

4. Increased rate and depth of 4. Increased rate and depth of respirations.respirations.


c. Skin: cool and pale in absence of c. Skin: cool and pale in absence of infection; decreased turgor.infection; decreased turgor.

d. Urine: oliguria to anuria, high d. Urine: oliguria to anuria, high specific gravity.specific gravity.

e. Eyes: soft, sunken.e. Eyes: soft, sunken.

f. Tongue: furrows.f. Tongue: furrows.

g. Lab data:g. Lab data:

1. Blood—increased hematocrit and 1. Blood—increased hematocrit and BUN.BUN.

2. Urine—decreased 17-2. Urine—decreased 17-ketosteroidsketosteroids..

D. Nursing care plan/implementation: D. Nursing care plan/implementation:

1. Goal: restore fluid and electrolyte balance1. Goal: restore fluid and electrolyte balance—increase fluid intake to hydrate client.—increase fluid intake to hydrate client.

a. IVs and blood products as ordered; small, a. IVs and blood products as ordered; small, frequent drinks by mouth.frequent drinks by mouth.

b. Daily weights (same time of day) to monitor b. Daily weights (same time of day) to monitor progress progress of fluid replacement.of fluid replacement.

c. I&O, hourly outputs (when in acute state).c. I&O, hourly outputs (when in acute state).

d. Avoid hypertonic solutions (may cause fluid d. Avoid hypertonic solutions (may cause fluid shift shift when when compensatory mechanisms compensatory mechanisms

begin to function).begin to function).

D. Nursing care plan/implementation:D. Nursing care plan/implementation:

2. Goal: promote comfort.2. Goal: promote comfort.

a. Frequent skin care (lack of a. Frequent skin care (lack of hydration hydration causes dry skin, which causes dry skin, which may increase may increase risk for skin risk for skin breakdown).breakdown).

b. Position: change every hour to b. Position: change every hour to relieve relieve pressure.pressure.

c. Medications as ordered: c. Medications as ordered: antiemetics, antiemetics, antidiarrheal.antidiarrheal.

D. Nursing care plan/implementation: D. Nursing care plan/implementation:

3. Goal: prevent physical injury.3. Goal: prevent physical injury.

a. Frequent mouth care (mucous membrane a. Frequent mouth care (mucous membrane dries due to dehydration; therefore, client is at dries due to dehydration; therefore, client is at risk for breaks in mucous membrane, risk for breaks in mucous membrane, halitosis).halitosis).

b. Monitor IV flow rate—observe for circulatory b. Monitor IV flow rate—observe for circulatory overload, pulmonary edema related to overload, pulmonary edema related to potential fluid shift when compensatory potential fluid shift when compensatory mechanisms begin or client is unable to mechanisms begin or client is unable to tolerate rate of fluid replacement.tolerate rate of fluid replacement.

E. Analysis/nursing diagnosis: E. Analysis/nursing diagnosis:

1. Fluid volume deficit related 1. Fluid volume deficit relatedto inadequate fluid intaketo inadequate fluid intake

F. Evaluation/outcome criteria: F. Evaluation/outcome criteria:

1. Mentally alert.1. Mentally alert.

2. Moist, intact mucous membranes.2. Moist, intact mucous membranes.

3. Urinary output approximately equal 3. Urinary output approximately equal to intake.to intake.

4. No further weight loss.4. No further weight loss.

5. Gradual weight gain.5. Gradual weight gain.

Fluid volume excess (fluid overload): Fluid volume excess (fluid overload):

most common cause is an most common cause is an increase in increase in sodium; sodium;

excessive quantities of fluid and excessive quantities of fluid and electrolytes may be due to increased electrolytes may be due to increased ingestion, tube feedings, intravenous ingestion, tube feedings, intravenous infusions, multiple tap-water enemas, infusions, multiple tap-water enemas, oror

a failure of regulatory systems, a failure of regulatory systems, resulting in inability to excrete resulting in inability to excrete excesses.excesses.


A. Pathophysiology: A. Pathophysiology: hypo-osmolar water excess in hypo-osmolar water excess in

extracellular compartment leads to extracellular compartment leads to intracellular water excess because the intracellular water excess because the concentration of solutes in the concentration of solutes in the intracellular fluid is greater than that in intracellular fluid is greater than that in the extracellular fluid. Water moves to the extracellular fluid. Water moves to equalize concentration, causing equalize concentration, causing swelling of the cells. The most common swelling of the cells. The most common cause is an increase in sodium.cause is an increase in sodium.


B. Risk factors: B. Risk factors: 1. Excessive intake of electrolyte-free fluids.1. Excessive intake of electrolyte-free fluids.2. Increased secretion of ADH in response to 2. Increased secretion of ADH in response to

stress, drugs, anesthetics.stress, drugs, anesthetics.3. Decreased or inadequate output of urine.3. Decreased or inadequate output of urine.4. Psychogenic polydipsia.4. Psychogenic polydipsia.5. Certain medical conditions: tuberculosis; 5. Certain medical conditions: tuberculosis;

encephalitis; meningitis; endocrine encephalitis; meningitis; endocrine disturbances; tumors of lung, pancreas, disturbances; tumors of lung, pancreas, duodenum, heart failure.duodenum, heart failure.

6. Inadequate kidney function or kidney 6. Inadequate kidney function or kidney failure.failure.

Fluid volume excess (fluid overload):Fluid volume excess (fluid overload):

C. Assessment: C. Assessment: 1. Subjective data1. Subjective data

a.a. Behavioral changes: irritability, Behavioral changes: irritability, apathy,apathy,

confusion, confusion, disorientation.disorientation.

b. Headache.b. Headache.c. Anorexia, nausea, cramping.c. Anorexia, nausea, cramping.d. Fatigue.d. Fatigue.e. Dyspnea.e. Dyspnea.

Fluid volume excess (fluid Fluid volume excess (fluid overload):overload):

2. Objective data2. Objective data

a. Vital signs: elevated blood a. Vital signs: elevated blood pressure.pressure.

b. Skin: warm, moist; edema—b. Skin: warm, moist; edema—eyelids, facial, dependent, pitting.eyelids, facial, dependent, pitting.

c. Sudden weight gain of 5 lb.c. Sudden weight gain of 5 lb.d. Pink, frothy sputum; productive.d. Pink, frothy sputum; productive.e. Constant, irritating cough.e. Constant, irritating cough.

Objective dataObjective data(cont.)(cont.)

f. Crackles in lungs.f. Crackles in lungs.g. Pulse, bounding.g. Pulse, bounding.h. Engorgement of neck veins in h. Engorgement of neck veins in sitting position.sitting position.

i. Urine: polyuria, nocturia.i. Urine: polyuria, nocturia.j. Lab data:j. Lab data:

1. Blood—decreasing hematocrit, 1. Blood—decreasing hematocrit, BUN.BUN.

2. Urine—decreasing specific 2. Urine—decreasing specific gravitygravity..


D. Analysis/nursing diagnosis: D. Analysis/nursing diagnosis:

1. Fluid volume excess related to 1. Fluid volume excess related to excessive fluid intake or excessive fluid intake or decreased fluid output.decreased fluid output.

E. Nursing care plan/implementation: E. Nursing care plan/implementation:

1. Goal: maintain oxygen to all cells. 1. Goal: maintain oxygen to all cells.

a. Position: semi-Fowler's or Fowler's a. Position: semi-Fowler's or Fowler's to to facilitate facilitate improved gas improved gas exchange.exchange.

b. Vital signs: PRN, minimum q4hr.b. Vital signs: PRN, minimum q4hr.

c. Fluid restriction.c. Fluid restriction.

2. Goal: promote excretion of excess 2. Goal: promote excretion of excess fluid.fluid.

a. Medications as ordered: a. Medications as ordered: diuretics.diuretics.

b. Monitor electrolytes, especially b. Monitor electrolytes, especially Mg++, K+Mg++, K+

c. If in kidney failure: may need c. If in kidney failure: may need dialysis; explain procedure.dialysis; explain procedure.

d. Assist client during d. Assist client during paracentesis, paracentesis, thoracentesis, thoracentesis, phlebotomy.phlebotomy.

Nursing care plan/implementation:Nursing care plan/implementation:

3. Goal: obtain/maintain fluid balance.3. Goal: obtain/maintain fluid balance.

a. Daily weights; a. Daily weights; 1 kg = 1000 mL 1 kg = 1000 mL fluidfluid..

b. Measure: all edematous parts, b. Measure: all edematous parts, abdominal girth, I&O.abdominal girth, I&O.

c. Limit: fluids by mouth, IVs, sodium.c. Limit: fluids by mouth, IVs, sodium.

d. Strict monitoring of IV fluids.d. Strict monitoring of IV fluids.

Fluid volume excess (fluid overload): Fluid volume excess (fluid overload): Nursing care plan/implementation:Nursing care plan/implementation:

4. Goal: prevent tissue injury.4. Goal: prevent tissue injury.

a. Skin and mouth care as needed.a. Skin and mouth care as needed.b. Evaluate feet for edema and b. Evaluate feet for edema and discoloration when client is out of discoloration when client is out of bed.bed.

c. Observe suture line on surgical c. Observe suture line on surgical clientsclients

d. IV route preferred for parenteral d. IV route preferred for parenteral medications; Z track if medications medications; Z track if medications are to be given IM.are to be given IM.

5. Goal: health teaching.a. Improve nutritional status with low

sodium diet.

b. Identify cause that put client at risk for imbalance.

c. Desired and side effects of diuretics and other prescribed medications.

d. Monitor urinary output, ankle edema;

e. Limit fluid intake when kidney/cardiac function Impaired.

Fluid volume excess (fluid overload): Fluid volume excess (fluid overload): Nursing care plan/implementation Nursing care plan/implementation Evaluation/outcome criteriaEvaluation/outcome criteria

F. Evaluation/outcome criteria: F. Evaluation/outcome criteria:

1. Fluid balance obtained.1. Fluid balance obtained.

2. No respiratory, cardiac 2. No respiratory, cardiac complications.complications.

3. Vital signs within normal limits.3. Vital signs within normal limits.

4. Urinary output improved, no 4. Urinary output improved, no evidence of edema.evidence of edema.

Common electrolyte imbalancesCommon electrolyte imbalances

electrolytes are taken into the body in foods electrolytes are taken into the body in foods and fluids; and fluids;

normally lost through sweat and urine. normally lost through sweat and urine. May also be lost through hemorrhage, May also be lost through hemorrhage,

vomiting, and diarrhea. vomiting, and diarrhea.

Electrolytes have major influences on:Electrolytes have major influences on:body water regulation and osmolality, body water regulation and osmolality, acid-base regulation, enzyme acid-base regulation, enzyme

reactions, reactions, and neuromuscular activity. and neuromuscular activity.

Clinically important electrolytes:Clinically important electrolytes:

A.A. Sodium (Na+): Sodium (Na+):

Normal 135–145 mEq/L. Normal 135–145 mEq/L. – Most prevalent cation in Most prevalent cation in

extracellular extracellular fluid. fluid. – Controls osmotic pressure; essential Controls osmotic pressure; essential

for neuromuscular functioning and for neuromuscular functioning and intracellular chemical reactions. intracellular chemical reactions.

– Aids in maintenance of acid-base Aids in maintenance of acid-base balance. balance.

– Necessary for glucose to be Necessary for glucose to be transported into cells.transported into cells.

1. Hyponatremia1. Hyponatremia

—sodium deficit, resulting from —sodium deficit, resulting from either a either a sodium loss or water excess. sodium loss or water excess.

Serum-sodium level below 135 Serum-sodium level below 135 mEq/L; mEq/L;

symptoms usually do not occur until symptoms usually do not occur until below 120 mEq/L unless rapid drop.below 120 mEq/L unless rapid drop.

2. Hypernatremia2. Hypernatremia

——excess sodium in the blood, resulting excess sodium in the blood, resulting from either high sodium intake, from either high sodium intake,

water loss, or low water intake. water loss, or low water intake.

Serum-sodium level above 145 mEq/L.Serum-sodium level above 145 mEq/L.


B. Potassium (K+): B. Potassium (K+):

normal 3.5–5.0 mEq/L. normal 3.5–5.0 mEq/L. • Direct effect on excitability of nerves Direct effect on excitability of nerves

and muscles. and muscles. • Contributes to intracellular osmotic Contributes to intracellular osmotic

pressure and influences acid-base pressure and influences acid-base balance. balance.

• Major Major intracellular cationintracellular cation. . • Required for storage of nitrogen as Required for storage of nitrogen as

muscle protein.muscle protein.


1. Hypokalemia1. Hypokalemia——potassium deficit related to dehydration, potassium deficit related to dehydration, starvation, vomiting, diarrhea, diuretics. starvation, vomiting, diarrhea, diuretics. Serum-potassium level below 3.5 mEq/L; Serum-potassium level below 3.5 mEq/L; symptoms may not occur until below 2.5 symptoms may not occur until below 2.5 mEq/L.mEq/L.

2. Hyperkalemia2. Hyperkalemia——potassium excess related to severe tissue potassium excess related to severe tissue damage, renal disease, excess administration damage, renal disease, excess administration of oral or IV potassium.of oral or IV potassium.

Serum-potassium level above 5 mEq/L; Serum-potassium level above 5 mEq/L; symptoms usually occur when above 6.5 symptoms usually occur when above 6.5 mEq/L.mEq/L.

Clinically important electrolytesClinically important electrolytes

C. Calcium (Ca++): C. Calcium (Ca++):

Normal 4.5–5.5 mEq/L. Normal 4.5–5.5 mEq/L.

• Essential to muscle metabolism, Essential to muscle metabolism, cardiac function, and bone health. cardiac function, and bone health.

• Controlled by parathyroid hormone; Controlled by parathyroid hormone; reciprocal relationship between reciprocal relationship between calcium and phosphorus.calcium and phosphorus.

Calcium (Ca++):Calcium (Ca++):

1. Hypocalcemia1. Hypocalcemia——loss of calcium related to loss of calcium related to

inadequate intake, vitamin D deficiency, inadequate intake, vitamin D deficiency, hypoparathyroidism, damage to the hypoparathyroidism, damage to the parathyroid gland, decreased absorption in parathyroid gland, decreased absorption in the GI tract, excess loss through kidneys. the GI tract, excess loss through kidneys. Serum-calcium level below 4.5 mEq/L.Serum-calcium level below 4.5 mEq/L.

2. Hypercalcemia2. Hypercalcemia——calcium excess related to calcium excess related to

hyperparathyroidism, immobility, bone hyperparathyroidism, immobility, bone tumors, renal failure, excess intake of Ca+tumors, renal failure, excess intake of Ca++ or vitamin D. Serum-calcium level above + or vitamin D. Serum-calcium level above 5.5 mEq/L.5.5 mEq/L.

Clinically important electrolytesClinically important electrolytes

D. Magnesium (Mg++): D. Magnesium (Mg++): Normal 1.5–2.5 mEq/L. Normal 1.5–2.5 mEq/L.

• Essential to cellular metabolism of Essential to cellular metabolism of carbohydrates and proteins.carbohydrates and proteins.

1. Hypomagnesemia1. Hypomagnesemia——magnesium deficit related to magnesium deficit related to

impaired absorption from GI tract, impaired absorption from GI tract, excessive loss through kidneys, and excessive loss through kidneys, and prolonged periods of poor nutritional prolonged periods of poor nutritional intake. intake. Hypomagnesemia leads to Hypomagnesemia leads to neuromuscular irritability. neuromuscular irritability. Serum-Serum-magnesium level below 1.5mEq/L.magnesium level below 1.5mEq/L.

Magnesium (Mg++):Magnesium (Mg++):

2. Hypermagnesemia2. Hypermagnesemia

——magnesium excess related to magnesium excess related to

renal insufficiency, overdose during renal insufficiency, overdose during replacement therapy, severe replacement therapy, severe dehydration, repeated enemas with dehydration, repeated enemas with Mg++ sulfate. Mg++ sulfate.

Serum-magnesium level above 2.5 Serum-magnesium level above 2.5 mEq/L.mEq/L.

Electrolyte ImbalancesElectrolyte ImbalancesHyponatremia Hyponatremia

Disorder and Related Condition: Disorder and Related Condition: • Addison's diseaseAddison's disease• StarvationStarvation• GI suctionGI suction• Thiazide diureticsThiazide diuretics• Excess water intake, enemasExcess water intake, enemas• FeverFever• Fluid shiftsFluid shifts• AscitesAscites• BurnsBurns• Small-bowel obstructionSmall-bowel obstruction• Profuse perspirationProfuse perspiration

Electrolyte ImbalancesElectrolyte ImbalancesHyponatremiaHyponatremiaAssessmentAssessment

Subjective Data: Subjective Data:

• • Apathy, apprehension, mental Apathy, apprehension, mental confusion, deliriumconfusion, delirium

• • FatigueFatigue

• • Vertigo, headacheVertigo, headache

• • Anorexia, nauseaAnorexia, nausea

• • Abdominal and muscle crampsAbdominal and muscle cramps

Electrolyte ImbalancesElectrolyte ImbalancesHyponatremiaHyponatremiaAssessmentAssessment

Objective Data: Objective Data:

• • Pulse: rapid and weakPulse: rapid and weak

• • BP: postural hypotensionBP: postural hypotension

• • Shock, comaShock, coma

• • GI: weight loss, diarrhea, loss GI: weight loss, diarrhea, loss through NG tubesthrough NG tubes

• • Muscle weaknessMuscle weakness

Electrolyte ImbalancesElectrolyte ImbalancesHyponatremiaHyponatremia

» Analysis/Nursing Diagnosis: » Analysis/Nursing Diagnosis:

– – DiarrheaDiarrhea

– – Fluid volume excessFluid volume excess

– – Altered nutrition, less than body Altered nutrition, less than body requirementsrequirements

– – Sensory-perceptual alteration Sensory-perceptual alteration (kinesthetic)(kinesthetic)

HyponatremiaHyponatremia

» Nursing Care Plan/Implementation: » Nursing Care Plan/Implementation:

– – Obtain normal sodium level: identify cause Obtain normal sodium level: identify cause of deficit, increase sodium intake PO (salty of deficit, increase sodium intake PO (salty foods), IVs–hypertonic solutionsfoods), IVs–hypertonic solutions

– – Prevent further sodium loss: irrigate NG Prevent further sodium loss: irrigate NG tubes with saline; hourly I&O to monitor tubes with saline; hourly I&O to monitor kidney outputkidney output

– – Prevent injury related to shock, dizziness, Prevent injury related to shock, dizziness, decreased sensorium; dangle before decreased sensorium; dangle before ambulationambulation

– – Skin careSkin care

Electrolyte ImbalancesElectrolyte ImbalancesHyponatremiaHyponatremia

» Evaluation/Outcome Criteria: » Evaluation/Outcome Criteria:

– – Na+ 135–145 mEq/LNa+ 135–145 mEq/L

– – No complications of shock presentNo complications of shock present

– – Return of muscle strengthReturn of muscle strength

– – Alert, orientedAlert, oriented

– – Limits intake of plain waterLimits intake of plain water

Electrolyte ImbalancesElectrolyte ImbalancesHypernatremia Hypernatremia

Disorder and Related Condition: Disorder and Related Condition: High sodium intakeHigh sodium intake Low water intakeLow water intake DiarrheaDiarrhea High fever with rapid respirationsHigh fever with rapid respirations Impaired renal functionsImpaired renal functions Acute tracheobronchitis Acute tracheobronchitis

Electrolyte ImbalancesElectrolyte ImbalancesHypernatremia Hypernatremia AssessmentAssessment

Subjective Data: Subjective Data: • • LethargyLethargy• • Restlessness, agitationRestlessness, agitation• • ConfusionConfusion

Objective Data: Objective Data: • • BP and temperature: elevatedBP and temperature: elevated• • Neuromuscular: diminished reflexesNeuromuscular: diminished reflexes• • Skin: flushed; firm turgorSkin: flushed; firm turgor• • GI: mucous membrane dry, stickyGI: mucous membrane dry, sticky• • GU: decreased outputGU: decreased output

Electrolyte ImbalancesElectrolyte ImbalancesHypernatremiaHypernatremia


– – Fluid volume deficitFluid volume deficit

– – Fluid volume excessFluid volume excess

– – Altered nutrition, less than body Altered nutrition, less than body requirementsrequirements

– – Sensory-perceptual alteration Sensory-perceptual alteration (kinesthetic)(kinesthetic)



– – Obtain normal sodium level: Obtain normal sodium level: decrease sodium in takedecrease sodium in take

– – I&O to recognize signs and I&O to recognize signs and symptoms of complications (e.g., symptoms of complications (e.g., heart failure, pulmonary edema)heart failure, pulmonary edema)



– – Na+ 135–145 mEq/LNa+ 135–145 mEq/L

– – No complaint of thirstNo complaint of thirst

– – Alert, orientedAlert, oriented

– – Relaxed in appearanceRelaxed in appearance

– – Identifies high sodium foods to Identifies high sodium foods to avoidavoid

– – K+ 3.5–5.0 mEq/LK+ 3.5–5.0 mEq/L

Hypokalemia Hypokalemia Disorder and Related Condition:Disorder and Related Condition:

Decreased intake: Decreased intake: » Poor potassium food intake» Poor potassium food intake» Excessive dieting» Excessive dieting» Nausea» Nausea» Alcoholism» Alcoholism» IV fluids without added potassium» IV fluids without added potassium

Increased loss: Increased loss: » GI suctioning, vomiting, diarrhea» GI suctioning, vomiting, diarrhea» Ulcerative colitis» Ulcerative colitis» Drainage: ostomy, fistulas» Drainage: ostomy, fistulas» Medications: potassiumlosing diuretics, digoxin, » Medications: potassiumlosing diuretics, digoxin,

catharticscathartics» Increased aldosterone production; Renal » Increased aldosterone production; Renal

disordersdisorders

HypokalemiaHypokalemia» Assessment» Assessment


• • Apathy, lethargy, fatigue, Apathy, lethargy, fatigue, weaknessweakness

• • Irritability, mental confusionIrritability, mental confusion

• • Anorexia, nauseaAnorexia, nausea

• • Leg crampsLeg cramps

HypokalemiaHypokalemia» Assessment» Assessment

Objective Data:Objective Data:

• • Muscles: weakness, paralysis, paresthesia, Muscles: weakness, paralysis, paresthesia, hyporeflexiahyporeflexia

• • Respirations: shallow to respiratory arrestRespirations: shallow to respiratory arrest• • Cardiac: decreased BP; elevated, weak, irregular Cardiac: decreased BP; elevated, weak, irregular

pulse; arrhythmiaspulse; arrhythmias• • ECG: low, flat T waves; prolonged ST segment; ECG: low, flat T waves; prolonged ST segment;

elevated U wave; potential arrestelevated U wave; potential arrest• • GI: vomiting, flatulence, constipation; decreased GI: vomiting, flatulence, constipation; decreased

motility distention paralytic ileusmotility distention paralytic ileus• • GU: urine not concentrated; polyuria, nocturia; GU: urine not concentrated; polyuria, nocturia;

kidney damagekidney damage• • Speech: slowSpeech: slow

HypokalemiaHypokalemia


– – Decreased cardiac outputDecreased cardiac output

– – FatigueFatigue

– – Altered cardiopulmonary tissue perfusionAltered cardiopulmonary tissue perfusion

– – Ineffective breathing patternsIneffective breathing patterns

– – ConstipationConstipation

– – Bathing/hygiene self-care deficitBathing/hygiene self-care deficit

– – Impaired home maintenance managementImpaired home maintenance management

– – Sensory-perceptual alteration (gustatory)Sensory-perceptual alteration (gustatory)


» Nursing Care Plan/Implementation: » Nursing Care Plan/Implementation: • Replace lost potassium: increase Replace lost potassium: increase

potassium in diet; liquid PO potassium in diet; liquid PO potassium medications—dilute in potassium medications—dilute in juice to aid taste; give potassium juice to aid taste; give potassium only if kidneys functioningonly if kidneys functioning

• Prevent injury to tissues: prevent Prevent injury to tissues: prevent infiltration, pain, tissue damageinfiltration, pain, tissue damage

• Prevent potassium loss: Irrigate NG Prevent potassium loss: Irrigate NG tubes with saline, not watertubes with saline, not water



– – Identifies cause of imbalanceIdentifies cause of imbalance

– – Lists foods to include in dietLists foods to include in diet

– – Lists signs and symptoms of Lists signs and symptoms of imbalanceimbalance

– – Return of muscle strengthReturn of muscle strength

– – No cardiac arrhythmiasNo cardiac arrhythmias

Hyperkalemia Hyperkalemia Disorder and Related Disorder and Related Condition:Condition:

BurnsBurns Crushing injuriesCrushing injuries Kidney diseaseKidney disease Excessive infusion or ingestion of Excessive infusion or ingestion of

K+K+ Adrenal insufficiencyAdrenal insufficiency Mercurial poisoningMercurial poisoning

HyperkalemiaHyperkalemia

» Assessment» Assessment

– – Subjective Data: Subjective Data:

• • IrritabilityIrritability

• • Weakness, muscle crampsWeakness, muscle cramps

• • Nausea, intestinal crampsNausea, intestinal cramps

Hyperkalemia Hyperkalemia » Assessment» AssessmentObjective DataObjective Data::

• • Muscles: paresthesia, flaccid muscle Muscles: paresthesia, flaccid muscle paralysis (later)paralysis (later)

• • Cardiac; irregular pulse; arrhythmias; Cardiac; irregular pulse; arrhythmias; bradycardia asystolebradycardia asystole

• • ECG: high T waves; depressed ST ECG: high T waves; depressed ST segment; widened QRS complex; segment; widened QRS complex; diminished or absent P waves; diminished or absent P waves; ventricular fibrillationventricular fibrillation

• • GI: explosive diarrhea; GI: explosive diarrhea; hyperactive bowel soundshyperactive bowel sounds

• • Kidney: scanty to no urineKidney: scanty to no urine


» Analysis/Nursing Diagnosis: » Analysis/Nursing Diagnosis: • Decreased cardiac outputDecreased cardiac output• Altered urinary eliminationAltered urinary elimination• Activity intoleranceActivity intolerance• Ineffective breathing patternsIneffective breathing patterns• DiarrheaDiarrhea• Impaired home maintenance Impaired home maintenance

managementmanagement


» Nursing Care Plan/Implementation: » Nursing Care Plan/Implementation: • Decrease amount of potassium in body; Decrease amount of potassium in body;

identify and treat cause of imbalance; give identify and treat cause of imbalance; give foods low in K+; avoid drugs or IV fluids foods low in K+; avoid drugs or IV fluids containing K+containing K+

• If kidney failure present, may need to If kidney failure present, may need to prepare for dialysisprepare for dialysis

» Evaluation/Outcome Criteria: » Evaluation/Outcome Criteria: K+ 3.5–5.0 mEq/LK+ 3.5–5.0 mEq/L No complications (e.g., arrhythmias, No complications (e.g., arrhythmias,

acidosis, respiratory failure)acidosis, respiratory failure)

Hypocalcemia Hypocalcemia Disorder and Related Disorder and Related Condition:Condition:• Acute pancreatitisAcute pancreatitis• DiarrheaDiarrhea• PeritonitisPeritonitis• Damage to parathyroid during thyroidectomyDamage to parathyroid during thyroidectomy• HypothyroidismHypothyroidism• BurnsBurns• Pregnancy and lactationPregnancy and lactation• Low vitamin D intakeLow vitamin D intake• Multiple blood transfusionsMultiple blood transfusions• Renal disordersRenal disorders• Massive infectionMassive infection

HypocalcemiaHypocalcemia


Subjective Data: Subjective Data: • • FatigueFatigue• • Tingling/numbness; fingers and Tingling/numbness; fingers and

circumoralcircumoral• • Abdominal crampsAbdominal cramps• • PalpitationsPalpitations• • DyspneaDyspnea

HypocalcemiaHypocalcemia» Assessment» Assessment

Objective Data: Objective Data: • • Muscle spasms: tonic muscles, Muscle spasms: tonic muscles,

carpopedal, laryngealcarpopedal, laryngeal• • Neuromuscular: grimacing, Neuromuscular: grimacing,

hyperirritable facial nerveshyperirritable facial nerves• • Tetany convulsionsTetany convulsions• • Orthopedic: osteoporosis fracturesOrthopedic: osteoporosis fractures• • Cardiac: arrhythmias arrestCardiac: arrhythmias arrest• • GI: diarrheaGI: diarrhea


» Analysis/Nursing Diagnosis: » Analysis/Nursing Diagnosis: • PainPain• DiarrheaDiarrhea• Altered nutrition, less than body Altered nutrition, less than body

requirementsrequirements• Risk for injuryRisk for injury• Sensory-perceptual alteration Sensory-perceptual alteration

(gustatory)(gustatory)


» Nursing Care Plan/Implementation: » Nursing Care Plan/Implementation: • Prevent tetany (medical emergency): Prevent tetany (medical emergency):

calcium gluconate IV, 2.5–5.0 mL 10% calcium gluconate IV, 2.5–5.0 mL 10% solution; repeated q10min to solution; repeated q10min to maximum dose of 30 mLmaximum dose of 30 mL

• Prevent tissue injury due to hypoxia Prevent tissue injury due to hypoxia and sloughing; administer slowly; and sloughing; administer slowly; avoid infiltrationavoid infiltration

Nursing Care Plan/Implementation: Nursing Care Plan/Implementation: (cont.)(cont.)

• Prevent injury related to Prevent injury related to medication administration. medication administration. Caution: drug interaction with Caution: drug interaction with carbonate, phosphate, digitalis; carbonate, phosphate, digitalis; avoid hypercalcemiaavoid hypercalcemia

• In less acute condition: increase In less acute condition: increase calcium intake—calcium calcium intake—calcium gluconate or lactategluconate or lactate



Ca++ 4.5–5.5 mEq/L No signs of tetany Absent Trousseau's and

Chvostek's signs Lists foods high in vitamin D and foods high in vitamin D and

calciumcalcium

Hypercalcemia Hypercalcemia Disorder and Related Condition:Disorder and Related Condition:

• Parathyroid glands: overactive, Parathyroid glands: overactive, tumortumor

• Increased immobilityIncreased immobility• Decreased renal functionDecreased renal function• Bone cancerBone cancer• Increased vitamin D and calcium Increased vitamin D and calcium

intakeintake• Milk-alkali syndrome—self-Milk-alkali syndrome—self-

administration of antacids; increased administration of antacids; increased milk in diet to relieve GI symptomsmilk in diet to relieve GI symptoms

HypercalcemiaHypercalcemia


Subjective Data: Subjective Data: • • Pain: flank, deep bone, shin Pain: flank, deep bone, shin

splintssplints• • Muscle weakness, fatigueMuscle weakness, fatigue• • Anorexia, nauseaAnorexia, nausea• • HeadacheHeadache• • Thirst polyuriaThirst polyuria

Hypercalcemia Hypercalcemia » Assessment» Assessment


• • Muscles: relaxedMuscles: relaxed

• • GU: kidney stonesGU: kidney stones

• • GI: increased milk intake, GI: increased milk intake, constipation, dehydrationconstipation, dehydration

• • Neurological: stupor comaNeurological: stupor coma




– – ConstipationConstipation

– – Activity intoleranceActivity intolerance

– – Altered urinary eliminationAltered urinary elimination

– – PainPain

HypercalcemiaHypercalcemiaNursing Care Plan/Implementation:Nursing Care Plan/Implementation:

Reduce calcium intake: decrease Reduce calcium intake: decrease foods high in calcium; identify cause foods high in calcium; identify cause of imbalance; give steroids, diuretics of imbalance; give steroids, diuretics as ordered; isotonic saline IVas ordered; isotonic saline IV

Prevent injury: prevent pathological Prevent injury: prevent pathological fractures (e.g., advanced cancer); fractures (e.g., advanced cancer); prevent renal calculi by increasing prevent renal calculi by increasing fluid intakefluid intake


» Evaluation/Outcome Criteria: » Evaluation/Outcome Criteria: Ca++ 4.5–5.5 mEq/LCa++ 4.5–5.5 mEq/L No pain reportedNo pain reported No fractures/calculi seen on x-ray No fractures/calculi seen on x-ray

examexam

Hypomagnesemia Hypomagnesemia Disorder and Related Disorder and Related Condition:Condition:

• Impaired GI absorptionImpaired GI absorption• Prolonged malnutrition or starvationProlonged malnutrition or starvation• AlcoholismAlcoholism• Excess loss of magnesium through Excess loss of magnesium through

kidneys, related to increased kidneys, related to increased aldosterone productionaldosterone production

• Prolonged diarrheaProlonged diarrhea• Draining GI fistulasDraining GI fistulas

HypomagnesemiaHypomagnesemia» Assessment» Assessment

Subjective Data: Subjective Data: • • AgitationAgitation• • DepressionDepression• • ConfusionConfusion• • ParesthesiaParesthesia

Objective Data: Objective Data: • • Muscles: irritable, tremors, spasticity, Muscles: irritable, tremors, spasticity,

tetany convulsionstetany convulsions• • Cardiac: arrhythmias, tachycardia Cardiac: arrhythmias, tachycardia

HypomagnesemiaHypomagnesemia


– – Risk for injury related to seizure Risk for injury related to seizure activityactivity


HypomagnesemiaHypomagnesemia


– – Provide safety: prevent injury to client Provide safety: prevent injury to client who is disoriented; administer who is disoriented; administer magnesium salts PO or IVmagnesium salts PO or IV

– – Health teaching: prevention; diet—high Health teaching: prevention; diet—high magnesium foods: fruits, green magnesium foods: fruits, green vegetables, whole grain cereals, milk, vegetables, whole grain cereals, milk, meats, nutsmeats, nuts

» Evaluation/Outcome Criteria: » Evaluation/Outcome Criteria: Mg++ 1.5–2.5 mEq/LMg++ 1.5–2.5 mEq/L

Hypermagnesemia Hypermagnesemia Disorder and Related ConditionDisorder and Related Condition

• Renal failureRenal failure• Diabetic ketoacidosisDiabetic ketoacidosis• Severe dehydrationSevere dehydration• Antacid therapyAntacid therapy

HypermagnesemiaHypermagnesemia» Assessment» Assessment


• • Drowsiness, lethargyDrowsiness, lethargy


• • Neuromuscular: loss of deep Neuromuscular: loss of deep tendon reflexestendon reflexes

• • Respiratory: depressionRespiratory: depression

• • Cardiac: arrest, hypotensionCardiac: arrest, hypotension

HypermagnesemiaHypermagnesemia


• Ineffective breathing patternIneffective breathing pattern• Decreased cardiac outputDecreased cardiac output• Fluid volume deficitFluid volume deficit• Fluid volume excessFluid volume excess• Altered cardiopulmonary tissue Altered cardiopulmonary tissue

perfusionperfusion

HypermagnesemiaHypermagnesemia

» Nursing Care Plan/Implementation: » Nursing Care Plan/Implementation: – – Obtain normal magnesium level: IV Obtain normal magnesium level: IV

calcium, fluids; possible dialysiscalcium, fluids; possible dialysis

» Evaluation/Outcome Criteria: » Evaluation/Outcome Criteria: Mg++ 1.5–2.5 mEq/LMg++ 1.5–2.5 mEq/L No complications (e.g., respiratory No complications (e.g., respiratory

depression, arrhythmias)depression, arrhythmias) Identifies magnesium-based antacids Identifies magnesium-based antacids (e.g., Gelusil)(e.g., Gelusil) Deep-tendon reflexes 2+Deep-tendon reflexes 2+

Acid-Base BalanceAcid-Base Balance

concentration of hydrogen ions in concentration of hydrogen ions in extracellular fluid is determined by the extracellular fluid is determined by the ratio of bicarbonate to carbonic acid. ratio of bicarbonate to carbonic acid.

The normal ratio is 20: 1. Even when The normal ratio is 20: 1. Even when arterial blood gases are abnormal, if arterial blood gases are abnormal, if the ratio remains at 20: 1, no the ratio remains at 20: 1, no imbalance will occur. imbalance will occur.

A. Causes of blood gas abnormalities:A. Causes of blood gas abnormalities: * *

Acid-base balanceAcid-base balance

B. Types of acid-base imbalance: B. Types of acid-base imbalance:

1. Acidosis: hydrogen ion concentration 1. Acidosis: hydrogen ion concentration increases and pH decreases.increases and pH decreases.

2. Alkalosis: hydrogen ion concentration 2. Alkalosis: hydrogen ion concentration decreases and pH increases.decreases and pH increases.

3. Metabolic imbalances: bicarbonate is the 3. Metabolic imbalances: bicarbonate is the problem. In primary conditions, the level of problem. In primary conditions, the level of bicarbonate is directly proportional to pH.bicarbonate is directly proportional to pH.

Metabolic imbalancesMetabolic imbalances

a. Metabolic acidosis: excessive acid is produced a. Metabolic acidosis: excessive acid is produced or added to the or added to the body, bicarbonate is lost, body, bicarbonate is lost, or acid is retained due to poorly functioning or acid is retained due to poorly functioning kidneys. Deficit of bicarbonate.kidneys. Deficit of bicarbonate.

b. Metabolic alkalosis: excessive acid is lost or b. Metabolic alkalosis: excessive acid is lost or bicarbonate or alkali is retained. Excess of bicarbonate or alkali is retained. Excess of bicarbonate.bicarbonate.

c. As compensatory mechanism, Pco2 will be low c. As compensatory mechanism, Pco2 will be low in metabolic acidosis, as the body attempts to in metabolic acidosis, as the body attempts to eliminate excess carbonic acid eliminate excess carbonic acid and elevate and elevate pH. Pco2 will become elevated in metabolic pH. Pco2 will become elevated in metabolic alkalosis.alkalosis.


44. . Respiratory imbalances: carbonic acid Respiratory imbalances: carbonic acid is the problem. In primary conditions, is the problem. In primary conditions, Pco2 is inversely proportional to the Pco2 is inversely proportional to the pH.pH.

a. Respiratory acidosis: pulmonary a. Respiratory acidosis: pulmonary ventilation decreases, causing an ventilation decreases, causing an elevation in the level of carbon dioxide elevation in the level of carbon dioxide or carbonic acid. Excess of Pco2.or carbonic acid. Excess of Pco2.

Respiratory imbalancesRespiratory imbalances

b. Respiratory alkalosis: pulmonary b. Respiratory alkalosis: pulmonary ventilation increases, causing a ventilation increases, causing a decrease in the level of carbon dioxide decrease in the level of carbon dioxide or carbonic acid. Deficit of Pco2.or carbonic acid. Deficit of Pco2.

c. As a compensatory mechanism, the c. As a compensatory mechanism, the level of bicarbonate will increase in level of bicarbonate will increase in respiratory acidosis and decrease in respiratory acidosis and decrease in respiratory alkalosis.respiratory alkalosis.


C. Assessment: C. Assessment: **

D. Analysis/nursing diagnosis: D. Analysis/nursing diagnosis:

1. Impaired gas exchange related to hyperventilation.1. Impaired gas exchange related to hyperventilation.

2. Ineffective breathing pattern related to decreased 2. Ineffective breathing pattern related to decreased thoracic movements.thoracic movements.

3. Ineffective airway clearance related to retained 3. Ineffective airway clearance related to retained secretions.secretions.

4. Risk for injury related to poorly functioning kidneys.4. Risk for injury related to poorly functioning kidneys.

5. Altered renal tissue perfusion related to 5. Altered renal tissue perfusion related to dehydration.dehydration.

6. Altered urinary elimination related

to renal failure.7. Fluid volume excess related

to altered kidney function.8. Fluid volume deficit related

to diarrhea or dehydration.9. Knowledge deficit (learning need)

related to self-administration of antacid medications.

E. Nursing care plan/implementation * F. Evaluation/outcome criteria *

Acid-Base ImbalancesAcid-Base ImbalancesRespiratory AcidosisRespiratory Acidosis

Disorder and Related Conditions: Disorder and Related Conditions: Acute bronchitisAcute bronchitisEmphysemaEmphysemaRespiratory obstructionRespiratory obstructionAtelectasisAtelectasisDamage to respiratory centerDamage to respiratory centerPneumoniaPneumoniaAsthmatic attackAsthmatic attackDrug overdoseDrug overdose

Acid-Base ImbalancesAcid-Base ImbalancesRespiratory AcidosisRespiratory Acidosis» Assessment» Assessment


• HeadacheHeadache• IrritabilityIrritability• DisorientationDisorientation• WeaknessWeakness• Dyspnea on exertionDyspnea on exertion• NauseaNausea

Acid-Base ImbalancesAcid-Base ImbalancesRespiratory AcidosisRespiratory Acidosis» Assessment» Assessment

Objective Data: Objective Data: • Hypoventilation: rate or rapid and shallowHypoventilation: rate or rapid and shallow• Cyanosis; TachycardiaCyanosis; Tachycardia• DiaphoresisDiaphoresis• DehydrationDehydration• Coma (CO2 narcosis)Coma (CO2 narcosis)• Hyperventilation to compensate if no Hyperventilation to compensate if no

pulmonary pathology presentpulmonary pathology present• HCO3, normalHCO3, normal• Paco2, elevated; pH <7.35Paco2, elevated; pH <7.35


Nursing Care Plan/Implementation: Nursing Care Plan/Implementation: Assist with normal breathing: Assist with normal breathing:

encourage coughing; suction airway; encourage coughing; suction airway; postural drainage; pursedlip breathing; postural drainage; pursedlip breathing;

Protect from injury: Protect from injury: oxygen as needed; encourage fluids; oxygen as needed; encourage fluids;

avoid sedation; medications as ordered—avoid sedation; medications as ordered—antibiotics, bronchial dilatorsantibiotics, bronchial dilators

Health teaching: identify cause, prevent Health teaching: identify cause, prevent future episodes; increase awareness future episodes; increase awareness regarding risk factors and early signs of regarding risk factors and early signs of impending imbalance; encourage impending imbalance; encourage compliancecompliance


» Evaluation/Outcome Criteria: » Evaluation/Outcome Criteria: Normal acid-base balance obtainedNormal acid-base balance obtained Respiratory rate: 16–20Respiratory rate: 16–20 No signs of pulmonary infection No signs of pulmonary infection

(e.g., sputum colorless, breath (e.g., sputum colorless, breath sounds clear)sounds clear)

Demonstrates breathing exercises Demonstrates breathing exercises

(e.g., diaphragmatic breathing)(e.g., diaphragmatic breathing)

Metabolic AcidosisMetabolic Acidosis

Disorder and Related Conditions: Disorder and Related Conditions:

Diabetic ketoacidosisDiabetic ketoacidosis HyperthyroidismHyperthyroidism Severe infectionsSevere infections Lactic acidosis in shockLactic acidosis in shock Renal failure uremiaRenal failure uremia Prolonged starvation diet; low protein dietProlonged starvation diet; low protein diet Diarrhea, dehydrationDiarrhea, dehydration HepatitisHepatitis BurnsBurns

Metabolic AcidosisMetabolic Acidosis» Assessment» Assessment


HeadacheHeadache RestlessnessRestlessness Apathy, weaknessApathy, weakness Disorientation ThirstDisorientation Thirst Nausea, abdominal painNausea, abdominal pain

Metabolic AcidosisMetabolic Acidosis» Assessment» Assessment

Objective Data:Objective Data:

Kussmaul's respirations: deep, rapid air Kussmaul's respirations: deep, rapid air hunger;hunger;

TemperatureTemperature Vomiting, diarrheaVomiting, diarrhea DehydrationDehydration Stupor convulsions comaStupor convulsions coma HCO3, below normalHCO3, below normal Paco2 normalPaco2 normal K+ >5K+ >5 pH <7.35pH <7.35


Nursing Care Plan/Implementation: Nursing Care Plan/Implementation: Restore normal metabolism: Restore normal metabolism:

– correct underlying problem; sodium correct underlying problem; sodium bicarbonate PO/IV; sodium lactate; fluid bicarbonate PO/IV; sodium lactate; fluid replacement, Ringer's solution; diet: high replacement, Ringer's solution; diet: high caloriecalorie

Prevent complications: Prevent complications: – regular insulin for ketoacidosis; hourly regular insulin for ketoacidosis; hourly

outputs; prepare for dialysis if in kidney outputs; prepare for dialysis if in kidney failurefailure

Health teaching:Health teaching:– identify signs and symptoms of primary identify signs and symptoms of primary

illness, prevent complications, cardiac illness, prevent complications, cardiac arrest; diet instructionsarrest; diet instructions


Evaluation/Outcome Criteria:Evaluation/Outcome Criteria: Normal acid-base balance obtainedNormal acid-base balance obtained No rebound respiratory alkalosis No rebound respiratory alkalosis

following therapyfollowing therapy No tetany following return of normal No tetany following return of normal

pHpH Alert, orientedAlert, oriented No signs of K+ excessNo signs of K+ excess

Respiratory Alkalosis Respiratory Alkalosis

Disorder and Related Conditions: Disorder and Related Conditions:

Hyperventilation—CO2 lossHyperventilation—CO2 loss Hypoxia, high altitudesHypoxia, high altitudes FeverFever Metabolic acidosisMetabolic acidosis Increased ICP, encephalitisIncreased ICP, encephalitis Salicylate poisoningSalicylate poisoning After intensive exerciseAfter intensive exercise

Respiratory Alkalosis Respiratory Alkalosis » Assessment» Assessment

Subjective Data:Subjective Data:

Circumoral paresthesiaCircumoral paresthesia WeaknessWeakness ApprehensionApprehension

Respiratory Alkalosis Respiratory Alkalosis » Assessment» Assessment

Objective Data: Objective Data: Increased respirationsIncreased respirations Increased neuromuscular irritability; Increased neuromuscular irritability;

hypereflexia, muscle twitching, tetany, hypereflexia, muscle twitching, tetany, positive Chvostek's signpositive Chvostek's sign

ConvulsionsConvulsions UnconsciousnessUnconsciousness HypokalemiaHypokalemia HCO3, normalHCO3, normal Paco2 decreasedPaco2 decreased pH >7.45pH >7.45

Respiratory AlkalosisRespiratory Alkalosis

Nursing Care Plan/Implementation: Nursing Care Plan/Implementation:

> Increase carbon dioxide level: > Increase carbon dioxide level: rebreathing into a paper bag; adjusting rebreathing into a paper bag; adjusting

respirator for CO2 retention and oxygen respirator for CO2 retention and oxygen inspired; correct hypoxiainspired; correct hypoxia> Prevent injury:> Prevent injury:

safety measures for those who are safety measures for those who are unconscious; hypothermia for elevated unconscious; hypothermia for elevated temperaturetemperature

> Health teaching: > Health teaching: recognize stressful events; counseling recognize stressful events; counseling

if problem is hysteriaif problem is hysteria

Respiratory AlkalosisRespiratory Alkalosis

Evaluation/Outcome Criteria: Evaluation/Outcome Criteria: Normal acid-base balance obtainedNormal acid-base balance obtained Recognizes psychological and Recognizes psychological and

environmental factors causing environmental factors causing conditioncondition

Respiratory rate returns to normal Respiratory rate returns to normal limitslimits

No cardiac arrhythmiasNo cardiac arrhythmias Alert, orientedAlert, oriented

Metabolic AlkalosisMetabolic Alkalosis

Disorder and Related Conditions: Disorder and Related Conditions: Potassium deficienciesPotassium deficiencies VomitingVomiting GI suctioningGI suctioning Intestinal fistulasIntestinal fistulas Inadequate electrolyte replacementInadequate electrolyte replacement Increased use of antacidsIncreased use of antacids Diuretic therapy, steroidsDiuretic therapy, steroids Increased ingestion/injection of Increased ingestion/injection of

bicarbonatesbicarbonates

Metabolic Alkalosis Metabolic Alkalosis » Assessment» Assessment


LethargyLethargy IrritabilityIrritability DisorientationDisorientation NauseaNausea

Metabolic Alkalosis Metabolic Alkalosis » Assessment» Assessment


Respirations: shallow; apnea, decreased Respirations: shallow; apnea, decreased thoracic movement; cyanosisthoracic movement; cyanosis

Pulse: irregular cardiac arrestPulse: irregular cardiac arrest Muscles: twitching tetany, convulsionsMuscles: twitching tetany, convulsions G. I.: vomiting, diarrhea, paralytic ileusG. I.: vomiting, diarrhea, paralytic ileus HCO3, elevated above 26HCO3, elevated above 26 Paco2 normal,Paco2 normal, K+ <3.5,K+ <3.5, pH >7.45pH >7.45


Nursing Care Plan/Implementation: Nursing Care Plan/Implementation: Obtain, maintain acid-base balance: Obtain, maintain acid-base balance:

irrigate NG tubes with saline; monitor irrigate NG tubes with saline; monitor I&O; IV saline, potassium I&O; IV saline, potassium added; added; isotonic solutions PO; monitor vital signsisotonic solutions PO; monitor vital signs

Prevent physical injury: Prevent physical injury: monitor for potassium loss, side effects monitor for potassium loss, side effects

of medicationsof medications

Health teaching: increase sodium when loss Health teaching: increase sodium when loss expected; instructions regarding self-expected; instructions regarding self-administration of medications (e.g., baking administration of medications (e.g., baking soda)soda)


Evaluation/Outcome Criteria: Evaluation/Outcome Criteria:

Normal acid-base balance obtainedNormal acid-base balance obtained No signs of potassium deficitNo signs of potassium deficit Respiratory rate: 16–20Respiratory rate: 16–20 No arrhythmias—pulse regularNo arrhythmias—pulse regular Lists food sources high in potassiumLists food sources high in potassium

Blood Gas Abnormalities: CausesBlood Gas Abnormalities: Causes

Decreased Po2 Decreased Po2 Collapsed alveoli (atelectasis)Collapsed alveoli (atelectasis)

– 1. Airway obstruction1. Airway obstruction a. By the tonguea. By the tongue b. By a foreign bodyb. By a foreign body

– 2. Failure to take deep breaths2. Failure to take deep breaths a. Pain (rib fracture, pleurisy)a. Pain (rib fracture, pleurisy) b. Paralysis of respiratory muscles (spinal cord b. Paralysis of respiratory muscles (spinal cord

injury, polio)injury, polio) c. Depression of the respiratory center (head c. Depression of the respiratory center (head

injury, drug overdose)injury, drug overdose)

– 3. Collapse of the whole lung (pneumothorax)3. Collapse of the whole lung (pneumothorax)

Blood Gas Abnormalities: Causes Blood Gas Abnormalities: Causes (cont.)(cont.)

Decreased Po2Decreased Po2 Fluid in the alveoliFluid in the alveoli

– 1. Pulmonary edema1. Pulmonary edema– 2. Pneumonia2. Pneumonia– 3. Near-drowning3. Near-drowning– 4. Chest trauma4. Chest trauma

Other gases in the alveoliOther gases in the alveoli– 1. Smoke inhalation1. Smoke inhalation– 2. Inhalation of toxic chemicals2. Inhalation of toxic chemicals– 3. Carbon monoxide poisoning3. Carbon monoxide poisoning

Respiratory arrestRespiratory arrest

Blood Gas Abnormalities: CausesBlood Gas Abnormalities: Causes

• • Elevated Pco2Elevated Pco2 Decreased CO2 elimination Decreased CO2 elimination

(hypoventilation)(hypoventilation)1. Decreased tidal volume1. Decreased tidal volume

a. Pain (rib fractures, pleurisy)a. Pain (rib fractures, pleurisy)b. Weakness (myasthenia gravis)b. Weakness (myasthenia gravis)c. Paralysis (spinal cord injury, polio)c. Paralysis (spinal cord injury, polio)

2. Decreased respiratory rate2. Decreased respiratory ratea. Head injurya. Head injuryb. Depressant drugsb. Depressant drugsc. Strokec. Stroke

Increased CO2 productionIncreased CO2 production1. Fever1. Fever2. Muscular exertion2. Muscular exertion3. Anaerobic metabolism3. Anaerobic metabolism

““Always treat your patients as you Always treat your patients as you would treat your family.”would treat your family.” - Dra. Uy - Dra. Uy

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Fluid & Electrolytes and Acid Base Balance