1 / 45

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e. Chapter 16: Caring for Clients with Fluid, Electrolyte, and Acid-Base Imbalances. Fluid and Electrolyte Balance. Human body is 60% water Intra cellular (mostly); Extra cellular

ria-mullen
Download Presentation

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Timby/Smith: Introductory Medical-Surgical Nursing, 10/e Chapter 16: Caring for Clients with Fluid, Electrolyte, and Acid-Base Imbalances

  2. Fluid and Electrolyte Balance • Human body is 60% water • Intracellular (mostly); Extracellular • Average oral fluid intake-2500ml; primary sources of body fluid is food and liquids • Functions: Maintain or restore equilibrium in fluid volume • Translocation: Fluid and chemical exchange • Electrolytes; Acids and bases; Fluid balance • Physiologic processes • Osmosis; Filtration; Passive and facilitated diffusion; Active transport

  3. Question Is the following statement true or false? A function of fluid and electrolyte balance is to maintain or restore equilibrium.

  4. Answer True. A function of fluid and electrolyte balance is to maintain or restore equilibrium, promoting homeostasis.

  5. Fluid and Electrolyte Regulation Distribution of body fluid at the cellular level, pg 182

  6. Fluid and Electrolyte Balance • Osmosis • Water movement through semi-permeable membrane; Tonicity (concentration of substances); Osmotic pressure (power to draw H2O toward an area of grater concentration) • Fluid distribution: Flows from dilute (low) to concentrated (high); Figure 16-3 pg 183 • Filtration • Movement: Fluid, dissolved substances through semi-permeable membrane; Relocates: Water; Chemicals • From high pressure to low pressure • Affects kidney function; kidneys filter abt 180 L of fluid from blood daily; all but 1 – 1.5 L is reabsorbed

  7. Question Is the following statement true or false? In osmosis, the fluid flows from the dilute to the concentrated.

  8. Answer True. In osmosis, the fluid flows from the dilute to the concentrated.

  9. Fluid and Electrolyte Balance • Passive Diffusion • Movement: Dissolved substances • High to low concentration • Remains fairly static (post-equilibrium) • Facilitated Diffusion • Certain dissolved substances require assistance • Carrier molecule • To pass through semipermeable membrane

  10. Fluid and Electrolyte Balance • Active Transport • Energy source • Adenosine triphosphate (ATP): Drives dissolved chemicals; low-to-high concentration • Sodium-potassium pump system • Metabolic disorders: Diminish ATP • Significant change in fluid volume

  11. Fluid-Electrolyte Regulation Mechanisms • Maintain normal fluid volume and electrolyte concentrations • Urine formation; Thirst promotion • Osmoreceptors • Fluid volume regulation • Located: Hypothalamus; Senses serum osmolality • Sensitive: Changes in blood volume and BP • Baroreceptors (stretch receptors in aortic branch that signals brain to release ADH when blood volume decreases OR to inhibit release if blood volume is increased)

  12. Question Is the following statement true or false? The body is without regulatory mechanisms to maintain fluid-electrolyte balance.

  13. Answer False. The body has several regulatory mechanisms to maintain fluid-electrolyte balance, including thirst and urine formation.

  14. Fluid-Electrolyte Regulation Mechanisms • Renin-Angiotensin-Aldosterone System • Chain of chemicals • Increase: BP; Blood volume • Juxtaglomerular apparatus (Cells) • Angiotensin II: Raises BP via vasoconstriction • Aldosterone: causes kidneys to reabsorb Na which in turn increases blood volume & BP • Natriuretic Peptides: Hormone-like substances • Works the opposite to renin-angiotensin-aldosterone system; reduce blood volume = urine release

  15. Fluid Imbalances • Is a general term describing any of several conditions in which the body’s water/fluid is not in the proper volume or location • Common fluid imbalances: - Hypovolemia - Hypervolemia - Third-spacing

  16. Fluid Imbalances: Hypovolemia • Fluid imbalance: Fluid volume deficit (Table 16-2, pg 185) • Hypovolemia: Only blood volume low • Dehydration: All fluid compartments deficient • Pathophysiology and Etiology • Inadequate fluid intake; Fluid loss in excess of intake; Translocation • Assessment Findings • Thirst – earliest • Hemoconcentration; Concentrated urine (high specific gravity) • Serum electrolyte levels normal

  17. Fluid Imbalances: Hypovolemia Medical Management Treat etiology (cause) Increasing oral intake volume IV fluid replacement Controlling fluid loss Nursing Management Gather assessment data Fluid deficit: Measures to restore balance Teaching plan: Prevent hypovolemia REVIEW: Nsg Care Plan 16-1 pg 187 REVIEW: Nsg Guidelines 16-1 pg 188

  18. Fluid Imbalances: Hypervolemia • High volume of water: Intravascular fluid compartment • Pathophysiology and Etiology • Fluid intake > fluid loss • Heart failure • Renal disease • Corticosteroid drugs • Fluid retention • Circulatory overload

  19. Fluid Imbalances:Hypervolemia • Assessment Findings • Weight gain; Elevated BP; Dependent edema, Fig 16-7 pg 188 • Low blood cell count; Hemodilution; Dilute urine (low specific gravity) • Medical Management • Treat etiology; Daily weight • Restrict fluids; Medications: Diuretics • Limit: Salt (sodium) intake

  20. Fluid Imbalances: Hypervolemia • Nursing Management • REVIEW: Nursing Process, pg 186-190 • Daily weight (same time/ same clothes, etc) • Accurate I & O’s; Restrict fluids per Dr’s order – maintain oral hygiene • Monitor v/s; check for edema; administer prescribed diuretics • Limit: Salt (sodium) intake: Refer to Box 16-1, Foods high in Salt or Sodium

  21. Question Is the following statement true or false? The treatment for hypovolemia and hypervolemia are the same.

  22. Answer True. While the steps taken during treatment may differ, the treatment principle is the same – you treat the cause (etiology).

  23. Fluid Imbalances: Third-spacing • Fluid translocation to intracellular compartments • Trapped, useless; Colloid loss • Assessment Findings • Hypovolemia symptoms (except weigh loss); Ascites; Generalized edema • Medical Management • Restore circulatory volume • Eliminate trapped fluid; • IV solutions • Blood products, albumin • IV diuretic

  24. Electrolyte Imbalances • Electrolytes • Ions (including Bicarbonate; Protein; Organic acids) • Extracellular fluid (more concentrated): Sodium, Calcium; Chloride • Intracellular fluid (more concentrated): Potassium; Magnesium; Phosphate • Imbalances; Identified – blood labs • Electrolyte imbalances: Deficit or excess of electrolytes; Electrolyte translocation • Sodium; Potassium; Calcium; Magnesium of particular concern

  25. Sodium Imbalances • Hyponatremia: Sodium deficit (Na <135 mEq/L) • Etiology • Inadequate food intake; excessive water intake • Administration of certain meds • Profuse diaphoresis or diuresis • Loss of GI secretions (Prolonged vomiting; GI suctioning, etc) • Assessment Findings • Mental confusion; Elevated body temp; Tachycardia; N/V; Personality changes; Coma • Medical Management • Treat underlying cause; Sodium administration

  26. Sodium Imbalances • Hypernatremia: Sodium excess (Na > 145 mEq/L) • Etiology • Overabundance of orally consumed or IV electrolytes • Kidney Failure; Endocrine dysfunction • Profuse watery diarrhea; Decreased H2O intake • High fever • Assessment Findings • Dry, sticky mucous membranes; Decreased urine output; Fever; Lethargy • Medical Management • Treat underlying cause; Restrict sodium

  27. Sodium Imbalances • Nursing Management for Sodium Imbalances • Assess sodium imbalances – EARLY detection! • Monitor: Laboratory findings - serum potassium • Monitors oral and IV fluid therapy closely • Accurate I & O’s • Assess vital signs q 1 to 4hrs • Client education • Review dietary restrictions: Nutrition Notes 16-1, pg 191 • Review: Pharmacy Considerations, pg 191

  28. Potassium Imbalances • Hypokalemia: Potassium deficit (K+ <3.0 mEq/L) • Potassium-wasting diuretics (Lasix, Hyrdodiuril); Loss of fluid from the GI tract; Large corticosteroid doses • Assessment Findings • Fatigue; N/V; Cardiac dysrhythmias; Paresthesias; Leg cramps • Medical Management • Treat underlying cause; Potassium sparing diuretic substitution • Potassium-rich foods; Oral potassium supplement

  29. Potassium Imbalances • Hyperkalemia: Potassium excess (K+ >5.5 mEq/L) • Severe renal failure; Severe burns; Overuse of potassium supplements; Potassium-sparing diuretics; Addison’s disease • Assessment Findings • Diarrhea, Nausea; Muscle weakness; Paresthesias; Cardiac dysrhythmias (Tall T wave) • Medical Management • Treatment dependent on cause, severity: Decrease potassium-rich foods; Kayexalate • IV-insulin; Peritoneal dialysis; Hemodialysis

  30. Potassium Imbalances Top left: Normal tracing Top right: Serum potassium level below normal results in U wave Lower Right: High potassium on ECG produces a tall T wave

  31. Potassium Imbalances • Nursing Management for Potassium Imbalances • Assess potassium imbalances • Monitor: Laboratory findings - serum potassium • Consults with the physician: Prolonged IV fluid therapy without added potassium • Client education • Potassium-excreting medications • Pharmacy Considerations: pg 193 • Food sources: Vegetables, dried peas and beans, wheat bran, bananas, oranges (and juice), melon, prune juice, potatoes, milk • Supplements

  32. Calcium Imbalances • Hypocalcemia: Calcium deficit (Ca++ < 8.8 mg/dL) • Vitamin D deficiency; Hypoparathyroidim; Severe burns; Acute pancreatitis; Corticosteroids • Assessment Findings • Tingling in extremities, around mouth; Abdominal and muscle cramps; Trousseau’s sign; Mental changes; Positive Chvostek’s sign; Tetany (Figure 16-9, pg 193) • Medical Management • Mild: Oral calcium, Vitamin D • Severe: Calcium salt (IV)

  33. Calcium Imbalances • Hypercalcemia; Calcium excess ( Ca++ >10 mg/dL) • Parathyroid gland tumors; Paget’s disease; Hyperparathyroidism; Chemotherapeutic agents; Specific malignancies; Prolonged immobilization • Assessment Findings • Polyuria; Constipation; N/V; Thirst; Mental changes • Medical Management • Treat underlying cause when possible; Oral fluid intake; Limit calcium consumption

  34. Calcium Imbalances • Nursing Management for Calcium Imbalances • Assess closely for neurological manifestations: tetany, seizures, spasms • Monitor: Laboratory findings; watch for signs of bruising or bleeding • Consults with the dietician: limit Ca intake w/ increased Ca; increase w/low CA • Client education • Take medications as ordered • Pharmacy Considerations: pg 194

  35. Magnesium Imbalances • Hypomagnesemia: Magnesium deficit (Mg++< 1.3 mEq/L) • Conditions: Excessive diuresis; Prolonged gastric suction; Chronic alcoholism; Severe burns and renal disease • Assessment Findings • Cardiac dysrhythmias; Paresthesias; Leg and foot cramps; Hypertension; Mental changes; Positive Chvostek’s, Trousseau’s signs • Medical Management • Dietary; Severe: Magnesium sulfate (IV)

  36. Magnesium Imbalances • Hypermagnesemia: Magnesium excess (Mg++ > 2.1 mEq/L) • Renal failure; Excessive antacid or laxative use • Assessment Findings • Flushing, warmth; Hypotension; Lethargy; Bradycardia; Depressed respirations; Coma • Medical Management • Decrease magnesium intake; Discontinue parenteral replacement; Hemodialysis

  37. Magnesium Imbalances Hypermagnesemia: Magnesium excess (Mg++ > 2.1 mEq/L) • Nursing Management for Magnesium Imbalances • Monitor vital signs closely • Client education • REVIEW Pharmacy Considerations, pg 195 • REVIEW Stop, Think & Respond, pg 195

  38. Acid-Base Balance • Chief acid: Carbonic acid (H2CO3) - Lungs • Chief base (alkaline): Bicarbonate (HCO3) - Kidneys • Acid, base content: Influence pH; pH values (7 is neutral) • Normal plasma pH (7.35-7.45) maintained by • Chemical regulation; Organ regulation • Figure 16-10, pg 195 • Chemical Regulation • Add Hydrogen ions: Increases acidity • Eliminate Hydrogen ions: Promotes alkalinity

  39. Acid-Base Balance • Chemical Regulation (Cont’d) • Major chemical regulator of plasma pH • Bicarbonate–carbonic acid buffer system • Oxygen Regulation • Lungs, kidneys facilitate: Ratio of bicarbonate to carbonic acid • Lungs: Regulate carbonic acid levels by releasing or conserving CO2:(quickly by breathing faster or slower) • Kidneys: regulate bicarbonate ion retention or excretion (slower process) • Compensation: Regulatory processes

  40. Acid-Base Imbalances • Life-threatening • Acidosis: Excess acids OR Excess loss of bicarbonate • Alkalosis: Excess bases OR Excess loss of acids • Four sub-types of acid-base imbalances • Metabolic Acidosis: Increase in acids or decreased bicarbonate • Occurrence: Shock; Cardiac arrest; Starvation; Diabetic ketoacidosis; Renal failure • Assessment Findings: Kussmaul’s breathing; N/V; Headache; Confusion; Lethargy; Dangerous cardiac dysrhythmias

  41. Acid-Base Imbalances • Metabolic Acidosis (Cont’d) • Diagnostic Findings: ABG values; Decreases in pH • Medical Management • Eliminating cause • Replacing lost fluids and electrolyte • Severe cases: IV bicarbonate

  42. Acid-Base Imbalances • Metabolic Alkalosis: Increased plasma pH; Rapid decrease in extracellular fluid volume • Causes: Diuretic therapy; Prolonged gastric suctioning; Vomiting; Hypokalemia • Assessment Findings • Circumoral paresthesias; Confusion; N/V; Carpopedal spasm; Hypertonic reflexes; Tetany • ABGs; Compensatory respiratory mechanisms • Medical Management • Eliminating cause; Sodium chloride solutions

  43. Acid-Base Imbalances • Respiratory Acidosis: Excess carbonic acid • Causes: Pneumo-hemothorax; Pulmonary edema; Asthma; Atelectasis; Pneumonia; COPD; Cystic fibrosis • Assessment Findings • Extreme respiratory insufficiency; Decreased expiratory volumes; Cyanosis; Behavioral changes due to CO2 accumulation • ABG values; Compensatory mechanism • Medical Management • Individualized treatment dependent upon cause, acute or chronic

  44. Acid-Base Imbalances • Respiratory Alkalosis: Carbonic acid deficit from deficient CO2 due to rapid breathing • Assessment Findings • Increased respiratory rate; Lightheadedness; Numbness, tingling of hands and feet; Circumoral paresthesias; Sweating; Panic • Kidney excretes bicarbonate ions: HCO3 falls • ABG values • Medical Management • Treat cause: (Temporary) Breathe into paper bag and rebreathe expired air; Sedation

More Related