Grace Alexander MSc Nursing I year PION

1. Acid-base balance: Refers to homeostasis of

hydrogen ion (H+) concentration in the body fluids. 2. Homeostasis: The tendency to maintain relatively constant condition. 3. Fluid volume excess: Increase in body water. 4. Fluid volume deficit: Occurs when there is less water than normal in the body. 5. Extracellular fluid (ECF): Fluid outside the cell 6. Intracellular fluid (ICF): fluid inside the cell 7. Interstitial fluid: Fluid surrounding the cells.

1. FLUID 2. ELECTROLYTES

1. ADH 2. ALDOSTERONE 3. THIRST 4. ATRIAL NATRIURETIC PEPTIDE

PARAMETER pH pCO2 HCO3

ARTERIAL BLOOD 7.38 - 7.45 35 - 45 23 - 27 meq/L

VENOUS BLOOD 7.35 - 7.45 45 - 50 24 - 25meq/L

The normal metabolic activity of tissues results in production of 2 types of acid. i. Carbonic acid: Volatile acid derived from CO2 ii. Nonvolatile: Organic acids, uric acid, inorganic phosphates produced from incomplete combustion of carbohydrates, fats, proteins and organic phosphates.

Respiratory Acidosis: Hypoventilation results in CO2 retention and a rise in pCO2 causing respiratory acidosis. ii. Respiratory Alkalosis: Hyperventilation results in CO 2 washout and consequent drop in arterial pCO2, causing respiratory alkalosis. iii. Metabolic Acidosis: Increased non-volatile acids in body causes in metabolic acidosis. iv. Metabolic Alkalosis: Decreased non-volatile acids in body causes metabolic alkalosis.
i.

CONDITION CAUSES Respiratory Acidosis Hypoventilation

pH

HCO3

PaCO2 Increased

Decreased Normal

Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

Hyperventilation Increased
Diabetic Ketoacidosis HCO3 Retention

Normal

Decreased

Decreased Decreased Normal

Increased

Increased Normal

i. ii. iii. iv. v. vi.

Hyponatremia Hypernatremia Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia

Hyponatremia is termed as serum sodium level less than 130meq/L CAUSES 1. Actual deficiency of Sodium Eg: Excessive Sodium loss in vomiting, diarrhea, diaphoresis. 2. Increase in body water that dilutes sodium excessively a. Excessive secretion of ADH (SIADH) b. Nephrotic syndrome c. CCF

i.

ii.
iii. iv.

v.
vi. vii.

Headache Muscle Weakness Fatigue Apathy Confusion Abdominal cramps Orthostatic Hypotension

Restriction of fluids ii. Hypertonic saline iii. Diuretics (furosemide)

i.

Hypernatremia is termed as serum sodium >150 meq/L. It is a serious imbalance that can lead to death if not corrected. The high level of sodium in the extracellular fluid causes water to shift out of cells.This creates a condition of cellular dehydration.

CAUSES: Hypernatremia occurs when there is excessive loss of water or excessive retention of sodium. i. Vomiting ii. Diarrhoea iii. Diaphoresis iv. Insufficient ADH

CLINICAL MANIFESTATION Thirst, flushed skin, dry mucous membrane, low urine output, restlessness, increased heart rate, convulsions, postural hypotension.

MANAGEMENT Replacement of water to restore balance Fluids with reduced sodium content (like N/2 or N/3 or N/5 DNS)

Hypokalemia is termed as serum potassium < 3.5meq/L.

CAUSES i. Vomiting ii. Diarrhoea iii. Nasogastric Suction iv. Inadequate dietary intake of potassium v. Diabetic Ketoacidosis vi. Drugs such as potassium wasting diuretics, corticosteriods

CLINICAL MANIFESTATIONS As potassium is necessary for normal cellular functions, deficiencies results in gastrointestinal, renal, cardiovascular and neurologic disturbances. Most important effect is on myocardial cells, which tend to cause abnormal, potentially fatal, cardiac rhythms.

MANAGEMENT Potassium replacement by intravenous or oral route. Cardiac monitoring Include foods such as bananas, oranges or orange juice. Potassium is always diluted before intravenous administration. Rapid infusion can cause cardiac arrest.

Hyperkalemia is termed as serum potassium > 5meq/L It is a serious imbalance as it can cause life threatening dysarrthymias.

CAUSES i. Decreased renal function ii. Metabolic acidosis iii. Traumatic injuries(loss of potassium from damaged cells into ECF)
iv.

CLINICAL MANIFESTATION 1. Cardiovascular : Increased potassium first causes bradycardia , then tachycardia, there is risk of cardiac arrest. 2. GI System: Explosive diarrhea, vomiting. 3. Neuromuscular: Muscle cramps, weakness, paresthesia. 4. Others: Irritability, anxiety, abdominal cramps, decreased urine output.

MANAGEMENT 1. Treatment of underlying cause, restricting potassium intake 2. Kayexalate(Polysterene sulfonate) administration orally or rectally. 3. Intravenous administration of calcium gluconate to decrease effects of potassium on myocardium. 4. Administration of Insulin+ glucose or sodium bicarbonate to promote the shifting of potassium into cells.

Calcium in blood is regulated by parathyroid glands, which secrete parathyroid hormone (PTH). Hypocalcemia stimulates PTH secretion. PTH enhances calcium retention by the kidneys, promotes calcium absorption in intestine and mobilizes calcium from the bones to raise serum level. CAUSES 1. Diarrhoea 2. Inadequate dietary intake of calcium, Vit D. 3. Multiple blood transfusions(banked blood contains citrates that bind to calcium) 4. Hypothyroidism

CAUSES 1. Hyperthyroidism 2. Immobility(causes stores of calcium in the bones to enter bloodstream)

It is divided into:
1.

FLUID VOLUME DEFICIT

2. FLUID VOLUME EXCESS

It occurs when there is less water than normal in body.They are of two types:

Isotonic extracellular fluid deficit(hypovolemia) 2. Hypertonic extracellular fluid deficit(dehydration)

1.

ISOTONIC ECF DEFICIT DEFINITION Deficiency of both water and relative electrolytes. ETIOLOGY

HYPERTONIC ECF DEFICIT Deficiency of water without electrolyte efficiency.

Decreased fluid intake Increased water loss related to inability to to related to blood glucose obtain or ingest fluids. as in DM,inadequate Excessive fluid loss related to ADH production, high vomiting, diarrhea. fever, sweating. Shifting of fluid into Decreased fluid intake interstitial space(third with continued intake spacing)related to increased of electrolytes as with capillary permeability. concentrated tube feedings.

ISOTONIC ECF DEFICIT CLINICAL MANIFESTATIONS BP Hypotension Heart Rate Increased Urine Output Decreased MANAGEMENT

HYPERTONIC ECF DEFICIT

Hypotension Increased Increased or decreased

Correct underlying Correct underlyng cause cause Replace water and Replace water. electrolytes

ISOTONIC ECF EXCESS DEFINITION CAUSES Excess of both fluid and electrolytes Retention of water and electrolytes related to kidney disease, overload with intravenous fluid

HYPERTONIC ECF EXCES Excess of body water without excess electrolytes. Overhydration in presence of renal failure

CLINICAL MANIFESTATION BP PULSE MANAGEMENT

Increased Bounding and increased rate Correct underlying cause Restrict water and sodium intake Diuretics Digitalis toimprove cardiac output Dialysis if kidney failure is a factor Salt restriction

Increased systolic Decreased rate Correct underlying cause Restrict water intake Give demeclocycline (declomycin) to decrease kidney response to ADH.