Preserve life Prevent further harm Promote recovery

Airway Breathing Circulation Deadly bleeding/Defibrillation

Breathing Bleeding Brain Bones

Avulsion torn, flap Bruise bleeding under the skin, blue-black Cut split, jagged or smooth edge Puncture pierced Scrape - rubbed

Body part torn off wrap, plastic bag, ice but not freeze, help Impaled object do not remove, immobilize, support, help Splinters - remove with tweezers Nosebleeds Tooth sterile gauze on the gap, pick by the crown, cool/fresh milk or water

Ingestion what, how much, when Inhalation Absorption - flush, wash, paste Injection remove stinger by finger nail, card, tweezers, wash, cover, ice

Scorpions/spiders - wash, ice, help Sting rays, sea anemones, jelly fish soak in salt water, paste, ice, help Snake wash, immobilize, dependent position, no ice/cuts/tourniquet, help Animal/pets get away, do not catch/hold but try to remember, wash if minor wound, control bleeding, antibiotic, help

Emergency management traditionally refers to urgent and critical care needs; however, the ED has increasingly been used for non-urgent problems, and emergency management has broadened to include the concept that an emergency is whatever the patient or family considers it to be The emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations

Nursing interventions are accomplished interdependently in consultation with or under the direction of a physician or nurse practitioner The emergency room staff works as a team

Make safety the first priority Preplan to ensure security and a safe environment Closely observe patient and family members in the event that they respond to stress with physical violence Assess the patient and family for psychological function

Patient and family-focused interventions  Relieve anxiety and provide a sense of security  Allow family to stay with patient, if possible, to alleviate anxiety  Provide explanations and information  Provide additional interventions depending upon the stage of crisis

Triage sorts patients by hierarchy based on the severity of health problems and the immediacy with which these problems must be treated The triage nurse collects data and classifies the illnesses and injuries to ensure that the patients most in need of care do not needlessly wait Protocols may be initiated in the triage area ED triage differs from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome

trier, meaning to sort used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated Categories

 Emergent - highest priority, life threatening, must be seen immediately.  Urgent - serious health problems, but not immediately life threatening,

must be seen within 1 hour  Non-urgent - episodic illnesses that can be addressed within 24 hours without increased morbidity  fast-track simple first aid or basic primary care.

 Anxiety and Denial Remorse and Guilt Anger Grief

Blunt trauma or penetrating injuries Abdominal trauma can cause massive life-threatening blood loss into abdominal cavity Assessment  Obtain history  Perform abdominal assessment and assess other body systems for injuries that frequently accompany abdominal injuries

Assessment (cont.)  Assess for referred pain that may indicate spleen, liver, or intraperitoneal injury  Perform laboratory studies, CT scan, abdominal ultrasound (FAST), and diagnostic peritoneal lavage  Assess stab wound via sonography

Ensure airway, breathing, and circulation Immobilize cervical spine Continually monitor the patient Document all wounds If viscera are protruding, cover with a sterile, moist saline dressing Hold oral fluids NG to aspirate stomach contents Provide tetanus and antibiotic prophylaxis Provide rapid transport to surgery if indicated

Use a team approach Determine the extent of injuries and establish priorities of treatment Assume cervical spine injury Assign highest priority to injuries interfering with vital physiologic function

A failure of heat regulating mechanisms Types

 Exertional: occurs in healthy individuals during exertion in

extreme heat and humidity  Hyperthermia: the result of inadequate heat loss

Elderly, very young, ill, or debilitated and persons on some medications are at high risk Can cause death

Manifestations: CNS dysfunction, elevated temperature, hot dry skin, anhydrosis, tachypnea, hypotension, and tachycardia

Use ABCs and reduce temperature to 39 C as quickly as possible Cooling methods

    

Cool sheets, towels, or sponging with cool water Apply ice to neck, groin, chest, and axillae Cooling blankets Iced lavage of the stomach or colon Immersion in cold water bath

Monitor temperature, VS, ECG, CVP, LOC, urine output Use IVs to replace fluid losses
Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces Manifestations: hard, cold, and insensitive to touch; may appear white or mottled; and may turn red and painful as rewarmed The extent of injury is not always initially known Controlled but rapid rewarming; 37 to 40 C circulating bath for 30- to 40-minute intervals Administer analgesics for pain Do not massage or handle; if feet are involved, do not allow patient to walk

Internal core temperate is 35 C or less Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk Alcohol ingestion increases susceptibility Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence Physiologic changes in all organ systems Monitor continuously

Use ABCs, remove wet clothing, and rewarm Rewarming

 Active core rewarming
 Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage

 Passive external rewarming

 Warm blankets and over-the-bed heaters

Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances

Poison is any substance that when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relativity small amounts injures the body by its chemical action Treatment goals:
 Remove or inactivate the poison before it is absorbed  Provide supportive care in maintaining vital organ systems  Administer specific antidotes  Implement treatment to hasten the elimination of the poison

Use ABCs Monitor VS, LOC, ECG, and UO Assess laboratory specimens Determine what, when, and how much substance was ingested Assess signs and symptoms of poisoning and tissue damage Assess health history Determine age and weight

Measures to remove the toxin or decrease its absorption

 Use of emetics  Gastric lavage  Activated charcoal  Cathartic when appropriate  Administration of specific antagonist as early as possible  Other measures may include diuresis, dialysis, or

hemoperfusion

Corrosive agents such as acids and alkalis cause destruction of tissues by contact; do not induce vomiting with corrosive agents

Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen Manifestations: CNS symptoms predominate

 Skin color is not a reliable sign and pulse oximetry is not valid

Treatment
 Get to fresh air immediately  Perform CPR as necessary  Administer oxygen: 100% or oxygen under hyperbaric pressure

Monitor patient continuously

Severity of the injury depends upon the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent Immediately flush the skin with running water from a shower, hose, or faucet Lye or white phosphorus must be brushed off the skin dry

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A sudden illness due to the ingestion of contaminated food or drink Food poisoning, such as botulism or fish poisoning, may result in respiratory paralysis and death ABCs and supportive measures Determination of food poisoning Treat fluid and electrolyte imbalances Control nausea and vomiting Provide clear liquid diet and progression of diet after nausea and vomiting subside

Acute alcohol intoxication: a multisystem toxin

 Alcohol poisoning may result in death  Maintain airway and observe for CNS depression and    

hypotension Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated Use a nonjudgmental, calm manner Patient may need sedation if noisy or belligerent Examine for withdrawal delirium, injuries, and evidence of other disorders

Commonly abused substances

How the patient is received and treated in the ED is important to his or her psychological well-being Crisis intervention begins as soon as the patient enters the facility; the patient should be seen immediately Goals are to provide support, reduce emotional trauma, and gather evidence for possible legal proceedings Patient reaction; rape trauma syndrome History taking and documentation Physical examination and collection of forensic evidence Role of the sexual assault nurse examiner (SANE)

Overactive, underactive, violent, and depressed or suicidal patients Management

 Maintain the safety of all persons and gain control of the

situation
 Determine if the patient is at risk for injuring himself or others  Maintain the person s self-esteem while providing care  Determine if the person has a psychiatric history or is

currently under care to contact the therapist

Crisis intervention Interventions specific to each of the conditions

Health care facilities are required by the Joint Commission on Accreditation of Healthcare Organizations to create a plan for emergency preparedness and to practice this plan twice a year Essential components of the plan:
     

An activation response An internal/external communication plan A plan for coordinated patient care Security plans Identification of external resources A plan for people management and traffic flow

Essential components of the plan:  A data management strategy  Deactivation response  Post-incident response  A plan for practice drills  Anticipated resources  Mass casualty incident planning  An education for all of the above

The sorting of patients to determine priority health care needs and the proper site of treatment In nondisaster situations, health care workers assign the highest priority and allocate the most resources to the most critically ill In disaster situations with large numbers of casualties, decisions are based on the likelihood of survival and the consumption of resources Triage categories

Provide active listening and emotional support Provide information as appropriate Refer to therapist or other resources Discourage repeated exposure to media regarding the event Encourage return to normal activities and social roles

Critical incident stress management (CISM)  Programs that include education, field support, defusing, debriefing, demobilization, and follow-up components Persons with ongoing stress reactions should be referred to mental health specialists

Purpose: to shield the health care provider from chemical, physical, biological, and radiologic hazards that may exist when caring for contaminated patients Categories of protective equipment:

 Level A: self-contained breathing apparatus (SCBA) and

vapor-tight chemical-resistant suit, gloves, and boots  Level B: high level of respiratory protection (SCBA) but lesser skin and eye protection; chemical-resistant suit  Level C: air-purified respirator, coverall with splash hood, and chemical-resistant gloves and boots  Level D: typical work uniform

Biological agents may be delivered or spread in a number of ways Due to modern travel, spread of infection may occur in areas thousands of miles apart Health care providers need to be aware of potential signs of biological weapon dissemination; signs and symptoms are similar to those of common disease process Isolation practices depend upon the infecting agent Always use Standard Precautions Some agents require Transmission-Based Precautions Terminal disinfection and disposal of wastes depends on the infecting agent

Chemical substances that quickly cause injury and/or death and cause panic and social disruption Agents
   

Nerve agents Blood agents Vesicants Pulmonary agents

Agents vary in volatility, persistence, toxicity, and period of latency Limitation of exposure is essential with evacuation and decontamination as soon possible and as close to the scene of the incident as possible

Sarin and soman organophosphates Inhibit cholinesterase-causing cholinergic symptoms progressing to loss of consciousness, seizures, copious secretions, apnea, and death Treatment: supportive care, atropine, benzodiazepine, and pralidoxime Decontaminate with copious amounts of soap and water or saline for at least 20 minutes Blot; do not wipe off Plastic equipment will absorb sarin gas

Lewisite, sulfur mustard, nitrogen mustard, and phosgene Cause blistering and burning Respiratory effects can be serious and cause death Decontaminate with soap and water; do not scrub or use hypochlorite solutions Eye exposure requires copious irrigation Treatment for lewisite exposure: dimercaprol IV or topically

Radiation exposure may occur due to nuclear weapons, nuclear reactor incidents, or exposure to radioactive samples Exposure to radiation is affected by time, distance, and shielding Types of radiation exposure:  External radiation: all or part of the body is exposed to radiation; as decontamination is not necessary, it is not a medical emergency

Types of radiation exposure (cont.):

 Contamination: exposure to radioactive gases liquids or

solids; requires immediate medical management to prevent incorporation

 Incorporation: uptake of the radioactive material into the

body

Triage outside the hospital

Cover floor and use strict isolation precautions to prevent the tracking of contaminants Seal air ducts and vents Waste is double bagged and put in a container labeled radiation waste Staff protection

 Water-resistant gowns, 2 pairs of gloves, caps, goggles,

masks, and booties  Dosimetry devices

Patients are surveyed for radiation and directed to the decontamination area Each patient is decontaminated with a shower outside the ED Water, tarps, towels, soap, gowns, all the patient s belongings, etc., must be collected and contained Patients are surveyed and showered again as necessary Showering should be performed so as not to contaminate clean areas with runoff from the showering Biologic samples: nasal and throat swabs; blood Internal contamination requires additional treatment: catharsis and gastric lavage with chelating agents

Acute radiation syndrome (ARS): dose of radiation determines if ARS will develop All body systems are affected by ARS Presenting signs and symptoms determine predicted survival Probable survivors have no initial symptoms or only minimal symptoms Possible survivors present with nausea and vomiting that persists for 24 to 48 hours Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock; neurologic symptoms suggest lethal dose; and survival time is variable

Necessary for life and homeostasis Nursing role is to help prevent and treat fluid and electrolyte disturbances

Approximately 60% of the typical adult is fluid Varies with age, body size, and gender Intracellular fluid Extracellular fluid (ECF)
 Intravascular  Interstitial  Transcellular

Third spacing : loss of ECF into a space that does not contribute to equilibrium

45%

solids

40%

55%

fluids

60%

75% 60%

55% 45%

IVF

3L
(20% of ECF)

plasma

15L
(20% of TBW) outside the cells ECF

ISF

12L
(80% of ECF) between the cells

lymph, CSF, gastric juices, synovial fluids, aqueous humor & vitreous fluids, endolymph & perilymph, serous fluids & glomerular filtrates

25L
(40% of TBW) within the cells

ICF

IVF

ISF

blood vessels
ECF

tissue cells

ICF

Water Gain

Water Loss

200-250 ml Metabolism

10%
30% 2500 ml

4%
8%

100 ml Feces via GIT 200 ml Sweat via skin 700 ml Insensible losses via skin (400 ml) & lungs (300 ml)

700-750 ml Ingested foods

28%

1500-1600 ml Ingested liquids

60%

60% 1500 ml Urine via kidney

Ingested foods 750 ml

GIT 100 ml

Ingested liquids 1500 ml

Skin 600 ml

Lungs 300 ml Cellular Metabolism 250 ml

Kidney 1500 ml

Active chemicals that carry positive (cations) and negative (anions) electrical charges Major cations: Major anions:

    

Sodium Potassium Calcium Magnesium Hydrogen ions

Chloride Bicarbonate Phosphate Sulfate Proteinate ions

Electrolyte concentrations differ in the fluid compartments

Major cation in ECF

 Sodium

Major cation in ICF

 Potassium

Movement of fluid through capillary walls depends on:  Hydrostatic pressure  Pressure exerted on the walls of blood vessels  Osmotic pressure  Pressure exerted by the protein in the plasma The direction of fluid movement depends on the differences of hydrostatic and osmotic pressure

Osmosis Diffusion Filtration Active transport

Movement of fluid from and area of lower solute concentration to an area of higher solute concentration

Movement of molecules and ions from an area of higher concentration to an area of lower concentration

Movement of water and solutes from an area of higher hydrostatic pressure to an area of lower hydrostatic pressure

Physiologic pump that moves fluid from an area of lower concentration to one of higher concentration Movement against the concentration gradient Sodium-potassium pump maintains the higher concentration of extracellular sodium and intracellular potassium Requires adenosine (ATP) for energy

Gain
 Dietary intake of fluid and food or enteral feeding  Parenteral fluids

Loss
 Kidney: urine output  Skin loss: sensible and insensible losses  Lungs  GI tract  Other

Reduced homeostatic mechanisms: cardiac, renal, and respiratory function Decreased body fluid percentage Medication use Presence of concomitant conditions

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Loss of extracellular fluid exceeds intake ratio of water, and electrolytes are lost in the same proportion as they exist in normal body fluids Dehydration refers to loss of water alone with increased serum sodium level May occur in combination with other imbalances Causes: fluid loss from vomiting, diarrhea, GI suctioning, sweating, decreased intake, and inability to gain access to fluid Risk factors: diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, and third space shifts

Manifestations: rapid weight loss, decreased skin turgor, oliguria, concentrated urine, postural hypotension, rapid and weak pulse, increased temperature, cool and clammy skin due to vasoconstriction, lassitude, thirst, nausea, muscle weakness, and cramps Laboratory data: elevated BUN in relation to serum creatinine, increased hematocrit, and possible serum electrolyte changes Medical management: provide fluids to meet body needs

 Oral fluids  IV solutions

Monitor intake and output (I&O) and volumetric solution (VS) Monitor for symptoms: skin and tongue turgor, mucosa, urinary output (UO), and mental status Initiate measures to minimize fluid loss Provide oral care Administer oral fluids Administer parenteral fluids

Due to fluid overload or diminished homeostatic mechanisms Risk factors: heart failure, renal failure, and cirrhosis of the liver Contributing factors: excessive dietary sodium or sodiumcontaining IV solutions Manifestations: edema; distended neck veins; abnormal lung sounds (crackles); tachycardia; increased BP, pulse pressure, and CVP; increased weight; increased UO; shortness of breath; and wheezing Medical management is directed at the cause, restriction of fluids and sodium, and the administration of diuretics

Take I&O and daily weights; assess for lung sounds, edema, and other symptoms; monitor responses to medications such as diuretics Promote adherence to fluid restrictions and patient teaching related to sodium and fluid restrictions Monitor and avoid sources of excessive sodium; include medications Promote rest Use semi-Fowler s position for orthopnea Provide skin care and positioning/turning

Sodium: hyponatremia and hypernatremia Potassium: hypokalemia and hyperkalemia Calcium: hypocalcemia and hypercalcemia Magnesium: hypomagnesemia and hypermagnesemia Phosphorus: hypophosphatemia and hyperphosphatemia Chloride: hypochloremia and hyperchloremia

Serum sodium less than 135 mEq/L Causes: adrenal insufficiency, water intoxication, SIADH, and losses by vomiting, diarrhea, sweating, and diuretics Manifestations: poor skin turgor, dry mucosa, headache, decreased salivation, decreased BP, nausea, abdominal cramping, and neurologic changes

Medical management: water restriction and sodium replacement Nursing management: assessment and prevention, monitoring of dietary sodium and fluid intake, identification and monitoring of at-risk patients and the effects of medications (diuretics and lithium)

Serum sodium greater than 145mEq/L Causes: excess water loss, excess sodium administration, diabetes insipidus, heat stroke, and hypertonic IV solutions Manifestations: thirst; elevated temperature; dry, swollen tongue; sticky mucosa; neurologic symptoms; restlessness; and weakness  Thirst may be impaired in the elderly or ill

Medical management: hypotonic electrolyte solution or D5W Nursing management: assessment and prevention, assess for over-the-counter (OTC) sources of sodium, offer and encourage fluids to meet patient needs, and provide sufficient water with tube feedings

Below-normal serum potassium (<3.5 mEq/L) may occur with normal potassium levels in alkalosis due to shift of serum potassium into cells Causes: GI losses, medications, alterations of acid base balance, hyperaldosteronism, and poor dietary intake Manifestations: fatigue, anorexia, nausea, vomiting, dysrhythmias, muscle weakness, cramps, paresthesias, glucose intolerance, decreased muscle strength, and deep tendon reflexes (DTRs)

Medical management: increased dietary potassium, potassium replacement, and IV for severe deficit Nursing management: assessment (severe hypokalemia is life-threatening), monitoring of electrocardiogram (ECG), arterial blood gases (ABGs), and dietary potassium, and providing nursing care related to IV potassium administration

Serum potassium greater than 5.0 mEq/L Causes: usually treatment-related, impaired renal function, hypoaldosteronism, tissue trauma, and acidosis Manifestations: cardiac changes and dysrhythmias, muscle weakness with potential respiratory impairment, paresthesias, anxiety, and GI manifestations

Medical management: monitor ECG, cation exchange resin (Kayexalate), IV sodium bicarbonate, IV calcium gluconate, regular insulin and hypertonic dextrose IV, and F-2 agonists; limit dietary potassium; and perform dialysis Nursing management: assess serum potassium levels, mix well IVs containing K+, monitor medication effects, and initiate dietary potassium restriction and dietary teaching for patients at risk

Hemolysis of blood specimen or drawing of blood above IV site may result in false laboratory result Salt substitutes and medications may contain potassium Potassium-sparing diuretics may cause elevation of potassium and should not be used in patients with renal dysfunction

Serum level less than 8.5 mg/dL must be considered in conjunction with serum albumin level Causes: hypoparathyroidism, malabsorption, pancreatitis, alkalosis, massive transfusion of citrated blood, renal failure, medications, other Manifestations: tetany, circumoral numbness, paresthesias, hyperactive DTRs, Trousseau s sign, Chovstek's sign, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, and anxiety

Medical management: IV of calcium gluconate; calcium and vitamin D supplements; diet Nursing management: assessment as severe hypocalcemia is life-threatening, weight-bearing exercises to decrease bone calcium loss, patient teaching related to diet and medications, and nursing care related to IV calcium administration

Serum level above 10.5 mg/dL Causes: malignancy and hyperparathyroidism, bone loss related to immobility Manifestations: muscle weakness, incoordination, anorexia, constipation, nausea and vomiting, abdominal and bone pain, polyuria, thirst, ECG changes, and dysrhythmias

Medical a a ement: treat nderlying ca se, administer s ates, calcit nin, and fl ids, f r semide, i s nates rsing management: assessment as y ercalcemic crisis as igh mortality, encourage ambulation, fluids of 3 to /d, rovide fluids containing sodium unless contraindicated and fiber for consti ation, and ensure safety

Serum level less than 1.8 mg/dL; evaluate in conjunction with serum albumin Causes: alcoholism, GI losses, enteral or parenteral feeding deficient in magnesium, medications, rapid administration of citrated blood; contributing causes include diabetic ketoacidosis, sepsis, burns, and hypothermia Manifestations: neuromuscular irritability, muscle weakness, tremors, athetoid movements, ECG changes and dysrhythmias, and alterations in mood and level of consciousness

Medical management: diet, oral magnesium, and magnesium sulfate IV Nursing management: assessment, ensure safety, patient teaching related to diet, medications, alcohol use, and nursing care related to IV magnesium sulfate Hypomagnesemia is often accompanied by hypocalcemia

 Monitor and treat potential hypocalcemia  Dysphagia is common in magnesium-depleted

patients; assess ability to swallow with water before administering food or medications

Serum level more than 2.7 mg/dL Causes: renal failure, diabetic ketoacidosis, and excessive administration of magnesium Manifestations: flushing, lowered BP, nausea, vomiting, hypoactive reflexes, drowsiness, muscle weakness, depressed respirations, ECG changes, and dysrhythmias Medical management: IV calcium gluconate, loop diuretics, IV NS of RL, hemodialysis Nursing management: assessment, avoid administering medications containing magnesium, and provide patient teaching regarding magnesium-containing OTC medications

Serum level below 2.5 mg/dL Causes: alcoholism, refeeding of patients after starvation, pain, heat stroke, respiratory alkalosis, hyperventilation, diabetic ketoacidosis, hepatic encephalopathy, major burns, hyperparathyroidism, low magnesium, low potassium, diarrhea, vitamin D deficiency, and diuretic and antacid use Manifestations: neurologic symptoms, confusion, muscle weakness, tissue hypoxia, muscle and bone pain, and increased susceptibility to infection Medical management: oral or IV phosphorus replacement Nursing management: assessment, encourage foods high in phosphorus, and gradually introduce calories for malnourished patients receiving parenteral nutrition

Serum level above 4.5 mg/dL Causes: renal failure, excess phosphorus, excess vitamin D, acidosis, hypoparathyroidism, and chemotherapy Manifestations: few symptoms, soft-tissue calcifications, symptoms occur due to associated hypocalcemia Medical management: treat underlying disorder; use vitamin D preparations, calcium-binding antacids, phosphate-binding gels or antacids, loop diuretics, NS IV, and dialysis Nursing management: assessment, avoid high-phosphorus foods, and provide patient teaching related to diet, phosphate-containing substances, and signs of hypocalcemia

Serum level less than 96 mEq/L Causes: Addison s disease, reduced chloride intake, GI loss, diabetic ketoacidosis, excessive sweating, fever, burns, medications, and metabolic alkalosis Loss of chloride occurs with loss of other electrolytes, potassium, and sodium Manifestations: agitation, irritability, weakness, hyperexcitability of muscles, dysrhythmias, seizures, and coma

Medical management: replace chloride IV, NS, or 0.45% NS Nursing management: assessment, avoid free water, encourage high-chloride foods, and provide patient teaching related to high-chloride foods Serum level more than 108 mEq/L Causes: excess sodium chloride infusions with water loss, head injury, hypernatremia, dehydration, severe diarrhea, respiratory alkalosis, metabolic acidosis, hyperparathyroidism, and medications

Manifestations: tachypnea, lethargy, weakness, rapid, deep respirations, hypertension, and cognitive changes Normal serum anion gap Medical management: restore electrolyte and fluid balance, LR, sodium bicarbonate, and diuretics Nursing management: assessment, provide patient teaching related to diet and hydration

Normal plasma pH is 7.35 to 7.45: hydrogen ion concentration Major extracellular fluid buffer system; bicarbonate-carbonic acid buffer system Kidneys regulate bicarbonate in ECF Lungs under the control of the medulla regulate CO2 and, therefore, carbonic acid in ECF Other buffer systems
 ECF: inorganic phosphates and plasma proteins  ICF: proteins, organic and inorganic phosphates  Hemoglobin

Low pH <7.35 Low bicarbonate <22 mEq/L Most commonly due to renal failure Manifestations: headache, confusion, drowsiness, increased respiratory rate and depth, decreased blood pressure, decreased cardiac output, dysrhythmias, shock; if decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less Correct the underlying problem and correct the imbalance; bicarbonate may be administered

With acidosis, hyperkalemia may occur as potassium shifts out of the cell As acidosis is corrected, potassium shifts back into the cell and potassium levels decrease Monitor potassium levels Serum calcium levels may be low with chronic metabolic acidosis and must be corrected before treating the acidosis

High pH >7.45 High bicarbonate >26 mEq/L Most commonly due to vomiting or gastric suction; may also be caused by medications, especially long-term diuretic use Hypokalemia will produce alkalosis Manifestations: symptoms related to decreased calcium, respiratory depression, tachycardia, and symptoms of hypokalemia Correct underlying disorder, supply chloride to allow excretion of excess bicarbonate, and restore fluid volume with sodium chloride solutions

Low pH <7.35 PaCO2 >42 mm Hg Always due to a respiratory problem with inadequate excretion of CO2 With chronic respiratory acidosis, the body may compensate and may be asymptomatic; symptoms may include a suddenly increased pulse, respiratory rate, and BP; mental changes; feeling of fullness in the head Potential increased intracranial pressure Treatment is aimed at improving ventilation

High pH >7.45 PaCO2 <35 mm Hg Always due to hyperventilation Manifestations: lightheadedness, inability to concentrate, numbness and tingling, and sometimes loss of consciousness Correct cause of hyperventilation

pH 7.35 (7.4) to 7.45 PaCO2 35 (40) to 45 mm Hg HCO3 22 (24) to 26 mEq/L (assumed average values for ABG interpretation) PaO2 80 to 100 mm Hg Oxygen saturation >94% Base excess/deficit 2 mEq/L

Fluid overload Air embolism Septicemia and other infections Infiltration and extravasation Phlebitis Thrombophlebitis Hematoma Clotting and obstruction