1 LINCOLN MEMORIAL UNIVERSITY Caylor School of Nursing Nursing 124/125 Fall 2010 LESSON PLAN: Fluid and

Electrolytes 1. Explain the distribution of fluid and electrolytes in the body. 2. Identify the compartments for water in the body. 3. Identify ways adult human persons lose fluids and nursing measures to replace fluid loss. 4. Recognize the mechanism and routes by which fluid is transported in the body. 5. Identify the major electrolytes of the body and the primary function and purpose of the electrolytes. 6. Identify common electrolytes and water imbalances, signs and symptoms of these imbalances and nursing interventions to prevent and correct such imbalances. 7. Accurately calculate intake and output. 8. Describe the relationship between normal fluid intake and output. 9. Identify common diagnostic tests regarding fluid and electrolyte balance. 10. Identify stimuli which may affect fluid and electrolyte balance in different the young adult and older adult. 11. Utilize the Roy Adaptation Model (RAM) nursing process to develop a plan of care for the adult with fluid and/or electrolyte imbalance. 12. Identify the physiologic action, use, side effects, and nursing implications of medications utilized in the pharmacologic management of fluid balance needs. 13. Identify appropriate interventions for the adult receiving parenteral fluid therapy. 14. Correctly calculate medication dosage and administration. 15. Identify the various acid base disorders, causes and interventions. 16. Describe the process of administering blood, assessing and evaluating complications. TOPICAL OUTLINE

I.
• •

Review of Fluid and Electrolyte Balance

Homeostasis- maintenance of this constant environment in the face of continual change. Fluid imbalance manifests as: o Excesses o Deficits o Abnormal shifts among body compartments

Nurses’ Functions related to F&E Balance • Daily weight is a major indicator of fluid status • Recognize situations causing imbalances • Intervene to prevent imbalances • Carry out preventive/therapeutic measures prescribed and monitor response • Monitor to prevent and recognize imbalances • Alleviate effects of disturbances in comfort and safety Rev 07/16/10

2 • Prevent imbalances in people at risk

Fluid • Approximately 60% of the typical adult is fluid • Varies with age, body size, and gender o 80% or greater in infants; decreases with age o Less in elderly o Less with obesity- fat cells contain little water Adequate body water is necessary in: • Maintenance of normal body temperature • Elimination of waste products • Making transportation within the body possible • Acts as tissue lubricant

A.

Distribution of Body Fluids

Distribution of Body fluid • Intracellular fluid (ICF) o Found within body cells o 60-70% total body o Major electrolytes in ICF  Potassium  Magnesium  Phosphate • Extracellular Fluid (ECF) o Found outside the cell o 30-40% total body fluid o In constant motion  Interstitial fluid (between cells)  Intravascular (plasma)  Cerebrospinal fluid  GI secretions Extracellular Fluid (ECF) • Highly determined by Na+ concentration • Contains large amounts of Na+, Cl-, and HCO3• Normal movement occurs between capillaries and interstitial spaces • If capillary of interstitial pressures are altered, fluid can shift abnormally Fluid spacing • Third spacing- occurs when fluid accumulates in areas that normally have little or no fluid (peritoneum, edema with burns, etc) o It is lost- body is not able to use = imbalance o What clinical manifestations will be seen? Rev 07/16/10

Major Cations (Na+. which is released from the thyroid. thirst. and helps regulate muscle contraction and relaxation. Magnesium • 2nd most abundant cation in ICF • Plays a role in carbohydrate and protein metabolism • Important for neuromuscular function • Also acts peripherally to produce vasodilation • Predominantly found in bone and soft tissues • Primarily excreted by kidneys • Mostly absorbed through GI tract Rev 07/16/10 . • Plays a role in blood coagulation • Excreted mostly through feces • Serum calcium level is controlled by PTH and calcitonin. K+. including cardiac muscle. Mg+) Sodium • Main electrolyte in ECF • Controls and regulates volume of body fluids • Maintains water balance • Primary regulator of ECF volume • Important for nerve impulse generation and transmission • Regulated by antidiuretic hormone. if kidneys are not functioning properly could cause increase in potassium Calcium • Plays a major role in transmitting nerve impulses. clammy skin Decreased urine output Give albumin to pull out trapped fluid B.3      Low BP Tachycardia Cold. Electrolytes 1. skeletal system. and angiotensin-aldosterone system Potassium • Major cation in ICF • Vital in transmission of electrical impulses in the heart. nervous system. intestinal and lung tissues • Chief regulator of cellular enzyme activity • 80% of potassium is lost through kidneys. Ca+.

Gains – dietary. Movement of body fluid and electrolytes 1. enteral. Diffusion Movement of molecules and ions from an area of higher concentration to an area of lower concentration 3. Major Anions (Cl-. the sodium-potassium pump actively moves the Na back to the ECF o Energy must be expended for Na+ and K+ to change places rapidly through the system o Sodium-potassium pump maintains the higher concentrations 4. parenteral o Dietary intake of fluid and food or enteral feeding o Parenteral fluids Rev 07/16/10 . Osmosis Movement of fluid from an area of lower solute concentration to an area of higher solute concentration 2. • • • • • Active transport 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 Sodium-potassium pump o Sodium concentration greater in ECF o Diffusion allows sodium to enter the cell o Once inside the cell. HCO3-. • • • • Filtration Movement of water and solutes from an area of higher hydrostatic pressure to an area of lower hydrostatic pressure Capillaries filter fluid from intravascular space to interstitial space Kidneys filter plasma allowing excretion of water and waste products Must have two factors present o Hydrostatic pressure = BP o Osmotic pressure D.4 2. Routes of gains and losses 1. PO4-) C.

approximately 300 ml/day (average adult) • GI Tract. GI tract. everyday o Same scale.Sensible vs. Losses . skin. insensible. Daily • • • Daily weights weights Provide estimate of fluid volume status Best indicator of fluid balance What principles should be remembered? o Same time of the day.lab test to identify BNP Rev 07/16/10 . other • Loss: o o o o o sensible (measurable) and insensible (unmeasurable) Kidney: urine output Skin loss-sweating Lungs GI tract Other. at least 30 ml/hr • Skin o Loss through sweat/perspiration.5 2. Kidneys Adjustments made in urine volume to balance fluid Excretion of metabolic waste and toxic substances Filters plasma Responds to ADH and aldosterone to regulate levels 2. increased temperature or metabolism o Evaporation through skin/lungs with respiration • Lungs.approximately 1500ml each day.hemorrhaging 3. make sure scales are properly zeroed o Same amount of clothes E. Cardiac Increase HR and CO Atrial natriuretic factor (ANF). lungs. kidneys. Intake and output Intake • Intake primarily regulated by thirst mechanism • Adult daily fluid intake is approximately 2600ml o 1300 ml from liquids o 1000 ml from foods o 300 ml from metabolism Output • Kidneys. • • • • • • Regulation of body fluid and electrolytes 1.approximately 200 ml/day 4.

measures the percentage of red blood cells in whole blood o Male Normal Range: 42-52 o Female Normal Range: 35-47 2.0 mEq/L Sodium Potassium Rev 07/16/10 . o Hormone blocks effects and excretion of aldosterone and renin 5. Diagnosis A. • Common tests 1. 4. • • Serum electrolytes 135-145 mEq/L 3.5-5. Lungs Hormones Through exhalation. o Promotes water reabsorption Atrial Natriuretic Peptide • Hormone that is released by the atrium of the heart when it is stretched from fluid overload.6 • • • Released when left atrium of heart is stretched from volume overload Vasodilates and increases urinary excretion of Na+ and H20 3. Thirst mechanism Thirst mechanism. the lungs remove about 300ml of fluid daily Regulation of Fluid • Renin-Angiotensin-Aldosterone System (RAAS) o A complex series of events triggered by decrease B/P and decreased perfusion to kidneys o Decrease BP = secretion of renin from kidneys o Renin combines with angiotensinogen to form Angiotensin I o Angiotensin I is converted in the lungs to Angiotensin II o Angiotensin II stimulates the adrenal cortex to release aldosterone o Aldosterone results in Na+ and H2O retention = also causes increase in BP Hormonal Effects on Fluid Balance • ADH regulation – anti-diuretic hormone secreted from posterior pituitary gland when increased serum osmolality (concentration) is increased.located in the hypothalamus • Activated by increased ECF osmolality (concentration) II. CBC (complete blood count) Hematocrit.

measures the kidney’s ability to excrete or conserve water o Less reliable indicator of concentration than osmolality o Normal urine specific gravity.10-20mg/dL 4.5-4.4mg/dL 5.2 mg/dL Magnesium 1.5 mg/dL Chloride 97-107 mEq/L Carbon Dioxide 24-32 mEq/L Glucose 60-110 mg/dL Albumin 3. and respiratory function Decreased body fluid percentage Medication use Presence of concomitant (History of other diseases) conditions 2.1.0 g/dL 3. Rev 07/16/10 . • Osmolarity/osmolality Osmolality.7-1.030 Urinary Sodium 75-200 mEq/day Urinary Potassium 26-123 mEq/day Urinary Chloride 110-250 mEq/day Urinary pH 4.5-8.3-2. renal.7 • • • • • • • • Calcium 8. • Creatinine Creatinine.measures the solute concentration per kilogram in blood and urine o Normal serum osmolality.003 – 1. Indicator of renal function o Normal creatinine.0.0 III. Age related differences 1. Pediatric Children are also at greater risk for fluid and electrolyte imbalance due to higher proportion of water in the body.is made up of urea.5 mEq/L Phosphorus 2.5-5. Gerontological • • • • • Reduced homeostatic mechanisms: cardiac.275 – 300 mOsm/kg o Normal urine osmolality. • • • • • Urine pH & specific gravity Specific Gravity.250 – 900 mOsm/kg 6. Blood urea nitrogen (BUN) BUN. the end product of metabolism of protein by the liver o Normal BUN.6-10. General Risk Factors A.the end product of muscle metabolism.

8 IV. diarrhea.elevated o Urine specific gravity. monitor I&O • • • Rev 07/16/10 . IVF’s (isotonic or hypotonic) o Tube feedings PRN o Monitor patient response. intestinal obstruction. coma. mental status o Monitor for signs of fluid volume overload. Fluid volume deficit (FVD): hypovolemia/dehydration Fluid Volume Deficit • Dehydration.deficiency in both water and electrolytes in the ECF. prolonged fever  Diuretics. dry mucus membranes o Decreased skin turgor. dizziness. nausea. ketoacidosis  Hemorrhage o Decreased intake of fluid  Anorexia. ascites. hemorrhage.elevated o BUN.elevated o Serum osmolality. analysis/nursing diagnosis and evaluation/expected outcomes. weight loss. inability to gain access to fluid o Third Spacing  Peritonitis. burns o Risk Factors: diabetes insipidus. fatigue o Cool. rapid and weak pulse. and GI suctioning  Diaphoresis. postural hypotension o Confusion. Utilize the RAM nursing process for fluid volume imbalances.a decrease volume of water. increased temperature o Decreased B/P.elevated Nursing interventions for FVD o Assess for presence or worsening of FVD (Always think why?) o Administer oral fluids as tolerated o Provide TPN. which includes risk factors. but not a change in electrolytes • Hypovolemia. (more severe) • Causes o Abnormal fluid losses  Vomiting. Renal disease. assessment. Adrenal Insufficiency. and third space shifts Assessment findings o Thirst. clammy skin o Muscle weakness and cramps o Flattened neck veins Labs o Na. oliguria o Increased HR. A. adrenal insufficiency. osmotic diuresis.elevated o HCT. edema o Decreases UOP. Diabetes Insipidus.

increased RR (tachycardia).excess retention of water and Na+ (Examples) • Due to fluid overload or diminished homeostatic mechanisms • Risk factors: heart failure. Na.burns. glucocorticosteroids) o Excessive sodium intake Assessment o Weight gain. and cirrhosis of the liver • Contributing factors: excessive dietary sodium or sodium-containing IV solutions • Causes o Fluid shift. renal failure. skin pale and cool o Increased BP and pulse o SOB.caused by excess water ingestion or from excess ADH secretions (heart failure.9 o Skin and oral care o Evaluate interventions B. altered LOC. hematocrit. dry.increase K for all except Aldactone • Intake & Output. Fluid volume excess (FVE): hypervolemia Fluid Volume Excess (FVE) • Hypervolemia. Pulmonary edema o Distended neck veins o Headache. protein administration o Water intoxication.careful and evening does not recommended • Take with or after meals in AM • Increase risk of orthostatic hypotension Rev 07/16/10 . edema. crackles. daily weight • Undesirable effects: fluid and electrolyte imbalances • Review BP and electrolytes • Elderly. weakness o Polyuria o Third spacing Labs o Decreased BUN. cirrhosis. and specific gravity Nursing Interventions o Assess for presence or worsening of FVE o I&O o Daily weights o Na+ restricted and/or fluid-restricted diet as ordered o Teaching/learning regarding adherence to fluid restrictions o Short term goals and offer fluids every 1-2 hours o Oral hygiene o Avoid salty. sweet foods o Evaluate if goals met and interventions useful o Administering diuretics • • • FVE/Diuretics • Diet.

10 • Cancel alcohol and cigarettes *See diuretics handout General Nursing Interventions for F&E Imbalances • 24 hour I & O • Monitoring of VS • Monitor for Neurologic changes • Daily weights • Monitor rates/types of IVF’s • Provide supplementary water if receiving tube feedings • Irrigate NG tube with saline not water V.D5W. hypertonic and hypotonic fluids 4 Classifications of IV fluids • Crystalloids o IV Fluids.) to the heart (subclavian artery) • Has to be done by physician or specially trained nurse • Can have 1-2 ports. B. IV Therapy IV Catheter PICC Line • Line is entered peripherally (usually through the A. Hep-lock 5ml • Has to be flushed once per shift or before and after medication • Always use a 10ml syringe Central Line • Usually entered through jugular artery or subclavian • Has 3 ports. has to be flushed with 5 ml saline. • • • • • • • • Site selection and initiation Complications Fluid overload Air embolism Septicemia and other infections Infiltration and extravasation Phlebitis Thrombophlebitis Hematoma Clotting and obstruction C. lactated ringers • Colloids Rev 07/16/10 . hep-lock 2 ml • Always use a 10ml syringe (because of amount of pressure) A.C. needs to be flushed with 10ml saline. Isotonic.

25 NaClo D5 ½ NS • Hypertonic fluids. Blood transfusions Blood Transfusions (Pg.half-strength normal saline  Hypertonic dehydration. burns. fluid lost as bile or diarrhea.concentration greater than ICF o 3% NaCl  o 10% Dextrose (D10) o 50% Dextrose (D50) D.concentration of dissolved particles equal to ICF o D5W. 1107-1113) • Patient History o History of transfusions and reactions • Physical assessment o Respiratory o Cardiac o Integumentary • Patient teaching • Obtain consent • Equipment: IV (20 gauge or greater for PRBCs).45 NaCl.9% NaCl. and normal saline solution • Procedure to identify patient and blood product Transfusion Reaction Types • Febrile nonhemolytic reaction o Most common o Chills followed by fever Rev 07/16/10 .5% dextrose in water  Hypernatremia.concentration less than ICF o 0. Na and Cl depletion.contains potassium and calcium in addition to sodium chloride  Hypovolemia. metabolic alkalosis. fluid loss.11 o Volume expanders  Hetastarch (can decrease HCT and PLT)  Plasmanate (protein) Blood o Whole or PRBC (packed red blood cells) Lipids • • Types of Fluids • Isotonic fluid. and gastric fluid loss o 0. and acute blood loss replacement • Hypotonic fluids. appropriate tubing. hypercalcemia o Lactated Ringers. and dehydration o 0.normal saline  Hypovolemia.

tachycardia o =decrease serum osmolarity (blood concentration) o Fluid shift can cause cerebral edema (swelling of cells) and cause confusion • Nursing Interventions o Water restriction may be the only necessary treatment o If neuro changes. Hyponatremia Hyponatremia (sodium <135) • Stimuli/causes o Vomiting/diarrhea. VI. assessment. about dehydration B. acute renal failure. nausea. nausea.obtain blood and urine specimens.teach pt. death Allergic reaction o Urticaria. analysis/nursing diagnosis and evaluation/expected outcomes. Listen for breath sounds when giving hypertonic. diuretics o Adrenal insufficiency. small amounts of hypertonic solutions (if sodium is dangerously low <120). dyspnea. o Possibly Lasix administration o Thorough nursing assessment o PREVENTION.not life-threatening Acute hemolytic reaction o Most dangerous o Fever. Document according to facility protocol. burns. Hypernatremia Hypernatremia (> 145) Rev 07/16/10 . Utilize the RAM nursing process for electrolyte imbalances. DIC. itching. headache. NG tube suction. vomiting o With Na+ loss.12 • o Often begins 2 hours after transfusion starts. chills. chest tightness. fluid shift will occur and need to monitor for fluid overload. flushing • Nursing management of transfusion reactions • Immediately stop transfusion • Assess patient • Notify physician of assessment findings • Notify blood bank • Return blood container and tubing to the blood bank • If hemolytic transfusion reaction or bacterial infection. confusion. which includes risk factors. low back pain. anxiety. A. wound drainage o CHF o Administration of hypotonic IVF (too much) o Excessive water intake • Behaviors/effects o With water excess-rapid weight gain. apprehension. confusion.irritability.

slow weak pulse. vertigo. muscle weakness and cramping o Deep tendon reflexes Rev 07/16/10 .polyuria.flat T wave.thirst o Usually doesn’t happen in the alert person o Can occur with hypertonic IVF’s or near drowning in salt water o Diabetes insipidus and heat stroke Behaviors/effects o Intense thirst (may be impaired in elderly or ill) o Elevated temperature o Dry. polydipsia o Fatigue.dysrhythmias. hypotonic solution or D5W o Seizure precautions • • C.shallow respirations o Renal. U wave. constipation. increased risk of digoxin toxicity o EKG. N/V.low grade temp  T – thirst Treatment o Depends on cause o I&O o VS o Daily weight o Increase fluids – to help decrease the concentration.causes potassium to go back into cell • Behaviors/effects o Neurologic.13 • Stimuli/causes o May occur with water loss or sodium gain o Primary protection. confusion o Cardiovascular. & or ST depression o GI. lethargy. Hypokalemia Hypokalemia (<3. hypotension.anorexia.5) • Stimuli/causes o Vomiting and Diarrhea o Diuretics o Dialysis o Hyperaldosteronism o Poor dietary intake o Increased insulin.fatigue. sticky mucus membranes o Firm rubbery turgor o Restlessness and weakness (moderate) o Confusion and hallucinations (severe) o SALT  S – skin flushed  A – agitation (altered LOC)  L . ileus o Respiratory.

0) • 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 • Stimuli/causes o Massive intake of K+. usually treatment related o Decreased renal excretion o Renal failure o Hypoaldosteronism o Tissue trauma. dialysis.may taste bad. I & O. mix with juice for liquid form o Teach s/s hypokalemia and digoxin toxicity D. may help to slow infusion to decreases burning or put ice pack over IV site if patient complains o Increase dietary intake K+ o Oral supplements. hypotension o EKG.5ml/kg/hr  IV.has to be mix in with at least 100 ml/fluid  Cardiac monitoring  Never exceed 20mEq/hour through peripheral line.increased HR then decreased HR.muscle weakness. diarrhea o Neuromuscular. and fluid status • • Rev 07/16/10 .peaked T wave. wide QRS o GI.forces potassium out of cell o Hyperglycemia and uncontrolled DM o Meds such as K+ sparing diuretics and Ace inhibitors Behaviors/effects o Cardiac.14 • Nursing Interventions o Oral or IV administration of KCL  Don’t give if UOP <0. no more than 40mEq/hr through central line  Never give IV push or IM!!!  Best to give through PICC or central line. UOP. Hyperkalemia Hyperkalemia (>5. nausea. VS.anorexia. arrhythmias (V-tach or V-fib). or Kayexalate) o Increase fluid intake o Force K+ from ECF to ICF by giving insulin IV along with glucose or by giving IV NaHCO3(sodium bi-carbonate) o Calcium gluconate IV (emergent situation) o Monitor cardiac rhythm. cramps Interventions o Eliminate oral and parenteral K+ o Increase elimination of K+ (diuretics. potassium is irritating to veins.

fluids of 3 to 4 L/d. ECG changes. patient teaching related to diet and medications. hyperactive DTRs. • • Hypomagnesemia Serum level less than 1.5 mg/dL must be considered in conjunction with serum albumin level Causes: hypoparathyroidism. incoordination. ECG changes and dysrhythmias. administer fluids. burns. malabsorption. GI losses. and ensure safety G. thirst. renal failure. and anxiety Medical management: IV of calcium gluconate. and magnesium sulfate IV Rev 07/16/10 . medications. contributing causes include diabetic ketoacidosis. nausea and vomiting. oral magnesium.5 mg/dL Causes: malignancy and hyperparathyroidism. and nursing care related to IV calcium administration F. polyuria. abnormal clotting. and biphosphonates Nursing management: assessment as hypercalcemic crisis has high mortality. bone loss related to immobility Manifestations: muscle weakness.8 mg/dL. rapid administration of citrated blood. and alterations in mood and level of consciousness • Medical management: diet. calcitonin. sepsis. abdominal and bone pain. tremors. enteral or parenteral feeding deficient in magnesium. respiratory symptoms of dyspnea and laryngospasm. evaluate in conjunction with serum albumin Causes: alcoholism. circumoral numbness. seizures. Trousseau’s sign. phosphates. pancreatitis. alkalosis. encourage ambulation. and dysrhythmias Medical management: treat underlying cause. muscle weakness. constipation. massive transfusion of citrated blood. • • • • • Hypercalcemia Serum level above 10. diet Nursing management: assessment as severe hypocalcemia is life-threatening. furosemide. medications. calcium and vitamin D supplements. Chovstek's sign. athetoid movements. weight-bearing exercises to decrease bone calcium loss.15 • Potassium and Sodium supplements o Monitor for adverse side effects o Administer meds according to manufacturer’s guidelines  Dilute K+ in juice or water  Most patients receiving diuretics will need K+ supplement unless K+ sparing diuretic (Aldactone) o Know risks associated with IV K+ o Check for drug-drug interactions E. paresthesias. and hypothermia • Manifestations: neuromuscular irritability. provide fluids containing sodium unless contraindicated and fiber for constipation. other Manifestations: tetany. • • • • • Hypocalcemia Serum level less than 8. anorexia.

16 • • Nursing management: assessment. therefore. muscle weakness. hypoactive reflexes. analysis/nursing diagnosis and evaluation/expected outcomes.ph over 7. organic and inorganic phosphates o Hemoglobin Bicarbonate • Major chemical base buffer • Found in both ECF and ICF • Essential for acid-base balance • Alkalosis. ECG changes. 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. ensure safety. avoid administering medications containing magnesium. and excessive administration of magnesium Manifestations: flushing. which includes risk factors. lowered BP. • • • • • Hypermagnesemia Serum level more than 2.4 • Acidosis. nausea. medications. IV NS of RL. and dysrhythmias Medical management: IV calcium gluconate.7 mg/dL Causes: renal failure.35 to 7. patient teaching related to diet.45: hydrogen ion concentration • Major ECF buffer system.ph under Rev 07/16/10 . alcohol use. depressed respirations. diabetic ketoacidosis. bicarbonate-carbonic acid buffer system • Kidneys regulate bicarbonate in the ECF • Lungs under the control of the medulla regulate CO2 and . Maintaining acid-base balance • Normal plasma ph is 7. and provide patient teaching regarding magnesium-containing OTC medications VII. drowsiness. loop diuretics. assessment. hemodialysis Nursing management: assessment. carbonic acid in the ECF • Other buffer systems o ECF: inorganic phosphates and plasma proteins o ICF: proteins. Utilize the RAM nursing process for acid base imbalances. assess ability to swallow with water before administering food or medications H. vomiting.

decreased blood pressure. 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 B. Metabolic alkalosis Metabolic Alkalosis • High pH >7.opposite pH pH M. drowsiness.45 Rev 07/16/10 .4) to 7. decreased cardiac output. confusion.35 (7. Metabolic acidosis Metabolic Acidosis • Low ph <7. hyperkalemia may occur as potassium shifts out of the cell • As acidosis is corrected.respiratory O. if decrease is slow.45 • PaCO2 35 (40) to 45 mm Hg • HCO3ˉ 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 Acid Base (ROME) R. 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.equal pH pH HCO3 HCO3 alkalosis acidosis PCO2 PCO2 alkalosis acidosis A. shock. increased respiratory rate and depth.17 Arterial Blood Gases • pH 7.35 • Low bicarbonate <22 meq/l • Most commonly due to renal failure • Manifestations: headache.metabolic E. dysrhythmias.

respiratory depression. & McCuistion. Questions 1-20 Chapter 10 Acid-Base Balance p. L. Chapter 9 Fluid and Electrolytes p. 158. 15.45 • PaCO2 <35 mm Hg • Always due to hyperventilation • Manifestations: lightheadedness. Ch. Bare. 173. Pharmacology a nursing process approach (6th ed. K. numbness and tingling. (2008). Respiratory acidosis Respiratory Acidosis • Low pH <7. Questions 1-12 Rev 07/16/10 . J. and symptoms of hypokalemia Correct underlying disorder. tachycardia. inability to concentrate. may also be caused by medications. J. Respiratory alkalosis Respiratory Alkalosis • High pH >7.. feeling of fullness in the head • Potential increased intracranial pressure • Treatment is aimed at improving ventilation D. especially long-term diuretic use Hypokalemia will produce alkalosis Manifestations: symptoms related to decreased calcium. 107.. 14 & Ch. St. L. PA: W. the body may compensate and may be asymptomatic.). B. (2005). S.35 • PaCO2 >42 mm Hg (mostly higher than 45) • Always due to a respiratory problem with inadequate excretion of CO2 • With chronic respiratory acidosis. Hayes. Questions 1-15 Chapter 15 Administration of Blood products p. E. supply chloride to allow excretion of excess bicarbonate. 87. Silvestri. Questions 1-10 Chapter 14 Intravenous Therapy p. Philadelphia: Lippincott Williams & Wilkins. Hinkle. (2009). A. MO: Mosby. Philadelphia. Saunders Company.). Smeltzer. Louis. and restore fluid volume with sodium chloride solutions C.).B. mental changes.18 • • • • • High bicarbonate >26 mEq/L Most commonly due to vomiting or gastric suction.. Saunders comprehensive review for NCLEX-RN (4th ed. Ch. 1103-1113. Brunner and Suddarth’s textbook of medical – surgical nursing (11th ed. symptoms may include a suddenly increased pulse. and BP. and sometimes loss of consciousness • Correct cause of hyperventilation REQUIRED READINGS: Kee. 33 pp. & Cheever. respiratory rate..

Participate in administering blood. Unit 5 (Ch. Accurately calculate intake and output on an adult with compromised or ineffective responses to fluid and electrolyte balance.1. 73 & 74). 5. Assessment Technologies Institute. 233-240) & Unit 4. Identify signs and symptoms of fluid and/or electrolyte imbalance. Adult medical-surgical nursing RN edition 7.19 Wissmann. Assessment Technologies Institute. J. J. CLINICAL OBJECTIVES: 1. develop a plan of care for the adult with fluid/electrolyte imbalance and acid base imbalance. Wissman. Unit 3 (pp. 6. 3. Current mastery series review module. Current mastery series review module. (2000-2007). Correctly calculate IV flow rate. (2000-2007). Develop teaching/learning strategies for the adult with fluid and/or electrolyte imbalance to promote adaptation. Using the Roy Adaptation Model nursing process. Assess hydration status. 2. 4. 7.1. Fundamentals of nursing edition 6. Rev 07/16/10 .

20 Rev 07/16/10 .

and hydration • Home care Patient report weight change of more than 3lb/day • Photosensitivity – wear sunscreen. edema. daily weight. IM. nocturia o Diuril (esp. AM to decrease • Generally salt (Na+ and weakness sleep disturbance. K+) • Photosensitivity o Chlorthalidone • Add K+ rich foods • Muscle weakness o Quinethazone or supplement or cramps • Monitor I & O.21 Diuretics Used for treatment of hypertension (HTN). • Administer early reabsorption of to sulfonamides vertigo. or IV 20mg/min) • Blood dyscrasias tubules and the mg • Used often • Check • Ototoxic (can loop of Henle Bumetanide (Bumex) with thiazides compatibility with cause irreversible fail or patient Ethacrynic acid (Edecrin) other meds and hearing loss – needs rapid IVF Torsemide (Demadex) especially when • • • • • • Rev 07/16/10 . sunglasses.• Same as thiazides • Same as • Same as thiazides reabsorption of acting thiazides • IV administration salt in the diuretic • Glycosuria o Slow IV proximal and Furosemide (Lasix) • Can be given push (10 – • Thrombophlebitis distal renal o Usual dose 20 – 80 PO. renal dysfunction Diuretic class Mechanism of General Contraindications Side effects/adverse Nursing action information effects considerations Thiazide diuretics Inhibit • Orally • Allergy and allergy • Dizziness. milk to decrease • Effective for • Diabetes thereby o Esidrix anorexia GI disturbance long-term use • Renal disease increasing o HydroDIURIL • Dry mouth • Stand slowly – • Can be • Liver disease excretion of salt safety precautions primary • Pregnancy/lactatio • Orthostatic and water treatment for hypotension • Monitor n Chlorothiazide HTN electrolyte levels • Polyuria. • Give with food or • Gout renal tubule Hydrochlorothiazide vomiting. and protective clothing • Increased risk of dig toxicity with hypokalemia Loop Diuretics Inhibits • Potent. rapid. mild side • F/E imbalance Cl-) in the distal effects • Nausea. congestive heart failure (CHF).

Rev 07/16/10 .. causing loss of Na+ and H2O and retention of K+ • Used especially if hypokalemia is a problem Also used to treat patient with high aldosterone levels • • • • • Allergy hyperK+ renal disease lactation use cautiously with ACE inhibitors • • • dizziness. J.22 diuresis • given rapid IV push) Rash • • • Potassium-Sparing Diuretics Blocks the effects of aldosterone in the renal tubule. L.. Philadelphia: Lippincott Williams & Wilkins. drowsiness. S. H. cramping rash • • • • Dizziness Nausea.). Brunner & Suddarth’s Textbook of medical-surgical nursing. Cheever. G. administer after meals Given IV only Do not refrigerate – causes crystallization Use IV filter with tubing Foley catheter (F/C) may be inserted to manage and monitor diuresis Monitor patient’s hydration status. anorexia Dry mouth. C. • • • Spironolactone (Aldactone) Triamterene (Dyrenium) Osmotic Diuretics • Mannitol (Osmitrol) Hinders reabsorption of water in the kidneys leading to loss of water and sodium chloride) • • • • • renal disease intracranial bleeding dehydration CHF • • • • • • Smeltzer. K. (11th ed. B. Hinkle. (2008). headache diarrhea.. Bare. thirst Diuresis Dizziness • • • • Protect from light Use within 24 hours after dilution Assess patient frequently for s/s of F/E imbalance similar to thiazides avoid high K+ foods avoid salt substitutes for GI problems.

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