Lab Values

Electrolytes

Sodium (Na+) 135-145 mEq/L

Potassium (K+) 3.5-5.5 mEq/L

Chloride (Cl-) 95-105 mEq/L

Calcium (Ca++) 4.5-5.3 mEq/L or 9-10.5 mg/dl

Phosphorus (HPO4) 1.7-2.6 mEq/L

Magnesium (Mg++) 1.5-2.5 mEq/L or 1.8-3 mg/dl

Bicarbonate (HCO3-) 22-24 mEq/L

Blood Studies

Red Blood Cells (RBC) Males: 4.7-6.1 million/mm3

Females: 4.2-5.4 million/mm3

Hemoglobin (Hgb) Males: 14-18 g/dl

Females: 12-16 g/dl

Hematocrit (Hct) Males: 42-52%

Females: 37-47%

White Blood Cells (WBC) 5,000-10,000/mm3

Sedimentation Rate (ESR) Males: 0-15 mm/hr

Females: 0-20 mm/hr

Platelet Count 150,000-400,000/mm3

Prothrombin Time (Pro Time) 11-12.5 seconds

 Partial Thromboplastin Time (PTT) 30-40 seconds

Bleeding Time 1-9 minutes

Clotting Time 3-9 minutes

Miscellaneous

Blood pH 7.35-7.45

Urine pH 4.6-8 (average 6.0)

Fasting Blood Sugar (FBS) 60-110 mg/dl

Blood Urea Nitrogen (BUN) 10-20 mg/dl

Creatinine 0.5-1.1 mg/dl

Arterial Blood Gases

pH 7.35-7.45

PaO2 80-100 mm Hg

PaCO2 35-45 mm Hg

HCO3- 22-24 mEq/L

O2 Saturation > 95%

.
Fluids and Electrolytes

Introduction

 The human body requires H2O (water)

 It is essential for life and homeostasis (state of constancy or equilibrium

within the body)

 Newborn - 70-80% water (premature 90%)

 12 year old to adult – 50-60%

  Elderly – 45-55%

 As we age the total % of body water (fluid) decreases

Function of Water

1. Delivers nutrients to cells

2. Carries waste from cells

3. Provides a medium where chemical reactions or metabolism occur

4. Lubricant for tissues

5. Aids in acid-base balance

6. Assists in heat regulation by evaporation

Those at greatest risk for complications when fluid volume changes

 Very young – ¾ of infant body make-up is H2O

 Very old – little or no reserves (H2O % decreases with age)

 Obese – more body fat, the less body H2O because body fat is essentially
free of H2O and therefore also with little or no reserve

Balanced Fluid Gain and Loss for an Adult

 Body fluid is in a state of balance when its fluid and electrolyte

components are present in proper proportions; when losses are replaced
and gains are eliminated

Body Fluid Distribution

1. ICF – Intracellular – inside the cell; 66% of the total

2. ECF – Extracellular – outside the cell; 34% of the total

a. Intravascular – inside the vessels = blood plasma = 7%; cells are

solid after they are removed the fluid is left = plasma

b. Interstitial – surrounding cells or between tissues = 27%; this is

where fluid accumulates when we have edema
  Third spacing – abnormal collection of fluid found in a potential space
(where normally not a great deal of fluid exists and the fluid becomes of
no use to the body)

 Ex. Pleural cavity – pleural effusion; pericardium – pericardial effusion;

ascites – abdominal cavity

 Third spacing represents a fluid loss that is difficult to assess because it

may not show up in weight or I&O until organ malfunction

 ICF and ECF are separated by 2 semi-permeable membranes which allows

constant back and forth movement of body fluids to maintain homeostasis;
nutrients in and waste out

Ways to Assess Fluid Balance – Daily Weights

 Most accurate

 1 L H2O or 1000 ml H2O = 2.2 lbs or 1 kg

 Therefore, if patient loses 1 kg or 2.2 lbs of weight that equals 1 L or 1000

ml fluid loss or vice versa for gain

 To be accurate weight – measure same time of day (usually early morning)

with same clothing or same scale

Ways to Assess Fluid Balance – Intake and Output

 Not as accurate but still important

 Intake = fluid ingested; H2O contained in food; H2O produced by

oxidation

 Output = lungs through expired air (amount lost varies with amount and
depth of respirations); skin by perspiration (amount lost depends on
temperature of environment and body); feces (most H2O is reabsorbed in
GI tract – loss 200 ml/day – diarrhea increases loss); kidneys – urine
(major source) – kidneys can adjust amount of H2O leaving the body
(1500 ml); any type of drainage

 Daily I = daily O but will never measure exact because of certain I&O you
cannot measure
  Normally drink 1500 ml in 24 hours and excrete 1500 ml in 24 hours;
magic number is 2500 ml intake needed by the body, therefore output
being 2500 ml

 The 1000 ml difference is called insensible losses and gains (not easily
measured); ex. H2O in food, skin loss, lung loss, etc.

 What you can easily measure is called sensible losses or gains (ex. fluid
drank, urine excreted)

Urine Production

 1ml/kg body weight/hr

 Must be at least 30 ml/hr

 If patient excretes less than 30 ml/hr for 2 hours – must report to HCP

 < 400 ml in 24 hours = oliguria

 <100 ml in 24 hours = anuria

 Large amount of output = poluria

Movement of Fluid and Electrolytes

 Diffusion
 Osmosis
 Filtration
 Active transport

Diffusion

 Movement of particles in all directions through a solution or gas

 Generally from an area of higher concentration to an area of lower

concentration

 Can occur across a membrane if it is permeable or allows free passage

 Ex. spray perfume into air (called a diffuser) – spreads throughout atmosphere
 Ex. movement of O2 and Co2 through alveoli and blood (internal respirations
– O2 in the air we breathe enters the intravascular compartment and then
travels to the cells by diffusion); O2 moves from alveoli (higher) to blood
vessel (lower); CO2 moves from vessel (higher) to alveoli (Lower)

Osmosis

 Movement of H2O from an area of lower concentration to an area of

higher concentration across a membrane (selectively permeable membrane
allows H2O to pass but not all solutes)

 This movement of H2O across a membrane will continue until the

concentration of particles on each side of the membrane are equal

 H2O (solvent)

 Substances (solute)

 Together form a solution

 Solutions are classified as isotonic, hypotonic, or hypertonic

Isotonic Solutions

 Equal concentrations of both solutions on both sides of the membrane =

little osmosis

 Have same concentration as body fluid

 No movement of H2O required

 Ex. NS, LR, and D5W

Hypotonic Solutions

 Increased concentration of H2O (solvent) and decreased concentration

of solute (substances or particles)

 Osmosis – water moves from lower concentration to higher

concentration

Hypertonic Solutions
  Decreased concentration of H2O (solvent) and increased concentration
of solutes (substances or particles)

 Osmosis – water moves from lower concentration to higher

concentration

Osmolarity

 The concentration of solutes in body fluids

 # of solutes in a solution expressed by a unit of measure called osmol

 Osmolarity = # of osmols (# of active particles solutes)/liter of solution =

osm/liter; osmolarity of body fluids = 270-290 osm/L

 Osmolarity reflects the potential for H2O movement and H2O distribution
between and within body fluid compartments

 Isotonic solutions have the same osmolarity of body fluids; therefore no

shift from ECF to ICF; cells remain normal; ex. NS, D5W, LR

 Hypotonic solutions (increased water and decreased solutes) has lower

osmolarity (compared to blood stream) (< 270 osmols/L) than body fluids;
therefore H2O moves from ECF into cells to maintain balance; this causes
circulating volume to expand temporarily and eventually to swell and
burst; hypotonic solutions cause ECF to have a decreased osmolarity and
ICF has higher – through osmosis H2o moves from lower to higher; when
a hypotonic solution is given to a patient, H2O leaves the blood and enters
the cells; ex. ½ NS

 Hypertonic solutions (decreased H2O and increased solutes); when

infused into the bloodstream, H20 moves out of the cells and into the
hypertonic solution to maintain balance; this causes the cells to shrink or
become crenated; draws cellular or interstitial water into intravascular
compartment; used to decrease cerebral edema or expand circulatory
volume; when hypertonic solution is given H2O leaves the cells and enters
the blood (> 290 osmols/L); causes ECF to have higher osmolarity; ex. 3%
NS, 5% NS

Filtration
  Transfer or movement of H2O and small solute particles from an area of
increased hydrostatic pressure to an area of decreased hydrostatic pressure
through a filtration membrane (hydrostatic pressure = force of fluid
pressing outward against a vessel/wall)

 Ex. kidneys – H2O and small solutes mover from blood vessels to kidneys
but protein and blood cells (large particles) do not pass through filter
membrane

 As BP increases pushes more particles through filter

 Wherever pressure is high H2O moves from there to an area of lower

pressure

Active Transport

 Requires an energy source for movement (where past 3 did not); an ion is
to move from an area of lower concentration to an area of higher
concentration; moves ions uphill against osmotic pressure

 That energy source is ATP (adenosine triphosphate) formed by the

mitochondria in cells

 Moves fluid and electrolytes from area of lower concentration to an area

of higher concentration

 Substances that require active transport through cell membrane are

sodium, calcium, hydrogen ions, potassium, iron, and amino acids

 Glucose + insulin (energy source) - cells

Electrolytes

 Body fluids consist of H2O and solutes such as electrolytes or non-

electrolytes, such as glucose and urea

 Electrolytes are substances whose molecules split into electrically

charged particles known as ions when placed in H2O

Cations
 Electrolytes with a positive charge
  Ex. Na+, K+, Ca++, Mg++

Anions
 Electrolytes with a negative charge

 Ex. Cl-, HCO3-, SO4-, HPO4_

Ex. NaCl placed in water – splits into 2 parts or ions Na+ and Cl-
H2O splits into 2 ions – H+ and OH-

 The # of electrically charged ions in a defined amount of solution =

mEq/L

 mEq (milliequivalents) = refers to the chemical activity of the ion,

whereas milligram only refers to the weight of substances

 Whenever an electrolytes moves out of a cell, another moves in to

take its place; fluid in each fluid compartment contains electrolytes
and each compartment has a certain make-up of electrolytes in the
right compartment in the right amount

 The number of cations and anions must be the same for

homeostasis to exist

 Osmolarity between the three compartments (ICF, interstitial, and

intravascular) must be equal – if not H2O will shift from and into
compartments

 Compartments are separated by semi-permeable membrane

Functions of electrolytes
1. Regulation of H2O distribution

2. Transmission of nerve impulses

3. Regulation of acid-base balance

Normal Serum Electrolyte Values

 Will give the values with each specific electrolyte

Regulation of Fluid and Electrolytes

 Cerebral regulation

o Thirst center (conscious desire for H2O) in hypothalamus

(as we age have a decreased sense of thirst)

 Pituitary

o Anti-diuretic hormone (ADH)

 Regulates water retention or reabsorption by the

kidneys

 Main function is to retain H2O

 Kidneys respond to ADH by becoming more

permeable to H2O, so H2O is reabsorbed into the
blood – leaving a more concentrated urine to be
excreted

 Secreted in response to decreased circulating fluid

volume; instructs kidneys to correct the fluid deficit
problems (ex. hemorrhage)

 If body has increased fluid, pituitary will decrease

the amount of ADH and this causes kidneys to rid
the body of extra H2O

 If body has decreased fluid, pituitary will increase

the amount of ADH and this causes the kidneys to
reabsorb H2O back into the blood

 Adrenal

o Aldosterone

 Helps maintain H2O balance by maintaining Na+

balance (Na+ holds water); conserves Na+ which
then conserves H2O

 Secreted in response to decreased fluid volume,

decreased Na+ and increased K+ levels – this
promotes increased reabsorption of Na+ while
simultaneously stimulating increased excretion of
 K+ (when aldosterone is increased, Na+, Cl-, and
H2O are retained and K+ excreted)

 Helps maintain BP and blood volume in shock

 Renal regulation (primary force)

o Primary organ for regulation of fluid and electrolytes

balance is the kidney

o Removes wastes from the body; also helps maintain proper

balance of H2O, electrolytes, and acid in body fluids by
excreting some substances into the urine and selectively
reabsorbing others into the bloodstream for use by the body

o Kidneys remove excess body fluid by increasing urine

output or diuresis; if a deficit in the body water is
conserved by decreasing urine output or anti-diuresis

o Impaired renal function – kidneys are unable to maintain

fluid and electrolyte balance – which results in edema, K+
retention, and many other problems

 Other regulators

o Lungs – helps maintain acid-base balance

o Parathyroid – Ca++ regulation by PTH (parathormone)

o Skin – H2O and electrolyte evaporation

o Heart/blood vessels

o GI tract

****Fluid and electrolytes must be kept in balance for health; when they remain out of
balance, death can occur
Electrolyte Imbalances
Sodium
o Na+ (cation)
o Most abundant electrolyte in the body
o Normal level 135-145 mEq/L
o Major or most abundant extracellular electrolyte
o Major source is the diet (mainly through salt) – frequently needs to be limited in diet than
encouraged
o Major source of elimination is kidneys
Functions of Sodium
o Maintains osmolarity of ECF and ECF volume (influences size of cell)
o Directly affects water balance (H2O follows Na+ in the body)
o Necessary for transmission of nerve impulses (especially important for function of CNS)
o Controls muscle contractility

Hyponatremia
o Low Na+ (< 135 mEq/L)
Causes of Hyponatremia
o Decreased or restricted Na+ intake
o Excessive intake of H2O (orally or by tap water enemas or water irrigations) – pulls Na+
out directly – this is why saline is used to irrigate – isotonic
o Loss of GI fluids (vomiting, diarrhea, NG suction)
o Extreme diaphoresis (sweating)
o Burns
o Excessive urine wastage – potent diuretics
o Excessive retention of H2O – causing massive edema – HF, cirrhosis (ascites), etc.

S/S Hyponatremia – depends on cause and how rapid of onset

o Most S/S results from the fact that decreased sodium in ECF causes it to become
hypotonic compared to ICF – causing H2O to move into cells (osmosis – H2O from low
concentration to high concentration) causing them to swell leading to cellular swelling and
cerebral edema causing changes in sensorium with signs of intracranial pressure
o Mental status changes – lethargy, confusion
o Headache
o Flushed skin
o Weakness
o Abdominal cramping
o Nausea, anorexia
o Muscle twitching and seizures
o Postural hypotension
o Coma, death
o S/S of associated fluid imbalance

Nursing Diagnoses and Interventions for Hyponatremia

Risk for Imbalanced Fluid Volume and Risk for Injury
• Identify the patient at risk (Assess for abnormal GI, renal, or skin losses of Na) –
individuals who engage in strenuous exercise or physical labor, especially in heat, need to
replace Na and H2O with sports drinks such as Gatorade, Powerade – H2O alone will not replace
Na los
• Treat cause – excess water retention, decreased sodium intake
• Monitor I&O
• Daily weights
• Assess level of consciousness, neuromuscular response, VS, skin turgor, mucous
membranes
• Maintain quiet environment
• Provide safety/seizure precautions
• Encourage foods high in sodium
• Irrigate with NS instead of water (wounds, enemas, NG tube)
• Monitor serum electrolytes
• Administer/restrict fluids dependent on fluid volume status
• May administer isotonic solution or hypertonic solution such as 3% NS (because with
low sodium, ECF is hypotonic – weak) – monitor for IV fluids for rate and infusion
• Administer medications as indicated
o Furosemide
o Potassium chloride (used to replace the potassium lost due to diuretic)
• Prepare for/assist with dialysis

Hypernatremia
• High Na+ (> 145 mEq/L)

Causes of Hypernatremia
• May result from excess Na intake, water loss, or decreased H2O intake
• Lose more H2O than sodium
o Decreased H2O intake or ingestion
o Watery diarrhea
o High fever
o Hyperventilation (insensible loss of H2O)
o Diabetes insipidus (H2O loss > Na loss and increased Na)
• Too much Na intake
o Overuse of table salt or food with high Na (prepared food, frozen, canned, smoked)
o Too many salt tablets
o Tube feedings (hypertonic) without water replacement
o IV saline too rapidly
o Consumption of antacids containing Na
• Too little H2O intake
o Decreased thirst with elderly
o Inability to swallow

S/S of Hypernatremia (typically vague and nonspecific)

• Occurs with decreased H2O (dehydration) – increased thirst, decreased skin turgor, dry
sticky mucous membranes, red rough swollen tongue
• Elevated body temperature, flushed skin
• Depressed reflexes, lethargy, weakness, fatigue, muscle twitching
• Oliguria
• Causes ECF to be hypertonic in relation to cells; therefore, H2O moves out of cells
causing shrinking of cells (cellular dehydration)
o Restlessness, delusions, excitement, delirium, irritability, disorientation, tachycardia,
convulsions, coma, death
Nursing Diagnoses and Interventions for Hypernatremia
Risk for Injury, Fluid Volume Deficit, Activity Intolerance, Impaired Skin Integrity
• Identify patient at risk
• Treat the cause – water deficit (fever, hyperventilation, diarrhea), sodium excess
• I&Os
• Daily weight
• Assess edema; level of consciousness; muscular strength, tone, and movement; skin
turgor, color, and temperature; mucous membranes; thirst
• Maintain safety/seizure precautions
• Skin care
• Frequent repositioning
• Oral care; avoid use of mouthwashes with alcohol
• Increased fluid intake
• Na restricted diets
• Diuretics
• IV fluids – hypotonic fluids such as ½ NS to make ECF weaker
• Monitor labs

Potassium
• K+ (cation)
• Normal level 3.5-5.5 mEq/L
• Major ICF electrolyte (ECF level is low of body’s K+: 98% in ICF and 2% in ECF –
measure in ECF)
• Major source is diet; foods high in K= are bananas, baked potatoes, many fruits
(especially dried fruits), cantaloupe, cokes, salt substitutes

• Excretion – kidneys 80-90%; feces and perspiration 10-20%

o Kidneys have primary role in K+ excretion; impaired kidney function can result in toxic
levels – kidneys unable to conserve K+ even in depletion states (cannot store K+) – must be
ingested daily

Functions of Potassium
• Maintenance of regular cardiac rhythm
• Essential for conduction of nerve and muscle impulses\
• Utilization of glucose by the cells
• Participates in acid-base balance

Hypokalemia – most common type of electrolyte imbalance

• Low potassium (<3.5 mEq/L)
Causes of Hypokalemia
• Potent diuretic therapy (K+ depleting)
• Decreased intake of K+ orally in diet
• Loss of GI fluids (loaded with K+)
o Vomiting
o Diarrhea
o NG suction
o Use of steroids
o Alkalosis – increased pH (as H+ ions move out of cell, K+ goes into the cell in attempt to
balance pH, so increased pH = decreased K+
o Burns

S/S of Hypokalemia
• Cardiac: irregular pulse (weak and thready), EKG changes/dysrhythmias
• Respiratory: muscle weakness, shallow respirations, can lead to respiratory failure
• Neuromuscular: muscle weakness, lethargy, decreased reflexes, paresthesia, leg cramps
• GI: anorexia, N/V, abdominal cramping, decreased bowel sounds – ileus (Obstruction of
the intestine due to paralysis of the intestinal muscles)

Nursing Diagnoses and Interventions for Hypokalemia

Decreased Cardiac Output
Activity Intolerance
Risk for Imbalanced Fluid Volume
Acute Pain
• Monitor heart rate and rhythm - telemetry
• Monitor respiratory rate, depth, and effort
• Encourage coughing/deep breathing exercises
• Reposition frequently
• Assess level of consciousness and neuromuscular function; auscultate bowel sounds
• I&O
• Monitor rate of IV potassium administration; provide ice pack as necessary; must be
diluted – if given IV push (not diluted) would cause cardiac arrest; should not exceed 20 mEq/hr
infused
• Encourage intake of foods and fluids high in potassium (40-60 mEq/L/day) especially on
diuretics
o Apricots
o Avocado
o Bananas
o Beef
o Cantaloupes
o Carrots
o Chocolate
o Figs
o Peaches
o Pork
o Potato
o Prunes
o Raisins
o Spinach
o Tomatoes
• Dilute liquid (always dilute potassium!) and effervescent K+ supplements with 4 oz
juice/water and give with meals
• Monitor patients on digoxin for toxicity because low potassium increases the heart’s
sensitivity to digoxin (check for bradycardia)
• Monitor labs
o Serum potassium
o ABGs (potassium burns in veins, always dilute or you’re going to kill a person)
• Restrict sodium intake and administer

Hyperkalemia (more serious, hypo more common)

• High potassium (> 5.5 mEq/L)
• More dangerous than hypokalemia due to overstimulation of the cardiac muscle; can lead
to cardiac arrest
Causes of Hyperkalemia
• Renal disease (K+ excretion decreased and K+ builds up)
• Conditions causing excess K+ from within the cells to enter blood
o Burns
o Crushing injuries
• Excess IV or PO K+ intake
• Acidosis (decreased pH = acidosis; H+ goes inside the cell and K+ comes out; thus K+
levels increase; decreased pH = increased K+)
• Rare cause – rapid infusion of old blood which could have damaged cells so K+ leaks out
into blood)
S/S of Hyperkalemia
• EKG changes
• Dysrhythmias – slow, irregular
• Cardiac arrest
• Irritability if muscles lead to muscle weakness, twitches, and cramps – leads to flaccid
paralysis and can lead to respiratory muscle weakness and infection
• Numbness and tingling of face, tongue, and extremities
• GI hyperactivity – hyperactive BS, N/V, diarrha

Nursing Diagnoses and Interventions for Hyperkalemia

Risk for Decreased Cardiac Output
Risk for Activity Intolerance
Risk for Imbalanced Fluid Volume
• Identify patient at risk
• Treat the cause – excess intake of potassium; decreased excretion
• Monitor heart rate/rhythm; telemetry
• Monitor respiratory rate and depth (try to compensate)
• Elevate HOB
• Encourage coughing/deep breathing exercises
• Monitor UO
• Assess level of consciousness, neuromuscular function
• Assist with ROM
• Encourage frequent rest periods; assist with self-care
• Discontinue potassium supplements and dietary sources
• Monitor labs
o Serum potassium
o ABGs
o BUN/Cre
o Glucose
• Administer medications
o Diuretics
o Glucose with insulin (facilitates movement of K+ back into cells)
o Sodium bicarbonate
o Calcium gluconate (antagonizes potassium depressant on heart and stimulates cardiac
contractility)
o NS
o Ion resin exchange – sodium polystyrene sulfonate (Kayexalate)
 Liquid or enema form
 Oral = 15g in sorbitol
 Enema = 30-50g in 100 ml sorbitol
 Causes diarrhea
 Exchanges potassium for sodium or calcium in the GI tract
o Force fluids
o Prepare for/assist with dialysis

Calcium
• Ca++ (cation)
• Normal level 4.5-5.3 mEq/L or 9-11 mg/dl
• 99% of Ca++ in the body is in the bones and teeth; the remaining 1% found in soft tissue
and ECF
• Source of calcium is diet – need daily intake; RDA 800 mg (we typically take in <
550mg)
o Milk and cheese
o Yogurt
o Rhubarb
o Collard greens
o Tofu
o Broccoli
o Green beans
o Carrots
o Cauliflower
o Egg yolks
o Nuts lettuce
• Kidneys help control; Ca++ and PO4- have an inverse relationship
o ↓Ph = ↑Ca
o ↑Ph = ↓Ca
• Calcium regulation depends on proper functioning of:
o Vitamin D: essential for absorption of Ca++ from small intestine; sources – milk, salmon,
egg yolks, butter fat, sunlight
o Parathormone: secreted by parathyroid glands and stimulates reabsorption of Ca++ into
the intravascular compartment which is then absorbed into the bone
o Calcitonin: secreted by thyroid gland – metabolizes Ca++ and decreases serum calcium
levels by absorbing Ca++ into bones and excretion by kidneys

Functions of Calcium
• Transmission of nerve impulses (has depressant effect on neuromuscular irritability)
• Proper muscle contraction (mainly skeletal and heart)
• Formation of bones and teeth
• Involved in blood clotting

Hypocalcemia
• Low calcium (<4.5 mEq/L)
Causes of Hypocalcemia
• Parathyroid (stimulates reabsorption of Ca++ into intravascular space) or
hypoparathyroidism (causing decreased secretion of parathyroid hormone)
• Dietary deficiency of Ca++ or vitamin D
• Chronic renal failure (retention of phosphorus so excretion of Ca++)
• Excessive loss per intestinal secretions (diarrhea)]
• Abuse of phosphate containing antacids (↑Ph = ↓Ca)

S/S of Hypocalcemia (chronic may not show up until broken bone)

• Excited neurological system or hyperactive CNS
o Hyperactive reflexes
o Muscle spasms of feet and hands
o Tingling around nose, mouth, ears gingers, toes (paresthesia)
o Tetany – sustained muscle contraction/rapid muscle spasms
 Chvostek’s: facial spasm induced by tapping the facial nerve in front of the ear
 Trousseau’s: when you inflate BP cuff 20 mmHg above patient’s systolic you will see a
spasm of hand and thumb (carpal spasm)
o Seizures
o Weakened cardiac contractions with tachycardia and irregular
o Osteoporosis – pathological fractures (blood pulls Ca++ out of bone to increase serum
Ca++)
o Increased GI motility

Nursing Diagnoses and Interventions for Hypocalcamia

Risk for Injury
• Treat cause
• Monitor heart rate/rhythm; telemetry
• Assess respiratory rate, rhythm effort – laryngeal spasms may develop
• Observe for neuromuscular activity – tetany, seizures, Chvostek’s, Trousseau’s
• Provide quiet environment
• Seizure precautions
• Promote relaxation/stress reduction techniques
• Increase vitamin D – increases absorption of Ca++
• Identify sources of calcium and vitamin D; restrict intake of phosphorus
• Check for bleeding from any source
• Encourage use of calcium containing antacids
• Monitor labs
o Serum calcium
• Oral IV Ca++ supplements (best given 30 mins AC and HS)
• Calcium gluconate IV (if IV calcium gluconate infiltrates, causes necrosis)
• Vitamin D supplement (Calcitrol)

Hypercalcemia
• Increased Ca++ (> 5.3 mEq/L)
Causes of Hypercalcemia
• Hyperparathyroidism
• Excess intake of milk products or overtaking antacids and Ca++
• Any condition causing movement of Ca++ from bone to ECF
o Multiple fractures
o Prolonged immobilization
o Tumors with bone metastasis
o Excess vitamin D intake

S/S of Hypercalcemia
• Depressed CNS
• Depressed reflexes
• Muscle weakness, decreased muscle tone, incoordination
• Lethargy and fatigue
• Bradycardia (late S/S)
• Confusion
• Renal stones (flank pain)
• Increased cardiac contractions, dysrhythmias, bradycardia
• Increased BP
• Abdominal distention, constipation

Nursing Diagnoses and Interventions for Hypercalcemia

Risk for Excess Fluid Volume
• Treat cause
• Monitor cardiac rate and rhythm – telemetry
• Assess level of consciousness and neuromuscular status
• Auscultate bowel sounds
• Maintain bulk in diet to help with constipation
• Turn frequently and do ROM; encourage ambulation if able
• Gentle handling when moving/transferring; safe, clutter free environment – due to risk of
fractures
• I&O
• Monitor labs
o Calcium
o Phosphate
• Hydrate with isotonic NS to encourage diuresis of Ca++
• May need surgery if hyperparathyroid is the cause
• Limit dietary intake of Ca++ and vitamin D (including calcium containing antacids)
• Encourage fluids (3000 - 4000 ml) daily
• I&O
• Daily weight
• Prevent prolonged immobilization (encourage mobility)
• Keep safe environment due to poor coordination and abnormal gait
• Administer medications ad ordered
o Oral phosphates may be given – high levels promote Ca++ excretion
o Loop diuretics (furosemide – Lasix) to promote Ca++ excretion
o Sodium bicarbonate
o Calcitonin – moves calcium back into bones
• Prepare for/assist with dialysis

Magnesium
• Mg++ (cation)
• 1.5-2.5 mEq/L
• 2nd most abundant intracellular ion
• 60% found in bone
• 39% found in muscle and soft tissue
• 1% ECF
• Major source – diet
o Whole grains
o Fruits
o Vegetables
o Meat
o Fish
o Dairy products
• Kidneys do conserve Mg++ if a deficiency occurs (which is opposite of K+ - cannot
conserve K+)

Functions of Magnesium
• Cofactor in activation of enzymes (especially carbohydrate and protein metabolism)
• Promotes regulation of Ca++ and K+ (works with Ca++ for proper functioning of
excitable cells – so Mg++ and Ca++ released)
• Essential for integrity of nervous tissue, skeletal muscle and cardiac function

Hypomagnesemia
• Low magnesium (< 1.5 mEq.L)

Causes of Hypomagnesemia
• Decreased intake as with prolonged malnutrition and alcoholism
• Increased excretion by kidneys
• Impaired absorption by GI tract
• Seen with other electrolyte deficits (K+ and Ca++)
• Diarrhea and vomiting

S/S of Hypomagnesemia
• Mg++ acts as a depressant do decreased Mg++ causes neuromuscular irritability
• Hyperactive reflexes
• Tetany
• Tremors
• Agitation
• Cardiac dysrhythmias - tachycardia
• Shallow respirations
• Hypocalcemia and hypokalemia
• Dysphagia

Nursing Diagnoses and Interventions for Hypomagnesemia

Risk for Injury
• Treat underlying cause
• Monitor cardiac rate/rhythm – telemetry
• Assess level of consciousness and neuromuscular status
• Seizure/safety precautions
• Provide quiet environment
• ROM exercises as tolerated
• Auscultate bowel sounds
• Encourage intake of dairy products; whole grains; green, leafy vegetables; meat; fish;
peanut butter; chocolate; bananas; and nuts
• Monitor lab results
o Serum magnesium level
o Calcium
o Potassium
• MgSO4 – IV, IM, or PO
o Calcium gluconate is the antidote for hypermagnesemia
o IV mag – monitor cardiac rhythm and reflexes
o Magnesium based antacids – can cause diarrhea
• Monitor for digoxin toxicity
• Test ability to swallow before food or fluid is given due to dysphagia

Hypermagnesemia
• High magnesium (> 2.5 mEq/L)

Causes of Hypermagnesemia – rare if kidneys are functioning

• Renal failure
• Excessive magnesium administration (antacids – Gaviscon, Mylanta, Maalox)
• Diabetic ketoacidosis with severe H2O loss

S/S of Hypermagnesemia
• Depresses the CNS and cardiac impulse transmission
• Hypotension
• Weak pulse – bradycardia
• Heat and facial flushing
• Muscle weakness
• Loss of deep tendon reflexes
• Paralysis
• Respiratory depression

Nursing Diagnoses and Interventions for Hypermagnesemia

Decreased Cardiac Output

Risk for Ineffective Breathing Pattern
Risk for Injury
Risk for Ineffective Health Maintenance

• Treat underlying cause

• Monitor cardiac rate/rhythm – telemetry
• Monitor BP
• Assess level of consciousness and neuromuscular status
• Assess respiratory rate/depth/rhythm
• Encourage coughing and deep breathing
• Elevate HOB
• Encourage increased fluid intake (only in absence of renal and cardiac failure)
• Monitor I&O
• Bed rest; assist with personal care activities
• Avoid magnesium containing antacids – Maalox. Mylanta, Gaviscon
• Reduce magnesium containing foods
• Monitor lab values
o Serum magnesium
o Calcium
• Administer IV fluids as ordered
• Administer thiazide diuretics as ordered
• Administer 10% calcium chloride or gluconate IV
• Assist with dialysis as needed

Phosphate (Phosphorus HPO4)

• HPO4- (anion)
• Intracellular
• Normal level 1.7-2.6 mEq/L
• Main source is the diet – many food contain phosphate and rarely a deficit
o Beef
o Pork
o Fish
o Liver
o Poultry
o Whole grains
• Excretion source – 90% kidneys
• 70-80% found in bones and teeth; 10% found in muscle; and 10% found in nervous tissue
• Phosphate has an inverse relationship with calcium
o ↓Ca = ↑PO4
o ↑Ca = ↓PO4
o So usually associated with Ca++ imbalances (increased Ca++ promotes PO4 excretion
and vice versa)
Functions of Phosphate
• Supports and maintains strong bones and teeth
• Buffer to help regulate acid/base
• Assist in normal nerve and muscle activity

Hypophosphatemia
• Low phosphate (< 1.7 mEq/L)

Causes of Hypophosphatemia
• Dietary insufficiency
• Increased urinary losses
• Use of phosphorus-binding antacids (antacids with magnesium and aluminum –
Amphojel)

S/S Hypophosphatemia
• Confusion, numbness, seizures and other neurological S/S
• Change in RBCs – decreased O2 carrying capacity – tissue anoxia
• Muscle weakness and pain (especially respiratory muscles)
• Incoordination

Nursing Diagnoses and Interventions for Hypophosphatemia

Impaired Physical Mobility
Ineffective Breathing Pattern
Decreased Cardiac Output
Risk for Injury
• Assess for risk factors
• Eliminate underlying cause
• Assess for S/S – restlessness, confusion, cyanosis
• Increase foods high in phosphorus
• Oral phosphate supplements
• IV sodium phosphate or IV potassium phosphate if severe – administering phosphate
salts is dangerous and decreased phosphate levels are usually not life threatening
• Assess for calcium imbalances – hypercalcemia (due to inverse relationship)

Hyperphosphatemia
• Increased phosphate (> 2.6 mEq/L)
Causes of Hyperphosphatemia
• Renal failure (due to eliminated by kidneys)
• High phosphate intake
S/S of Hyperphosphatemia
• Most related to decreased calcium (inverse relationship)
o Tetany
o Muscle spasms
o Numbness and tingling around mouth
o Anorexia
o N/V
o Increased reflexes

Nursing Diagnoses and Interventions for Hypophosphatemia

Risk for Injury
• Treat cause
• Monitor heart rate/rhythm; telemetry
• Assess respiratory rate, rhythm effort – laryngeal spasms may develop
• Observe for neuromuscular activity – tetany, seizures, Chvostek’s, Trousseau’s
• Provide quiet environment
• Seizure precautions
• Promote relaxation/stress reduction techniques
• Increase vitamin D – increases absorption of Ca++
• Identify sources of calcium and vitamin D; restrict intake of phosphorus
• Check for bleeding from any source
• Encourage use of calcium containing antacids
• Aluminum hydroxide gels (Amphojel) may be ordered because they bind with
phosphorus in the intestine
• Monitor labs
o Serum calcium
• Oral IV Ca++ supplements (best given 30 mins AC and HS)
• Calcium gluconate IV (if IV calcium gluconate infiltrates, causes necrosis)
• Vitamin D supplement (Calcitrol)
• Monitor renal function
Chloride
• Cl- (anion)
• 95-105 mEq/L
• Usually linked to sodium because can easily combine with sodium to form NaCl
• Foods containing sodium contain Cl- - major source is the diet
• Main route of excretion is kidneys
• Function
o Necessary for formation of hydrochloric acid in gastric juices
o Helps regulate acid/base balance
o Helps regulate osmotic pressure between ICF and ECF
• Imbalances
o Hypochloremia – occurs with hyponatremia
o Hyperchloremia – seen when bicarbonate falls because Cl- attempts to compensate to
keep equal # of anions and cations in ECF
o Both rarely occur alone – no specific S/S to identify

Bicarbonate
• HCO3- (anion)
• 22-24 mEq/L
• ECF
• Major function is regulation of acid/base balance; the major chemical base buffer in the
body means it acts to neutralize acids in the body
• Kidneys regulate the amount of bicarbonate retained and excreted

Fluid Imbalances
Risk Factors for Fluid Imbalances

 Age – very young and very old

 Amount of subcutaneous fat (less H2O reserves with more SQ fat)

 Environmental temperature – fluid lost by sweating

 Diet – many foods we eat have large amount of H2O

 Health status

o Losing body fluids from any route for any reason

o Altered food or fluid intake

o Confusion (unable to feed self)

o Alteration in kidney or heart function – if decreased cardiac output (CO)

kidneys receive less blood

Assessment

History

 Fluid and food intake

 Fluid output

 Fluid imbalances (signs and symptoms)

 Disease processes

 Medications

 Treatments

Physical Assessment

 Skin – color, temperature, moisture; use inspection and palpation;

should be pink, warm, and dry

 Mucous membranes – use inspection; should be pink and moist

 Skin turgor – pinch up skin – should bounce back instantly; best dome
on forehead or over chest bone

 Daily weights

o Most accurate assessment of fluid status

o 1 kg = 2.2 lbs = 1L = 1000ml

o Balance scale before each use

o Weight at same tine every day

o Have patient void before weighing

o Same or similar clothing

o Same scale

 Vital signs

 Urine characteristics

o Amount – approximately 1000-1500 ml if urine in each 24

hour period; the average is 1200 ml
 o Color – golden yellow to amber; if the urine is concentrated,
such as early morning or after a period of little intake, the color
will be darker; it will be lighter if the urine is dilute

o Clarity – clear; urine may turn cloudy on standing, owing to

normal phosphate precipitation

o Odor – faintly aromatic; some foods such as asparagus, and

certain drugs cause a pungent odor

o Specific gravity – reflects the kidneys ability to conserve or

excrete H2O (ability to concentrate urine)

o Acidity – average pH of 6 for persons on a standard diet’ a

range of 4.56 to 8 within normal range; vegetarians excrete
slightly alkaline urine; a high protein diet increased the acidity
of urine; certain drugs influence acidity/alkalinity of urine

o Protein – negative

o Glucose – negative; glucose may be found in the urine if the

person has eaten concentrated sweets such as candy

o Ketone bodies – negative

o Sediment – negative for RBCs, negative for WBCs, occasional

epithelia cells, occasional hyaline casts

 Breath sounds – use auscultation

 Eyes, veins, mental status

 Lab data

o Hematocrit (Hct) – measures volume or % of blood that is

composed of RBCs; measures volume of cells in relation to
plasma - # RBCs in liquid

 Normal male 42-52%; female 37-47%

 Decreased fluid (deficit) – increased hematocrit

 Increased fluid (excess) – decreased hematocrit

o Specific gravity - reflects the kidneys ability to conserve or

excrete H2O (ability to concentrate urine)
  Normal 1.010-1.030

 Fluid deficit = increased specific gravity – more

concentrated urine and less urine output (↓fluid = ↑sp
gr)

 Fluid excess = decreased specific gravity – less

concentrated urine and urine output may be increased
(↑fluid = ↓sp gr)

 Intake and Output

o Important but not as accurate as daily weights

o Measured in ml; 30 ml = 1 oz

o Check agency for charting I&O and for chart of specified

containers and measurements

o Inform patient and family of importance – post signs

o Who needs I&O

 Patients receiving IVF

 Disease affecting fluid balance

 Pediatric patients

o Can be started without an order from HCP

o Calculate 1 hour before shift ends

o Total intake and output totals and document; compare I&O –

normal 1500 ml per day; at least 30 ml/hr

o Exact (matched) amounts of fluid loss and gain is not possible

– due to insensible losses or gains

o If strict I&O – BE ACCURATE

o Intake = all fluid entering the body

 Oral fluids (1oz = 30 ml)

 Ice chips (1/2 their volume)

  Foods that become liquids at room temperature (jello,
ice cream, popsicles)

 Tube feedings (feedings or H2O)

 If continuous on pump – clear at end of shift

 If add H2O or liquid medications – must add to

intake

 IV fluids – parenteral

 3 methods

o Pump – total from bag (must know

beginning volume at start of shift); ex.
800 ml to count, end of shift have 200
ml left in bag – intake 600 ml; 200 ml to
count – added 1000 ml bag on your shift,
700 ml left at end – IV intake = 500 ml

o Pump – total from shift

o Multiply by hours

 Irrigation fluids (used to irrigate F/C, NG tubes, etc)

 Also must note any immediate return back as

output

 Enemas (no intake if with any results)

o Output

 Urine output

 Use graduated containers to measure

 Do not estimate (urinal, hat, bedpan)

 Catheters – bags are calibrated but best to empty

in measuring container for accuracy (empty at
end of shift)
  Incontinent patients – X1, X2 (if on strict I&O
must weigh diapers/briefs or bed linen); 1oz =
30 ml

 Emesis or liquid feces

 Tube drainage – NG, chest tube, wound drainage

(drainage on dressing as dime size, etc); with suction
always subtract from total output any amount irrigated
or ingested)

 Enemas (if no return)

Fluid Volume Deficit (Dehydration or Hypovolemia)

Causes of Fluid Deficit

o Abnormal fluid loss (vomiting; diarrhea; abnormal drainage from wounds, tubes,
or GI suction; excessive sweating)

o Decrease intake of fluid (imposed fluid restriction, difficulty feeding self,

decreased desire to drink, surgery with jaw wired)

o Extensive burns

o Blood loss (hemorrhage)

o Excess urine output (polyuria) – diuretics

o Third spacing – fluid going where it normally does not and not useful to the body
causing ECF deficit; ex. ascites

o Intestinal obstruction – water pooled in GI tract

o Increased body temperature - 101°

S/S Fluid Deficit – fluid deficit can be mild, moderate, or severe – early
recognition and intervention are crucial – can be life threatening
 o Dry skin and dry mucous membranes (look for furrowed tongue, or
between check and gum)

o Decreased skin turgor (when pinch the skin it should go back quickly; if
fluid deficit skin remains tented or slowly returns to normal – best to
check on chest or forehead especially with elderly because with age skin
loses elasticity)

o Weight loss (rapid)

o Decreased urine output – report anything less than 30 ml/hour output; also
urine will be dark and concentrated

o Increased thirst (caused by low blood volume) – elderly may not have due
to decreased sense of thirst; ask patient if thirsty

o Decreased BP and orthostatic hypotension (assess lying, sitting, and

standing BP); ask about dizziness and weakness

o Rapid pulse (but thread) – heart trying to pump faster to maintain cardiac
output (CO) in presence of decreased stroke volume (CO = HR X SV)

o Lab values

o Increased hematocrit

o Increased specific gravity of urine (concentrated)

o Increased BUN (blood urea nitrogen) – poor perfusion to kidneys

impairs their ability to excrete body waste

o Collapsed neck and hand veins (indicate decreased blood volume)

o Confusion – earliest S/S in elderly – if fluid volume deficit worsens can

lead to coma

o Infant – sunken fontanelles

Nursing Diagnosis
Fluid Volume Deficit
RT
 AEB

Nursing Interventions for Fluid Volume Deficit

o Assess S/S as discussed above

o Promote fluid replacement

o Assess IV solutions (usually isotonic NS or LR)

o Encourage po fluids

o Assess likes and dislikes

o Plan intake goal per shift

o Include patient and family in keeping record of intake

o Giver verbal and written instruct\ions

o Give reasons for increased intake

o Offer fluids more often, not all at once

o Make sure at right temperature

o Keep pitcher at bedside

o Prevent abnormal fluid loss

o Vomiting – assess effects of antiemetics

o Fever – assess effects of antipyretics and keep room cool

o Diarrhea – assess effects of antidiarrheals

o Assess lab values

o Protect skin and provide comfort measures

o I&Os

o Daily weights

Critical Thinking exercise

 Mrs. Levitt is a 92-year-old widow who has been in a nursing home for 4 years.
Today she complains that her urine smells bad and that her heart feels like it is
beating faster than usual. You suspect that she is becoming dehydrated.

 1. When taking the client’s vital signs, what changes would you expect and why?

Expect increased, weak, and thread pulse; decreased blood pressure; and possibly
increased temperature caused by hypovolemia

 2. What interventions should you provide at this time?

Encourage increased fluid intake; monitor I&O; recheck vital signs

Fluid Volume Excess (Overhydration or Hypervolemia)

Causes of Fluid Volume Excess
o Renal disease or renal failure

o Heart failure – decreased CO – malfunctioning heart

o Excess fluid intake (IVF or blood infused too rapidly or in excess) –

especially in patients with above 2 causes

o Excess Na intake (orally or IV solutions)

S/S Fluid Volume Excess – early recognition of S/S crucial here also
o Acute weight gain

o Dyspnea on exertion, SOB, orthopnea, cough, moist breath sounds {rales

(crackles) or rhonchi); ask if SOB

o Edema – pitting (when press on it and remove finger, the fit remains)

o If ambulatory first shows up in ankles

 o If bedridden first shows up in sacral area

o Anasarca – generalized edema throughout the body

o Tachycardia – pulse bounding

o Tachypnea

o Hypertension – due to increased cardiac output from fluid overload

o Engorged and distended neck veins and hand veins

o Taut, shiny skin

o Confusion

o Lab values

o Decreased hematocrit

o Decreased specific gravity of urine (dilute)

Nursing Diagnosis
Fluid Volume Excess
RT
AEB

Nursing Interventions for Fluid Volume Excess

o Assess for S/S

o Prevent fluid overload

o Maintain fluid restrictions per shift

 Divide total 24 hour amount fluid by 3 for 3 shifts and

determine how much they can have for each shift (more for
1st and 2nd than 3rd shifts)

 Explain to patient why restricting fluids and how much

they can get

 Give liquids they like

  Ice chips are good

 Good oral care frequently

 Prevent patient from eating salty and sweet foods because

they make you thirsty

 Assess diet (too much salt) – Na+ restricted as ordered

 Assess and maintain proper IV infusion

o Assess for dependent venous pooling; assess pitting edema

 Keep extremities elevated

 Consider TED hose

o Protect edematous skin from injury/prevent dry skin

o I&O

o Daily weight

o Assess labs

o Assess effects of diuretics

o Relieve symptoms – ex. dyspnea – semi-Fowler’s

Critical Thinking Exercise

 Mr. Peters is a 32-year-old man with a congenital heart problem. He has been
recovering from congestive heart failure and fluid overload. Today his blood
pressure is higher than usual, and his pulse is bounding. He is having trouble
breathing and presses the call light for your assistance.

 1. What should you do first when you assess Mr. Peters’ condition?

Place the head of the bed up to assist with breathing

 2. What questions should you ask him?

 When did your symptoms begin? Have you had these symptoms before? (If the
patient is too dyspneic to answer, do not ask many questions.)

 3. What other assessments should you perform?

Check breath sounds for crackles, observe for dependent edema and ascites,
observe for distended neck veins, assess skin for color and temperature, and
monitor intake and output.

Acid Base Imbalances

• Respiratory acidosis: Occurs when CO2 production is greater than removal of

CO2 by the lungs; increased CO2 in the blood. Remember, in blood CO2 combines with
H2O to form carbonic acid so pH is decreased (acidic).

o Causes: Caused usually by any condition resulting in depressed respirations

(hypoventilation) or impairment of CO2 exhalation

 Oversedation (by narcotics)

 General anesthesia

 Surgery or trauma (chest or abdomen)

 COPD

 Pneumonia

 Asthma

 Overdose

 Atelectasis

o Signs/symptoms:

 Hypoventilation

 Lethargy, weakness, confused, slow to respond (if not treated, coma)

 Shallow breathing
 CNS depression

 H/A

o Nursing Diagnoses:

 Impaired gas exchange

 Ineffective Breathing pattern

 Ineffective Tissue perfusion

 Acute confusion

 Risk for injury

o Nursing interventions:

 Assess for s/s

 Used IS, TCDB q1h- increases ventilations and decreases CO2

 Use postural drainage to remove secretions

 Improve ventilation

 Antibiotics for respiratory infection

 Bronchodilators- to help reduce bronchial spasms

 O2 (no greater than 3LPM)

 Mechanical ventilation may be necessary

 Narcan

pH<7.35, CO2>45, RR<

• Respiratory alkalosis: Occurs when excessive secretions of CO2 results in

decrease CO2 (decreased carbonic acid, increased pH), pH>7.45, CO2<45

o Causes: any condition resulting in increased rate and depth of respirations

(hyperventilation)
 Anxiety, pain, fear

 Lack of O2 (hypoxia)

 Fever

 Overventilation on a ventilator

o Signs/symptoms:

 Hyperventilation

 Dizziness, blurred vision

 Numbness, tingling

 Muscle weakness, twitching

 Tetany

 Hypokalemia

 CNS excited (could have convulsions)

 Anxiety, apprehension

 Diaphoresis, dry mouth

 Nausea/vomiting

o Nursing Diagnoses:

 Impaired gas exchange

 Ineffective Breathing pattern

 Ineffective Tissue perfusion

 Acute confusion

 Risk for injury

o Nursing Interventions:
 Assess for s/s

 Demonstrate slow, deep breathing

 Breath in a paper bag to increase CO2 levels

 Provide support by a calm manner and voice

 Seizure precautions

• Metabolic acidosis: Caused by decrease in base (HCO3-bicarbonate) or retaining

too many acids (H+ ions)

o Causes: caused by any event which there is decreased HCO3 or increased acid

 Malnutrition, starvation (breakdown of fats with resulting ketones)

 Diabetic ketoacidosis (breakdown of fats with resulting ketones)

 Renal failure (retain acids)

 Severe diarrhea (any loss from the lower GI loses basic so losing too much
HCO3)

o Signs/symptoms (result from CNS depression):

 Weak, apathetic, drowsy, disoriented, coma

 Kussmaul respirations (rapid and deep)- trying to blow off CO2- lungs working in
metabolic to compensate

 Hyperkalemia- K+ shifts from cells to plasma-look for arrhythmias

 Lower ph, lower HCO3

 Hypotension

o Nursing Diagnoses:

 Decreased Cardiac Output

 Risk for Fluid Volume Excess

 Risk for Injury

o Nursing interventions:

 Assess s/s

 Treat the cause

 Maintain complete bedrest to reduce cell metabolism (administer NaHCO3 may

be ordered)

 Monitor blood glucose levels

 Provide oral care

• Metabolic alkalosis: Caused by an event that increases HCO3 or decreases acid

(increased pH, increased HCO3)

o Causes:

 Vomiting or gastric suctioning (losing upper GI fluids which are acidic so losing
too much acid)

 Excess intake of NaHCO3 (mainly with antacids such as Mylanta, alka seltzer)

 Associated with any condition which causes hypokalemia (diuretic therapy,

burns)

o Signs/symptoms:

 Result from overexcited CNS (irritability, disoriented, convulsions, death

 Hypertonic muscles/tetany (Ca+ utilization decreased)

 Shallow, slow respirations with periods of apnea- lungs trying to compensate and
retain CO2

 Irregular pulse rate, arrhythmias (decreased K+)

o Nursing Diagnoses:

 Risk for Impaired Gas Exchange

 Fluid Volume Deficit

o Nursing interventions:

 Assess s/s

 Treat the cause

 Appropriate fluid and electrolyte replacement (esp. K+)

 Advise to avoid OTC antacids