NCMA113 Fundamentals of Nursing Lecture
BSN 1-YC-10 FINALS
Coverage for Lecture:
I. Urinary Elimination
II. Fecal Elimination
III. Oxygenation
IV. Fluid, Electrolyte and Acid Base Balance
Urinary Elimination
Physiology of Urinary Elimination
Kidneys
Situated on either side of the spinal column,
behind the perineal cavity
Right kidney: slight lower than the left due to
the position of the liver
Primary regulators of fluid and acid-base
balance in the body
Nephrons: functional units of the kidneys
which filter the blood and remove metabolic
wastes
In the average adult, 1200 mL of blood, or
about 21% of the cardiac output, passes
through the kidneys every minute
Each kidney contains approximately 1 million
nephrons
Urethra
Ureters
25 to 30 cm (10 to 12 inches) long about 1.25
in diameter in adults
Upper end of each ureter is funnel shapes as it
enters the kidney. Lower ends enter the bladder
at the posterior corners of the floors of the
bladder
At the junction, a flaplike fold mucous
membrane acts as a valve to prevent reflux
(backflow) to urine up the ureters
Pelvic Floor
Bladder
Hollow, muscular organ that serves as a
reservoir for urine and as the organ of excretion
In men, it lies in front of the rectum and above
the prostate gland
In women, it lies in front of the uterus and
vagina
Detrusor muscle: smooth muscle layers which
allows the bladder to expand as it fills with
urine, and to contract to release urine to the
outside of the body during voiding
Trigone: triangular area marked by the ureter
openings at the posterior corners and the
opening of the urethra at the anterior inferior
corner
Normal bladder capacity: 300 to 600mL of
urine
Extends from the bladder to the urinary meatus
(opening)
Male urethra: approximately 8 inches long
and serves as a passageway for semes as well
as urine
Female urethra: lies directly behind the
symphysis pubis, anterior to the vagina and is
1.5 inches long
Meatus: located at the distal end of the penis in
male and serves as passageway of semen and
urine in men; serves only as a passageway for
the elimination of urine in women
Women are prone to UTIs because of their
short urethra and the proximity of the urinary
vagina and anus
Consists of sheets of muscles and ligaments that
provide support to the viscera of the pelvis
Internal sphincter and Bladder neck: situated in
the proximal urethra composed of smooth muscle
under involuntary control; provides active tension
designed to close the urethral lumen
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 NCMA113 Fundamentals of Nursing Lecture
BSN 1-YC-10 FINALS
External sphincter muscle: composed of skeletal
muscle under voluntary control, allowing the
individual to choose when urine is eliminated
Urination
Micronutrition, voiding, and urination- all refer to
process of emptying the urinary bladder
Stretch receptors
special sensory nerve endings in the bladder wall
stimulated when urine is collected in the bladder.
This occurs when the adult bladder contains
between 250 and 450 mL of urine. In children, a
considerably smaller volume, 50 to 200 mL,
stimulates these nerves.
transmit impulses to the spinal cord, specifically to
the voiding reflex center located at the level of the
second to fourth sacral vertebrae, causing the
internal sphincter to relax and stimulating the urge
to void
If the time and place are appropriate for urination,
the conscious portion of the brain relaxes the
external urethral sphincter muscle and urination
takes place.
If the time and place are inappropriate, the
micturition reflex usually subsides until the bladder
becomes more filled and the reflex is stimulated
again.
The individual must be able to sense that the
bladder is full. Injury to any of these parts of the
nervous system—results in intermittent involuntary
emptying of the bladder.
Factors Affection Voiding
Developmental Factors
Fetuses The fetal kidney begins to excrete
urine between the 11th and 12th
week of development.
Infants
Ability to concentrate urine is
minimal because of immature
kidneys; therefore, urine is colorless
and odorless and has a specific
gravity of 1.008.
Because of neuromuscular
immaturity, voluntary urinary
control is absent and an infant may
urinate as often as 20 times a day
Children Most renal growth occurs during the
first 5 years of life.
The kidneys’ efficiency (i.e.,
regulation of electrolyte and acid–
base balance) greatly increases after
age 2.
At approximately 2 1/2 to 3 years of
age, the child can perceive bladder
fullness, hold urine after the urge to
void, and communicate the need to
urinate.
Full urinary control usually occurs
at age 4 or 5 years; daytime control
is usually achieved by age 3 years.
Adults The kidneys reach maximum size
between 35 and 40 years of age.
After 50 years, the kidneys begin to
diminish in size and function. Most
shrinkage occurs in the cortex of the
kidney as individual nephrons are
lost
Older An estimated 30% of nephrons are
Adults lost by age 80.
Renal blood flow decreases because
of vascular changes and a decrease
in cardiac output.
The ability to concentrate urine
declines.
Bladder muscle tone diminishes,
causing increased frequency of
urination and nocturia (awakening to
urinate at night).
Diminished bladder muscle tone and
contractibility may lead to residual
urine in the bladder after voiding,
increasing the risk of bacterial
growth and infection.
Urinary incontinence may occur due
to mobility problems or neurologic
impairments.
Psychosocial Factors
Conditions such as privacy, normal position,
sufficient time, and, occasionally, running
water help stimulate the micronutrition reflex
Circumstances that do not allow for the client’s
accustomed conditions may produce anxiety
and muscle tension. As a result, the client is
unable to relax abdominal and perineal muscles
and the external urethral sphincter
Clients may voluntarily suppress urination
because of perceived time pressure
Fluid and Food Intake
When the amount of fluid intake increases,
therefore, the output normally increases.
Certain fluids, such as alcohol, increase fluid
output by inhibiting the production of
antidiuretic hormone.
Fluids that contain caffeine also increase urine
production
Food and fluids high in sodium can cause fluid
retention because water is retained to maintain
the normal concentration of electrolytes.
Medications
Diuretics- increase urine formation by
preventing the reabsorption of water and
electrolytes from the tubules of the kidney into
the bloodstream
Some medications may alter the color of the
urine
Muscle Tone
Good muscle tone is important to maintain the
stretch and contractility of the detrusor muscle
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 NCMA113 Fundamentals of Nursing Lecture
BSN 1-YC-10 FINALS
so the bladder can fill adequately and empty
completely
Clients who require a retention catheter for a
long period may have poor bladder muscle tone
because continuous drainage of urine prevents
the bladder from filling and emptying normally
Pathologic Conditions
- Some diseases and pathologies can affect the
formation and excretion of urine
- Diseases of the kidneys may affect the ability
of the nephrons to produce urine
- Renal failure: kidneys virtually stop producing
urine altogether
- Heart and circulatory disorders such as heart
failure, shock, or hypertension can affect blood
flow to the kidneys, interfering with urine
production.
- Urinary stone: (calculus) may obstruct a
ureter, blocking urine flow from the kidney to
the bladder
- Hyperplasia: (enlargement) of the prostate
gland, a common condition affecting older
men, may obstruct the urethra, impairing
urination and bladder emptying
Surgical and Diagnostic Procedures
- Urethra may swell following a cystoscopy, and
surgical procedures on any part of the urinary
tract may result in some postoperative
bleeding; as a result, the urine may be red or
pink tinged for a time
- Spinal anesthetics can affect the passage of
urine because they decrease the client’s
awareness of the need to void. Surgery on
structures adjacent to the urinary tract (e.g., the
uterus) can also affect voiding because of
swelling in the lower abdomen
Altered Urine Production
Polyuria (diuresis)
- Production of abnormally large amounts of
urine by the kidneys, often several liters more
than the client’s usual output
- Can follow excessive fluid intake, a condition
known as polydipsia
- May be associated with diseases such as
diabetes mellitus, diabetes insipidus, and
chronic nephritis
- Can cause excessive fluid loss, leading to
intense thirst, dehydration, and weight loss
Oliguria and Anuria
- Oliguria: low urine output, usually less than
500 mL a day or 30 mL an hour for an adult
- Often indicates impaired blood flow to the
kidneys or impending renal failure and should
be promptly reported to the primary care
provider
- Anuria: refers to a lack of urine production
Altered Urinary Elimination
Frequency and Nocturia
- Urinary Frequency: Voiding at frequent
intervals, that, is, more than 4 to 6 times per
day which can be caused by conditions such as
UTI, stress, and pregnancy; total fluid intake
and output may be normal
- Nocturia: voiding 2 or more times at night
Urgency
- Sudden, strong desire to void
- Individual feels a need to void immediately
- Accompanies psychologic stress and irritation
of the trigone and urethra
- Common in individuals who have poor external
sphincter control and unstable bladder
contractions
- not a normal finding
Dysuria
- voiding that is either painful or difficult
- can accompany a stricture (decrease in
diameter) of the urethra, urinary infections, and
injury to the bladder and urethra.
- Often clients will say they have to push to void
or that burning accompanies or follows
voiding.
- Urinary hesitancy: a delay and difficulty in
initiating voiding usually associated with
dysuria.
Enuresis
- Involuntary urination in children beyond the
age when voluntary bladder control is normally
acquired, usually 4 or 5 years of age.
- Nocturnal enuresis often is irregular in
occurrence & affects boys more often than
girls.
- Diurnal (daytime) enuresis: may be persistent
and pathologic in origin which affects women
and girls more frequently.
Urinary Incontinence
- Any involuntary urine leakage
- Can lead to depression, feelings of shame and
embarrassment, and isolation, and can prevent
individual from traveling far from home
- Older adults are the highest risk
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 NCMA113 Fundamentals of Nursing Lecture
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- Stress urinary incontinence (SUI): he most - it is important for the nurse to assess the skin
common type of UI, occurs because of weak for color, texture, and tissue turgor as well as
pelvic floor muscles or urethral hypermobility, the presence of edema.
causing urine leakage with such activities as - If incontinence, dribbling, or dysuria is noted
laughing, coughing, sneezing, or any body in the history, the skin of the perineum
movement that puts pressure on the bladder. should be inspected for irritation because
- Urgency urinary incontinence (UUI): is also contact with urine can excoriate the skin.
called overactive bladder, is described as an
urgent need to void and the inability to stop Diagnostic tests
urine leakage
- Blood levels of two metabolically produced
- Mixed urinary incontinence: when symptoms
of both SUI and UUI are present substances, urea and creatinine, are routinely
- Overflow Urinary Incontinence: when the used to evaluate renal function
bladder overfills and urine leaks out due to - Urea: the end product of protein
pressure on the urinary sphincter metabolism, is measured as blood urea
- Neurogenic Bladder: impaired neurologic nitrogen (BUN)
function which interfere with the normal - Creatinine: produced in relatively constant
mechanisms of urine elimination quantities by the muscles
- Transient urinary incontinence: results from - Creatinine clearance test uses 24-hour
factors outside of the urinary tract urine and serum creatinine levels to
- Functional urinary incontinence (FUI): is a determine the glomerular filtration rate, a
subcategory of transient urinary incontinence, sensitive indicator of renal function
connected with a cognitive or physical
impairment, for example, unavailable toileting Diagnosing
facilities or the inability to reach a toilet due to
physical limitations
Urinary Retention
- Occurs when emptying of the bladder is
impaired then urine accumulates and the
bladder becomes overdistended
- experience overflow incontinence, eliminating
25-50 mL of urine at frequent intervals
- The bladder is firm and distended on palpation
and may be displaced to one side of the
midline.

Problems of urinary elimination also may become

the etiology for other problems experienced by the
client. Examples include the following:
- Risk for Infection
- Situational Low Self-Esteem or Social
Isolation
- Risk for Impaired Skin Integrity
Nursing Management - Toileting Self-Care Deficit
Assessing - Risk for Deficient Fluid Volume or Excess
Nursing History - Fluid Volume
- nurse determines the client’s normal voiding - Disturbed Body Image
pattern and frequency, appearance of the - Deficient Knowledge
urine and any recent changes, any past or - Risk for Caregiver Role Strain
current problems with urination, the - Risk for Social
presence of an ostomy, and fac- tors
influencing the elimination pattern.
Physical Assessment
- physical assessment of the urinary tract
usually includes percussion of the kidneys to
detect areas of tenderness. Palpation and
percussion of the bladder are also performed

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NCMA113 Fundamentals of Nursing Lecture
BSN 1-YC-10 FINALS

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 NCMA113 Fundamentals of Nursing Lecture
BSN 1-YC-10 FINALS
Nursing Management
Assessing
Physical Assessment significantly with FVD and hypovolemia or
increase with FVE.
- focuses on the skin, the oral cavity and mucous
- Measurement and recording of all fluid intake and
membranes, the eyes, the cardio- vascular and
output (I&O) during a 24-hour period provides
respiratory systems, and neurologic and muscular
important data about a client’s fluid and electrolyte
status.
balance. Generally, I&O are measured for
hospitalized clients, particularly those at increased
risk for fluid and electrolyte imbalance

To measure fluid intake, each item of fluid consumed

or administered is recorded, specifying the time and
type of fluid. All of the following fluids need to be
recorded:
- Oral fluids: Water, milk, juice, soft drinks, coffee,
tea, cream, soup, and any other beverages. Include
water taken with medications. To measure the
amount of water consumed from a water pitcher,
measure how much water remains in the pitcher
Clinical Measurements and subtract this amount from the volume of the
full pitcher.
- Daily Weights: provide a relatively accurate
assessment of a client’s fluid status. Significant - Ice chips: Record the fluid volume as
approximately one-half the volume of the ice
changes in weight over a short time, for example,
chips. For example, if the ice chips fill a cup
more than 2.3 kg (5 lb) in a week or more than 1
holding 200 mL and the client consumed all of the
kg (2.2 lb) in 24 hours, are indicative of acute fluid
ice chips, the volume consumed would be
changes.
recorded as 100 mL.
- Changes in vital signs may indicate, or in some
cases precede, fluid, electrolyte, and acid–base - Foods that are or become liquid at room
temperature: These include ice cream, sherbet,
imbalances. For example, elevated body
custard, and gelatin. Do not measure foods that are
temperature may be a result of dehydration or a
pureed, because purees are simply solid foods
cause of increased body fluid losses.
prepared in a different form.
- Tachycardia is an early sign of hypovolemia.
- Tube feedings: Remember to include the volume
- Pulse volume will decrease in FVD and increase in
of water used for flushes before and after
FVE.
medication administration, intermittent feedings,
- Irregular pulse rhythms may occur with electrolyte
residual checks, or any other water given via a
imbalances.
feeding tube.
- Changes in respiratory rate and depth may cause - Parenteral fluids: The exact amount of IV fluid
respiratory acid–base imbalances or indicate a administered must be recorded, since some fluid
compensatory mechanism in metabolic acidosis or containers may be overfilled. Blood transfusions
alkalosis.
are included in the total.
- Blood pressure (BP), a sensitive measure for
- IV medications: IV medications that are
detecting blood volume changes, may fall
administered as an intermittent or continuous

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 NCMA113 Fundamentals of Nursing Lecture
BSN 1-YC-10 FINALS
infusion must also be included (e.g., ceftazidime 1
g in 50 mL of sterile water). Most IV medications
are mixed in 50 to 100 mL of solution.
- Catheter or tube irrigants: Fluid used to irrigate
urinary catheters, nasogastric tubes, and intestinal
tubes must be recorded if not immediately
withdrawn as part of the irrigation.
To measure fluid output, measure the following flu-
ids (remember to observe appropriate infection
control precautions):
- Urinary output: Following each voiding, pour the
urine into a measuring container, note the amount,
and record the amount and time on the I&O form.
For clients with retention catheters, empty the
drainage bag into a measuring container at the end
of the shift (or at prescribed times if output is to be
measured more often). Note and record the amount
of urine output. In intensive care areas, urine
output often is measured hourly. If a client is
incontinent of urine, estimate and record these
outputs. For example, for an incontinent client the
nurse might record ;Incontinent * 3< or
“Drawsheet soaked in 12-in. diameter.” A more
accurate estimate of the urine output of infants and
incontinent clients may be obtained by first
weighing diapers or incontinence pads that are dry,
and then subtracting this weight from the weight of
the soiled items. Each gram of weight left after
subtracting is equal to 1 mL of urine. If urine is
frequently soiled with feces, the number of
voidings may be recorded rather than the volume
of urine.
- Vomitus and liquid feces: The amount and type of
fluid and the time need to be specified.
- Tube drainage: This includes gastric or intestinal
drainage.
- Wound and fistula drainage: Drainage may be
recorded by documenting the type and number of
dressings or linen saturated with drainage, or by
measuring the exact amount of drainage collected
in a vacuum drain- age (e.g., Hemovac) or gravity
drainage system.
Laboratory Tests
1. Serum Electrolytes- often ordered for clients
admitted to the hospital as a screening test for
electrolyte and acid–base imbalance; are for
sodium, potassium, chloride, magnesium, and
bicarbonate ions
2. Complete Blood count- another basic screening
test, includes information about hematocrit (Hct),
which measures the percentage of the volume of
whole blood that is composed of RBCs.
3. Hematocrit is a measure of the volume of cells in
relation to plasma and is, there- fore, affected by
changes in plasma volume; hematocrit increases
with dehydration and decreases with
overhydration.
4. Serum Osmolality- measure of the solute
concentration of blood. The particles included are
sodium ions, glucose, and urea (blood urea
nitrogen, or BUN). An increase in serum
osmolality indicates a fluid volume deficit; a
decrease reflects a fluid volume excess.
5. Specific Gravity- an indicator of urine
concentration that correlates with urine
osmolality, and it can be measured quickly and
easily by nursing personnel.
6. Urine pH- may be obtained by laboratory analysis
or by using a dipstick on a freshly voided
specimen. Because the kidneys play a critical role
in regulating acid– base balance, assessment of
urine pH can be useful in deter- mining whether
the kidneys are responding appropriately to acid–
base imbalances
7. Arterial blood gases (ABGs) are performed to
evaluate a client’s acid–base balance and
oxygenation. Arterial blood is used because it
provides a more accurate reflection of gas
exchange in the pulmonary system than venous
blood.
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 NCMA113 Fundamentals of Nursing Lecture
BSN 1-YC-10 FINALS
- Maintain or restore normal balance of electrolytes
in the intracellular and extracellular compartments.
- Maintain or restore gas exchange and oxygenation.
- Prevent associated risks (e.g., tissue breakdown,
decreased cardiac output, confusion, other
neurologic signs)
Examples of NIC interventions related to fluid,
electrolyte, and acid–base balance include the
following:
- Acid–base management
- Electrolyte management
- Fluid monitoring
- Hypovolemia management
- Intravenous (IV) therapy.
Nursing activities to meet goals and outcomes related
to fluid, electrolyte, and acid–base imbalances are dis-
cussed in the next section. These include:
- monitoring fluid intake and output, cardiovascular
and respiratory status, and results of laboratory
tests
- assessing the client’s weight, location and extent
of edema if present, skin turgor and skin status,
specific gravity of urine, and level of
consciousness and mental status;
- fluid intake modifications
- dietary changes
- parenteral fluid, electrolyte, & blood replacement
- other appropriate measures such as administering
prescribed medications
Promoting Fluid and Electrolyte Balance
- Consume six to eight glasses of water daily.
- Avoid excess amounts of foods or fluids high in
salt, sugar, and caffeine.
- Eat a well-balanced diet.
- Limit alcohol intake
- Increase fluid intake before, during, and after
strenuous exercise, particularly when the
environmental tempxerature is high, and replace
lost electrolytes from excessive perspiration as
needed with commercial electrolyte solutions.
Diagnosing - Maintain normal body weight and body mass
- decreased fluid volume, increased fluid volume, index for age and gender. Learn about and monitor
and altered gas exchange. side effects of medications that affect fluid and
- Fluid, electrolyte, and acid–base imbalances affect electrolyte balance (e.g., diuretics) and ways to
many other body areas & as a consequence may be handle side effects.
the etiology of other nursing diagnoses, such as - Recognize possible risk factors for fluid and
dry mucous membranes related to fluid volume electrolyte imbalance
deficit; skin breakdown related to dehydration or - Seek prompt professional healthcare for notable
edema; inadequate cardiac output related to signs of fluid imbalance
hypovolemia or cardiac dysrhythmias secondary to
Implementing
electrolyte imbalance; risk for injury related to
hypovolemia; confusion related to electrolyte - Promoting wellness, Enteral fluid and electrolyte
imbalance. replacement, Fluid intake medications, Dietary
changes, Oral Electrolyte Supplements, Parenteral
Planning Fluid and Electrolyte Replacement, Intravenous
When planning care a nurse identifies nursing solutions
interventions that will assist the client to achieve these
broad goals:
- Maintain or restore normal fluid balance.

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 NCMA113 Fundamentals of Nursing Lecture
BSN 1-YC-10 FINALS
FECAL ELIMINATION
Physiology of defacation
Large intestine
- extends from the ileocecal (ileocolic) valve, which
lies between the small and large intestines, to the
anus.
- It has seven parts: the cecum; ascending,
transverse, and descending colons; sigmoid colon;
rectum; and anus
- main functions are the absorption of water and
nutrients, the mucoid protection of the intestinal
wall, and fecal elimination
- As much as 1500 mL of chyme passes into the
large intestine daily, and all but about 100 mL is
reabsorbed in the proximal half of the colon. The
100 mL of fluid is excreted in the feces
- serves a protective function in that it secretes
mucus
- Mucus: protect the wall of the large intestine from
trauma by the acids formed in the feces, and it
serves as an adherent for holding the fecal material
together
- Flatus: largely air and the by-products of the
digestion of carbohydrates
- Peristalsis: wavelike movement produced by the
circular and longitudinal muscle fibers of the
intestinal walls; it propels the intestinal contents
forward
Rectum and Anal Canal
- rectum in the adult is usually 10 to 15 cm (4 to 6
in.) long; the most distal portion, 2.5 to 5 cm (1 to
2 in.) long, is the anal canal
- Rectum: has folds that extend vertically wherein
each of the vertical folds contains a vein and an
artery; folds help retain feces within the rectum.
- Hemorrhoids where the veins become distended,
as can occur with repeated pressure
- Anal canal: bounded by an internal (involuntary)
and external sphincter muscle (voluntary)
- Internal sphincter muscle: innervated by the
autonomic nervous system
- External sphincter: innervated by the somatic
nervous system.
Defecation
- expulsion of feces from the anus and rectum
- also called a bowel movement
- frequency of defecation is highly individual
varying from several times per day to two or three
times per week
- amount defecated also varies among individuals.
- when peristaltic waves move the feces into the
sigmoid colon and the rectum, the sensory nerves
in the rectum are stimulated and the individual
becomes aware of the need to defecate.
- Normal defecation is facilitated by (a) thigh
flexion, which increases the pressure within the
abdomen, and (b) a sitting position, which
increases the downward pressure on the rectum.
- If the defecation reflex is ignored, or if defecation
is consciously inhibited by contracting the external
sphincter muscle, the urge to defecate normally
disappears for a few hours before occurring again
- Repeated inhibition of the urge to defecate can
result in expansion of the rectum to accommodate
accumulated feces and eventual loss of sensitivity
to the need to defecate.
Feces
- 75% water and 25% solid materials. They are soft
but formed.
- Normal feces require a normal fluid intake; feces
that contain less water may be hard and difficult to
expel.
- Feces are normally brown, chiefly due to the
presence of stercobilin and urobilin, which are
derived from bilirubin (a red pigment in bile)
- Escherichia coli or staphylococci: normally
present in the large intestine that affects fecal color
Factors that Affect Defacation
Development
Stage Variations
Newborns Meconium is the first fecal material
& Infants passed by the newborn, normally up
to 24 hours after birth.
Transitional stool: which follow for
about a week, generally greenish
yellow; contain mucus & are loose.
Infants pass stool frequently
Stool becomes less frequent and
firmer after solid foods are started.
Breastfed infants have light yellow to
golden feces.
Infants who take formula have dark
yellow or tan, more formed stool.
Toddlers Some control of defecation starts at
11⁄2 to 2 years of age. Daytime control
is typically achieved by age 21⁄2, after
toilet training.
Children Patterns of defecation vary in
& frequency, quantity, and consistency.
adolescents Delay defecation because of an
activity such as play.
Older Suffer from constipation because of
Adults reduced activity levels, inadequate
fluid and fiber intake, and muscle
weakness.
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Diet
- Fiber is classified into two categories: insoluble
fiber and soluble fiber.
- Insoluble fiber: promotes the movement of
material & increases stool bulk.
- Soluble fiber: dissolves in water to form a gel-like
material; can help lower blood cholesterol and
glucose levels
- Irregular eating can impair regular defecation
- Individuals who eat at the same times every day
usually have a regularly timed, physiologic
response to the food intake and a regular pattern of
peristaltic activity in the colon
- Spicy foods can produce diarrhea and flatus in
some individuals
- Gas-producing foods: cabbage, onions, cauli-
flower, bananas, and apples
- Laxative-producing foods: bran, prunes, figs,
chocolate, and alcohol
- Constipation-producing foods: such as cheese,
pasta, eggs, and lean meat
Fluid Intake and Output
- reduced fluid intake slows the chyme’s passage
along the intestines, further increasing the
reabsorption of fluid from the chyme
- Healthy fecal elimination requires a daily fluid
intake of 2000 to 3000 mL
- If chyme moves abnormally quickly through the
large intestine; as a result, the feces are soft or
even watery
Activity
- stimulates peristalsis, thus facilitating the
movement of chyme along the colon
- Weak abdominal and pelvic muscles are often
ineffective in increasing the intraabdominal
pressure during defecation or in controlling
defecation
Psychological Factors
- anxious or angry experience increased peristaltic
activity and subsequent nausea or diarrhea
- depressed may experience slowed intestinal
motility, resulting in constipation
- how someone responds to these emotional states is
the result of individual differences in the response
of the enteric nervous system to vagal stimulation
from the brain.
Defecation Habits
- gastrocolic reflex: increased peristalsis of the
colon after food has entered the stomach
- when normal defecation reflexes are habitually
ignored, the urge to defecate is ultimately lost
Medications
- Laxatives: medications that stimulate bowel
activity and so assist fecal elimination
- Can affect the appearance of the feces
Anesthesia and Surgery
- general anesthetics: cause the normal colonic
movements to cease or slow
- clients who have regional or spinal anesthesia are
less likely to experience this problem.
- surgery that involves direct handling of the
intestines can cause temporary stoppage of
intestinal movement
Pathologic Conditions
- Spinal cord injuries and head injuries can decrease
the sensory stimulation for defecation
- impaired mobility may limit the client’s ability to
respond to the urge to defecate and the client may
experience constipation
Pain
- Clients who experience discomfort when
defecating often suppress the urge to defecate to
avoid the pain
- Clients taking opioid analgesics for pain may also
experience constipation as a side effect
Fecal Problems
Constipation
- fewer than three bowel movements per week
- infers the passage of dry, hard stool or no stool
- occurs when the movement of feces through the
large intestine is slow, thus allowing time for
additional reabsorption of fluid from the large
intestine
- Careful assessment of the client’s habits is
necessary
- Many causes and factors contribute to
constipation. Among them are the following:
o Insufficient fiber intake
o Insufficient fluid intake
o Insufficient activity or immobility
o Irregular defecation habits
o Change in daily routine
o Lack of privacy
o Chronic use of laxatives or enema
o Irritable bowel syndrome (IBS)
o Pelvic floor dysfunction or muscle damage
o Poor motility or slow transit
o Neurologic conditions, stroke, or paralysis
o Emotional disturbances such as depression
or mental confusion
o Medications such as opioids, iron
supplements, antihistamines, antacids, and
antidepressants
o Habitual denial and ignoring the urge to
defecate.
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swallowed air, and (3) gas that diffuses between
the bloodstream and the intestine.
Nursing Management
Assessing
Nursing History
- nurse obtains a description of usual feces and any
recent changes and collects information about any
past or current problems with elimination, the
presence of an ostomy, and factors influencing the
elimination pattern
Fecal Impaction
- mass or collection of hardened feces in the folds of Physical Examination
the rectum - inspection, auscultation, percussion, and palpation
- results from prolonged retention and accumulation with specific reference to the intestinal tract
of fecal material has a fecal impaction will - Auscultation precedes palpation because palpation
experience the passage of liquid fecal seepage can alter peristalsis
(diarrhea) and no normal stool. - Examination of the rectum and anus includes
- causes are usually poor defecation habits and inspection and palpation
constipation
Inspecting the Feces
Diarrhea
- passage of liquid feces and an increased frequency - Observe the client’s stool for color, consistency,
of defecation shape, amount, odor, and the presence of abnormal
- opposite of constipation and results from rapid constituents
movement of fecal contents through the large Diagnostic Studies
intestine.
- Some individuals pass stool with increased - include direct visualization techniques, indirect
frequency, but diarrhea is not present unless the visualization techniques, and laboratory tests for
stool is relatively unformed and excessively liquid abnormal constituents
-
Cause Physiologic Effect
Psychologic Increased intestinal motility and Diagnosing
stress mucous secretion - fecal eliminal problems can include bowel
Medications Inflammation and infection of incontinence, constipation, and diarrhea
mucosa due to overgrowth of - potential for decreased fluid volume or potential
pathogenic intestinal for altered electrolytes related to prolonged
microorganisms diarrhea, potential for developing altered skin
Antibiotics Irritation of intestinal mucosa integrity related to prolonged diarrhea or bowel
incontinence, impaired self- esteem related to fecal
Iron Irritation of intestinal mucosa
incontinence, lack of knowledge related to lack of
Cathartics Incomplete digestion of fluid/ food
previous experience.
Allergy to Increased intestinal motility and
fluid/food mucous secretion Planning
Intolerance Reduced absorption of fluid The major goals for clients with fecal elimination
to food/fluid problems are to:
Disease of Inflammation of the mucosa often a. Maintain or restore normal bowel elimination
the colon leading to ulcer formation pattern.
b. Maintain or regain normal stool consistency.
Bowel Incontinence c. Prevent associated risks such as fluid and
- also called fecal incontinence electrolyte imbalance, skin breakdown,
- refers to the loss of voluntary ability to control abdominal distention, and pain.
fecal and gaseous discharges through the anal Implementing
sphincter Promoting Regular Defecation
- generally associated with impaired functioning of
the anal sphincter or its nerve supply, such as in - (a) the provision of privacy, (b) timing, (c)
some neuromuscular diseases, spinal cord trauma, nutrition and fluids, (d) exercise, and (e)
and tumors of the external anal sphincter muscle positioning

Flatulence
- presence of excessive flatus in the intestines and
leads to stretching and inflation of the intestines
(intestinal distention).
- three primary sources of flatus are (1) action of
bacteria on the chyme in the large intestine, (2)
Privacy
- nurse should therefore provide as much privacy as
possible for such clients but may need to stay with
those who are too weak to be left alone
Timing

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- client should be encouraged to defecate when the Antiflatulent Medications
urge is recognized. To establish regular bowel
- coalesce the gas bubbles and facilitate their
elimination, the client and nurse can discuss when
passage by belching through the mouth or
peristalsis normally occurs and provide time for
expulsion through the anus
defecation
- Carminatives: herbal oils known to act as agents
Nutrition and Fluids that help expel gas from the stomach and intestines
- diet a client needs for regular normal elimination - Suppositories: given to relieve flatus by
increasing intestinal motility
varies, depending on the kind of feces the client
currently has, the frequency of defecation, and the
types of foods that the client finds assist with
normal defecation
For Constipation
- Increase daily fluid intake, and instruct the client
to drink hot liquids, warm water with a squirt of
fresh lemon, and fruit juices, especially prune
juice. Include fiber in the diet,
For Diarrhea
- Encourage oral intake of fluids and bland food.
Eating small amounts can be helpful because small
amounts are more easily absorbed. Excessively hot
or cold fluids should be avoided because they
stimulate peristalsis.
For Flatulence
- Limit carbonated beverages, the use of drinking
straws, and chewing gum—all of which increase Decreasing Flatulence
the ingestion of air. Gas-forming foods, such as
cabbage, beans, onions, and cauliflower, should - a number of ways to reduce or expel flatus,
also be avoided including exercise, moving in bed, ambulation, and
avoiding gas-producing foods
Exercise
- Bismuth subsalicylate (Pepto-Bismol): can be
- A client with weak abdominal and pelvic muscles effective; however, it should not be used as a
(which delay normal defecation) may be able to continuous treatment because it contains aspirin
strengthen them with the isometric exercises and could cause salicylate toxicity.
- Alpha- galactosidase (Beano): effective for
Positioning
reducing flatulence caused by eating fermentable
- Although the squatting position best facilitates carbohydrates
defecation, on a toilet seat the best position for
most individuals seems to be leaning forward
- Bedside commode: a portable chair with a toilet
seat and a receptacle beneath that can be emptied,
is often used for the adult client who can get out of
bed but is unable to walk to the bathroom
- Bedpan: a receptacle for urine and feces.
Teaching about medications
Cathartics and laxatives
- Cathartics: are drugs that induce defecation.
Examples of cathartics are castor oil, cascara,
phenolphthalein, and bisacodyl
- Laxative: mild in comparison to a cathartic, and it
produces soft or liquid stools that are sometimes
accompanied by abdominal cramps;
contraindicated in the client who has nausea,
cramps, colic, vomiting, or undiagnosed
abdominal pain.
Antidiarrheal medications
- slow the motility of the intestine or absorb excess
fluid in the intestine

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Oxygenation
Oxygen
- a clear, odorless gas that constitutes approximately
21% of the air we breathe, is necessary for proper
functioning of all living cells
- absence lead to cellular, tissue, and organism death
- cellular metabolism produces carbon dioxide,
which must be eliminated from the body to
maintain normal acid–base balance
Respiratory system: provides the movement and transfer
of gases between the atmosphere and the blood is the
process of gas exchange between the individual and the
environment and involves four components:
1. Ventilation or breathing, the movement of air in
and out of the lungs as we inhale and exhale
2. Alveolar-capillary gas exchange, which involves
the diffusion of oxygen and carbon dioxide
between the alveoli and the pulmonary capillaries
3. Transport of oxygen and carbon dioxide between
the tissues and the lungs
4. Movement of oxygen and carbon dioxide between
the systemic capillaries and the tissues.
Structure of the Respiratory System
Upper Respiratory System
1. Mouth
2. Nose- air enters through this, where it is warmed,
humidified, and filtered
o Hair- trap large particles in the air
3. Pharynx- shared pathway for air and food. It
includes both the nasopharynx and the
oropharynx, which are richly supplied with
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lymphoid tissue that traps and destroys pathogens
entering with the air
4. Larynx- important for maintaining airway
patency and protecting the lower airways from
swallowed food and fluids. During swallowing,
the inlet to the larynx (the epiglottis) closes,
routing food to the esophagus
o Epiglottis- open during breathing, allowing
air to move freely into the lower airway
Lower Respiratory System
1. Trachea- leads to the right and left main bronchi
(primary bronchi) and the other conducting
airways of the lungs
2. Lungs- soft, spongy, cone-shaped organ; right
lung consists of 3 lobes whereas the left lung
consist of 2
3. Bronchi- divide repeatedly into smaller and
smaller bronchi, ending with the terminal
bronchioles. Together these airways are known as
the bronchial tree
4. Bronchioles- have scattered air sacs in their wall
5. Alveoli- have very thin walled air sacs; composed
of a single layer of epithelial cells covered by a
thick mesh of pulmonary capillaries
o Alveolar & capillary walls form the
respiratory membrane where gas exchange
occurs
6. Pulmonary Capillary Network
7. Pleural Membranes- prevents friction during the
movements of breathing and serves to keep the
layers adherent through its surface tension
Respiration- exchange of gases that provides
oxygenation of blood and body tissues and elimination of
carbon dioxide from lungs
1. External respiration- involves both bringing air
into the lungs (inhalation) and releasing air to the
atmosphere (exhalation)
2. Internal respiration- involves capillary-tissue
gas exchange
Pulmonary Ventilation
Inspiration (inhalation)- as air flows into the lungs
Expiration (exhalation)- as ir moves out the lungs
Cough and Sneeze Reflex- work to keep airways open
and clear
Tidal volume
- degree of chest expansion during normal breathing
is minimal, requiring little energy expenditure
- in adults, approximately 500 mL of air is inspired
and expired with each breath.
Lung Compliance
- the expansibility or stretchability of lung tissue,
plays a significant role in the ease of ventilation
- necessary for inspiration
Lung recoil
- the continual tendency of the lungs to collapse
away from the chest wall necessary for expiration
Surfactant
- a lipoprotein produced by specialized alveolar
cells, reduces the surface tension of alveolar fluid
- without this, lung expansion is exceedingly
difficult and the lungs collapse
Alveolar Gas Exchange
- the diffusion of oxygen from the alveoli and into
the pulmonary blood vessels
- Diffusion: the movement of gases or other
particles from an area of greater pressure or
concentration to an area of lower pressure or
concentration
Transport of Oxygen and Carbon DIoxide
- oxygen needs to be transported from the lungs to
the tissues, and carbon dioxide must be transported
from the tissues back to the lung
- second factor influencing oxygen transport is the
number of erythrocytes or red blood cells (RBCs)
and the hematocrit
- Hematocrit: percentage of the blood that is
erythrocytes; about 40% to 54% in men and 37%
to 50% in women
- most of the oxygen (97%) combines loosely with
hemoglobin (oxygen-carrying red pigment) in the
red blood cells (RBCs) and is carried to the tissues
as oxyhemoglobin (the compound of oxygen and
hemoglobin)
Several factors affect the rate of oxygen transport from
the lungs to the tissues:
1. Cardiac output
2. Number of erythrocytes and blood hematocrit
3. Exercise.
Systemic Diffusion
- diffusion of oxygen and carbon dioxide between
the capillaries and the tissues and cells down to a
concentration gradient similar to diffusion at the
alveolar–capillary level
- as cells consume oxygen, the partial pressure of
oxygen in the tissues decreases, causing the
oxygen at the arterial end of the capillary to diffuse
into the cells.
- carbon dioxide from metabolic processes
accumulates in the tissues and diffuses into the
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capillaries where the partial pressure of carbon
dioxide is lower
- in reduced blood flow states such as shock,
capillary blood flow may decrease, interfering with
tissue oxygen delivery
Respiratory Regulation
- Chemosensitive center in the medulla oblongata
is highly responsive to increases in blood CO2 or
hydrogen ion concentration
- Special neural receptors sensitive to decreases in
oxygen concentration located outside the central
nervous system in the carotid bodies and aortic
bodies located above & below the aortic arch
- Hypoxic drive: decreased oxygen concentrations
are the main stimuli for respiration because the
chronically elevated carbon dioxide levels that
occur with emphysema “desensitize” the central
chemoreceptors
Chemoreceptors (Special Neural Receptor)
- in carotid and aortic bodies; respond to changes in
blood O2.
- send action potentials to the respiratory center and
produce an increase in the rate and depth of
breathing which increases O2 diffusion from the
alveoli into the blood.
Factors Affecting Respiratory Function
Age
- At birth, profound changes occur in the respiratory
systems. The fluid-filled lungs drain, the PCO2
rises, and the neonate takes a first breath. The
lungs gradually expand with each subsequent
breath, reaching full inflation by 2 weeks of age.
- changes of aging that affect the respiratory system
of older adults become especially important if the
system is compromised by changes such as
infection, physical or emotional stress, surgery,
anesthesia, or other procedures.
- Changes seen in adults:
o Chest wall and airways become more rigid
and less elastic.
o The amount of exchanged air is decreased.
o The cough reflex and cilia action are
decreased.
o Mucous membranes become drier and more
fragile.
o Decreases in muscle strength and endurance
occur
o If osteoporosis is present, adequate lung
expansion may be compromised.
o A decrease in efficiency of the immune
system occurs.
o Gastroesophageal reflux disease is more
common in older adults and increases the risk
of aspiration. The aspiration of stomach
contents into the lungs often causes
bronchospasm by setting up an inflammatory
response.
Environment
- Air Quality: air pollution such as cigarette smoke,
automobile emissions, mold spores, and radon, can
precipitate disease in vulnerable people
- Pulmonary allergens: Allergens, such as dust,
animal dander, cockroach particles, environmental
grasses, and foods such as peanuts and gluten; can
precipitate respiratory hypersensitivity responses
and allergies.
- Altitude: Low oxygen levels place strain on the
cardiopulmonary system ; lead to increased
ventilation, production of red blood cells and
hemoglobin, and vascularity of lungs and body
tissues
Lifestyle
- Smoking tobacco and inhaling second hand
smoke: Tobacco smoke contains tars, toxins, and
nicotine; tars and toxins are known to precipitate
cancer and nicotine constricts bronchioles. Smoke
also causes mucous membrane inflammation,
increases respiratory secretions, breaks down
elastin, and decreases the numbers and efficiency
of cilia
- Improper Nutrition: inappropriate balance of
proteins, carbohydrates, and fats may reduce the
immune system, impair cellular functioning,
impede tissue repair, and cause obesity.
- Lack of Exercise: Sedentary lifestyle results in a
depressed metabolic rate and an inability of the
cardiopulmonary system to respond when any
situation causes an increased metabolic rate
- Obesity: A BMI more than 30 increases the risk of
respiratory infections because excess abdominal
adipose tissue limits chest expansion and gas
exchange in the alveoli
- Occupational Hazards: Toxic agents include
chemical fumes from cleaning products, carbon
monoxide from automobile or machine
combustion, particles from construction debris,
such as asbestos, and coal dust from coal mines
Health Status
- diseases of the respiratory system, however, can
adversely affect the oxygenation of the blood
Medications
- Stimulants: amphetamines and cocaine,
hallucinogens, and marijuana, also adversely affect
lung tissue, increase the risk of aspiration, and
depress respirations
- medications that decrease the rate and depth of
respirations include most common medications
having this effect are the benzodiazepine sedative–
hypnotics and antianxiety drugs (e.g., diazepam
[Valium], lorazepam [Ativan], midazolam
[Versed]), barbiturates (e.g., pheno- barbital), and
opioids such as morphine
- Older clients are at high risk of respiratory
depression and usually require reduced dosages
Stress
- some individuals may hyperventilate in response
to stress
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- individual may experience light-headedness and
numbness and tingling of the fingers, toes, and
around the mouth as a result
- Epinephrine: causes the bronchioles to dilate,
increasing blood flow and oxygen delivery to
active muscle
Pregnancy
- Body metabolism increases by 15 percent and
oxygen consumption increases by 15 to 25 percent.
- The enlarging uterus rises into the abdominal
cavity, limiting enlargement of the chest cavity
and downward movement of the diaphragm.
- Maternal respiratory rate increases and the mother
may experience shortness of breath with activity.
Alterations in the Respiratory System
Respiratory function can be altered by conditions that
affect:
- Patency (open airway)
- The movement of air into or out of the lungs
- The diffusion of oxygen and carbon dioxide
between the alveoli and the pulmonary capillaries
- The transport of oxygen and carbon dioxide via the
blood to and from the tissue cells.
- Client may have altered arterial blood gas levels,
restlessness, dyspnea, and adventitious breath
sounds (abnormal breath sounds)
Sputum
- produced when lungs are damaged or diseased
- identify whether coughing is not bringing up
(nonproductive cough) sputum or bringing up
sputum (productive cough)
- Color
o Clear/white: Associated with viral infections.
o Yellow/green: Associated with infection
o Black: Associated with inhalation of smoke,
soot, or coal dust.
o Red/rust colored: Associated with the presence
of blood (hemoptysis), tuberculosis, and
pneumococcal pneumonia.
o Pink/frothy: Associated with pulmonary
edema
- Odor: Foul smelling, associated with bacterial
infections such as pneumonia and abscesses of the
lung.
Conditions Affecting the Airway
Upper airway obstruction
- occur when a foreign object such as food is
present, when the tongue falls back into the
oropharynx when an individual is unconscious, or
when secretions collect in the passageways
Lower airway obstruction
- involves partial or complete occlusion of the
passageways in the bronchi and lungs most often
due to increased accumulation of mucus or
inflammatory exudate
- Stridor: harsh, high-pitched sound may be heart
during inspiration
Partial obstruction of the upper airway
- passages is indicated by a low-pitched snoring
sound during inhalation.
Complete obstruction
indicated by extreme inspiratory effort that produces no
chest movement and an inability to cough or speak
Conditions Affecting Movement of Air
Breathing patterns- refers to the rate, volume, rhythm,
and relative ease or effort of respiration
Eupnea- quiet, rhythmic, and effortless
Tachypnea- rapid respirations seen with fevers,
metabolic acidosis, pain, and hypoxemia
Bradypnea- an abnormally slow respiratory rate, which
may be seen in clients who have taken drugs such as
morphine or sedatives, who have metabolic alkalosis, or
who have increased intracranial pressure
Apnea- the absence of any breathing.
Hypoventilation- inadequate alveolar ventilation, may be
caused by either slow or shallow breathing, or both.
Hyperventilation- the increased movement of air into
and out of the lungs
Hypercarbia or Hypercapnia- increased levels of
carbon dioxide
Orthopnea- inability to breathe easily unless sitting
upright or standing
Dyspnea- difficulty breathing or the feeling of being
short of breath
Platypnea- shortness of breath that is relieved when lying
down, and worsened when sitting or standing upright
Kussmaul’s breathing- hyperventilation that
accompanies metabolic acidosis by which the body
attempts to compensate for increased metabolic acids by
blowing off acid in the form of CO2; also occur in
response to stress or anxiety.
Cheyne-Stokes respirations- marked rhythmic waxing
and waning of respirations from very deep to very
shallow with short periods of apnea
Biot’s (cluster) respirations- shallow breaths interrupted
by apnea; may be seen in clients with CNS disorders
Conditions Affecting Diffusion
Hypoxemia- reduced oxygen levels in the blood, may be
caused by conditions that impair diffusion at the alveolar–
capillary level such as pulmonary edema or atelectasis
(collapsed alveoli) or by low hemoglobin levels.
Hypoxia- insufficient oxygen anywhere in the body;
cerebral cortex can tolerate hypoxia for only 3 to 5
minutes before permanent damage occur
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Cyanosis- bluish discoloration of the skin, nail beds, and
mucous membranes due to reduced hemoglobin and
decreased oxygen saturation which may be present with
hypoxemia or hypoxia.
Signs of Increased Respiratory Effort
- Use of accessory muscles of respiration:
intercostal, abdominal, trapezius muscles; to help
expand the chest cavity.
- Retractions: Intercostal, supraclavicular, and
subcostal tissues; required to increase the depth of
respirations
- Nasal flaring: Widening of the nares during
inhalation to reduce resistance to airflow; more
common in infants and young children
- Grunting immediately before exhalation: Closed
glottis at the height of inspiration keeps alveoli
open to enhance gas exchange; grunt occurs when
air is expelled through the larynx.
- Pursed-lip breathing: Exhalation through the
mouth with lips positioned to create a small
opening to prolong exhalation; keeps alveoli open
longer for gas exchange and more efficiently
expels trapped air
Distinguishing Abnormal Breath Sounds
Rhonchi (sonorous wheeze)
- Mucus accumulated in large bronchi.
- Loud, coarse, low-pitched sound heard during
inspiration and/or expiration
Wheeze (sibilant wheeze)
- Air moving through narrowed airways.
- High-pitched, musical sound that may be heard
throughout inspiration and expiration; more
prominent during expiration.
- May be audible without a stethoscope
Pleural Friction Rub
- Inflamed pleural surfaces rubbing together.
- Low-pitched, grating sound during inspiration
and/or expiration; more prominent at height of
inspiration.
- Heard at lateral, anterior, base of lung
Stridor
- High-pitched crowing sound; more prominent
during inspiration.
- Heard over larynx and trachea.
- May be audible without a stethoscope.
- Tracheal or laryngeal spasm § Partial airway
obstruction
Conditions Affecting Transport
- Conditions that decrease cardiac output, such as
heart failure or hypovolemia, affect tissue
oxygenation and also the body’s ability to
compensate for hypoxemia
Nursing Management
Assessment
Nursing History
- comprehensive nursing history relevant to
oxygenation status should include data about
current and past respiratory problems; lifestyle;
presence of cough, sputum (coughed-up material),
or pain; medications for breathing; and presence of
risk factors for impaired oxygenation status
Physical Examination
- inspection, palpation, percussion, and auscultation.
- nurse first observes the rate, depth, rhythm, and
quality of respirations, noting the position the
client assumes for breathing
- nurse also inspects for variations in the shape of
the thorax that may indicate adaptation to chronic
respiratory conditions
- nurse frequently auscultates the chest to assess if
the client’s breath sounds are normal or abnormal
Diagnostic Studies
- sputum specimens, throat cultures, visualization
procedures venous and arterial blood specimens,
and pulmonary function tests
- measurement of arterial blood gases is an
important diagnostic procedure
- blood for these tests is taken directly from the
radial, brachial, or femoral arteries or from
catheters placed in these arteries
- frequently the noninvasive measurement of oxygen
saturation (using a device placed on the fingertip)
is sufficient for attaining a measurement of
oxygenation of the arterial blood
Pulmonary Function Tests
- measure lung volume and capacity
- clients undergoing pulmonary function tests,
which are usually carried out by a respiratory
therapist, do not require an anesthetic.
Diagnosing
NANDA International (Herdman & Kamitsuru, 2014)
includer the following diagnostic labels for clients with
oxygenation problems
- Ineffective Airway Clearance: inability to clear
secretions or obstructions from the respiratory tract
to maintain a clear airway.
- Ineffective Breathing Pattern: inspiration and/or
expiration that does not provide adequate
ventilation.
- Impaired Gas Exchange: excess or deficit in
oxygenation and/or carbon dioxide elimination at
the alveolar-capillary membrane.
- Activity Intolerance: insufficient physiological or
psychological energy to endure or complete
required or desired daily activities
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Preceding Nursing Diagnoses may also be the etiology of and pregnant women can get very sick; thus they
several other nursing diagnoses, such as these: should be immunized.
- Anxiety related to ineffective airway clearance and Mobilization of Pulmonary Secretions
feeling of suffocation
- The ability of a patient to mobilize pulmonary
- Fatigue related to ineffective breathing pattern secretions makes the difference between a short-
- Fear related to chronic disabling respiratory illness term illness and a long recovery involving
- Insomnia related to orthopnea and required O2 complications
therapy - Nursing interventions promoting removal of
- Social Isolation related to activity intolerance pulmonary secretions assist in achieving and
- and inability to travel to usual social activities maintaining a clear airway and help to promote
Planning lung expansion and gas exchange.
The overall outcomes or goals for a client with Hydration
oxygenation problems are to:
- Maintenance of adequate systemic hydration keeps
- Maintain a patent airway. mucociliary clearance normal.
- Improve comfort and ease of breathing. - Excessive coughing to clear thick, tenacious
- Maintain or improve pulmonary ventilation and secretions is fatiguing and energy depleting.
oxygenation. - best way to maintain thin secretions is to provide a
- Improve the ability to participate in physical fluid intake of 1500 to 2500 mL/day unless
activities contraindicated by cardiac or renal status.
- Prevent risks associated with oxygenation
problems such as skin and tissue breakdown, Humidification
syncope, acid–base imbalances, and feelings of - is the process of adding water to gas.
hopelessness and social isolation. - Temperature is the most important factor affecting
Measurement Description the amount of water vapor a gas can hold.
Tidal volume Volume inhaled and exhaled - Relative humidity is the percentage of water in the
(VT) during normal quiet breathing gas.
- Air or oxygen with a high relative humidity keeps
Inspiratory Maximum amount of air that the airways moist and loosens and mobilizes
reserve volume can be inhaled over and above pulmonary secretions.
(IRV) a normal breath
- Humidification is necessary for patients receiving
Expiratory Maximum amount of air that
oxygen therapy at greater than 4 L/min (check
reserve volume can be exhaled following a
agency protocol).
(ERV) normal exhalation
- It might be necessary to add humidification at
Residual volume The amount of air remaining in
lower oxygen concentrations if the environment is
(RV) the lungs after maximal
dry and arid.
exhalation
Total lung The total volume of the lungs Nebulization
capacity (TLC) at maximum inflation;
- adds moisture or medications to inspired air by
calculated by adding the VT,
mixing particles of varying sizes with the air.
IRV, ERV, and RV
- aerosolization suspends the maximum number of
Vital capacity Total amount of air that can be
water drops or particles of the desired size in
(VC) exhaled after a maximal
inspired air
inspiration; calculated by
adding the VT, IRV, and ERV - moisture added through nebulization improves
clearance of pulmonary secretions.
Inspiratory Total amount of air that can be
capacity inhaled following normal quiet - used for administration of bronchodilators and
exhalation; calculated by mucolytic agents
adding the VT and IRV Chest physiotherapy (CPT) is a group of therapies for
Functional The volume left in the lungs mobilizing pulmonary secretions; may be implemented by
residual capacity after normal exhalation; a respiratory therapist.
(FRC) calculated by adding the ERV
and RV a. Postural drainage: Place the patient
sequentially in a variety of positions so that it
Minute volume The total volume or amount of
permits gravity to drain secretions from all
(MV) air breathed in 1 minute
lobes of the lungs.
b. Percussion: Strike the chest wall using cupped
Nursing Care for Patients with Respiratory Prob. hands to generate sounds and slight negative
Vaccination pressure that loosen secretions
c. Vibration: Apply vibrations to the chest wall
- Annual flu vaccines are recommended for all
with the hands or a vibrator to loosen
people 6 months and older.
secretions;
- Patients with chronic illnesses (heart, lung, kidney,
or immunocompromised), infants, older adults, Promote Lung Expansion

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- Encourage an intake of air in which the abdomen
expands on deep inhalation and abdominal
muscles tighten on exhalation (diaphragmatic
[abdominal] breathing) to increase the amount of
air entering and exiting the lungs.
- Encourage the patient to exhale through the mouth
with the lips positioned to create a small opening
(pursed-lip breathing) to prolong exhalation.
- Doing so keeps alveoli open longer for gas
exchange and more efficiently expels trapped air.
- This is a beneficial breathing technique for patients
with obstructive airway diseases, such as
emphysema, asthma, and chronic bronchitis.
- Encourage use of an incentive spirometer 10 times
every hour to help prevent atelectasis and reexpand
collapsed alveoli; device promotes deep breaths by
providing a visual goal to progressively increase
the volume of breaths
Suctioning Techniques- necessary when patients are
unable to clear respiratory secretions from the airways by
coughing or other less invasive procedures.
1. Oropharyngeal or nasopharyngeal suctioning-
used when the patient is able to cough effectively
but unable to clear secretions by expectorating.
2. Orotracheal or nasotracheal suctioning -
necessary when a patient with pulmonary
secretions is unable to manage secretions by
coughing and does not have an artificial airway
present

Fluid, Electrolyte and Acid-Base Balance

Homeostasis- depends on multiple physiologic processes
that regulate fluid intake and output, as well as the
movement of water and the substances dissolved in it
between body compartments
Body Fluids and Electrolytes
Average adult: Approximately 60% of the average
healthy adult’s weight is water, the primary body fluid. In
good health this volume remains relatively constant, and
an individual’s weight varies by less than 0.2 kg (0.5 lb)
in 24 hours, regardless of the amount of fluid ingested
Infants: have the highest proportion of water, accounting
for 70% to 80% of their body weight
Older adults: represents only about 50% of total body
weight. Women generally have a lower percentage of
body water than men.

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Intracellular fluid (ICF)
- is found within the cells of the body. It constitutes
approximately two-thirds of the total body fluid in
adults
- The major ICF é are K+, PO-4 & Mg++
Extracellular fluid (ECF)
- is found outside the cells and accounts for about
one-third of total body fluid. It is further
subdivided into compartments.
- The major ECF é are Na+, HCO-3 & Cl-
o Intravascular fluid, or plasma:
accounts for approximately 20% of
ECF and is found within the vascular
system.
o Interstitial fluid: accounting for
approximately 75% of ECF,
surrounds the cells; vital to normal
cell functioning for it contains solutes
suck as oxygen, electrolytes and
glucose
Composition of Body Fluid
- Sodium chloride: breaks up into one ion of sodium
(Na+) and one ion chloride Cl-)
- Electrolytes: charged particles capable of
conducting electricity
- Cations: ions that carry a positive charge
- Anions: ions that carry a negative charge
- Measurement of electrolytes: milliequivalent per
liter (mEq/L) or milligram per 100 milliliters
(mg/100mL)
- Milliequivalent: refers to the chemical combining
power of the ion, or the capacity of cations to
combine with anions to form molecules, whereas
the term milligram refers to the weight of an ion
Functions of the Body Fluids
- Transporter of nutrients
- Medium or milieu for metabolic processes
- Body temperature regulation
- Lubricant of musculoskeletal joints
- Insulator and shock absorber
Movement of Body Fluids and Electrolytes
The body fluid compartments are separated from one
another by cell membranes and the capillary membrane.
Although these membranes are completely permeable to
water, they are considered to be selectively permeable to
solutes, because substances other than water move across
them with varying degrees of ease.
Solutes
- Substances dissolved in a liquid
- Crystalloids: salts that dissolve readily into
solutions
- Colloids: substances such as a large protein
molecules that do not readily dissolve into true
solutions
Solvent
- Component of a solution that can dissolve a solute
- Electrolytes, gases such as oxygen and carbon
dioxide, glucose, urea, amino acids, and proteins
Osmolality
- Used to express concentration of solutes in body
- Determined by the total solute concentration
within a fluid compartment and is measured as
parts of solute per kilogram of water
- Reported as milliosmoles per kilogram
- Sodium: the greatest determinant of the osmolality
of plasma, or serum osmolality
- Tonicity: may also be used to refer to the
osmolality of one solution in relation to another
solution.
o Concentration of particles in a solution
o Body fluids are isotonic comparable with
0.9% NaCl
Solutions may be termed as:
- Isotonic solution: has the same osmolality as
ECF. Normal saline, 0.9% sodium chloride, is an
example of an isotonic solution.
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- Hypertonic solutions: such as 3% sodium
chloride, have a higher osmolality than ECF.
Hypotonic solutions: such as 0.45% sodium
chloride, have a lower osmolality than ECF
Osmotic pressure
- power of a solution to pull water across a
semipermeable membrane
- When two solutions of different concentrations are
separated by a semi- permeable membrane, the
solution with the higher solute concentration exerts
a higher osmotic pressure, pulling water across the
membrane to equalize the concentrations of the
solutions.
- Colloid osmotic pressure/ oncotic pressure:
osmotic pressure from plasma proteins, an
important mechanism for maintaining vascular
volume
Methods by which water and solutes move
1. Diffusion- occurs when two solutes of different
concentrations are separated by a semipermeable
membrane; rate of diffusion of a solute varies
according to the size, concentration, and temperature
of the solution. Factors affecting the rate of diffusion:
- Size of the molecules: larger size moves slower
than smaller size
- Concentration of solution: wide difference in
conc. has a faster rate of diffusion
- Temperature: low in T = low rate of diffusion
2.
3. Facilitated Diffusion- require assistance from a
carrier molecule to pass through as semipermeable
membrane
4. Osmosis- specific kind of diffusion in which water
moves across cell membranes, from the less
concentrated solution (the solution with less solute and
more water) to the more concentrated solution (the
solution with more solute and less water)
5. Filtration- process whereby fluid and solutes move
together across a membrane from an area of higher
pressure to an area of lower pressure.
- Filtration pressure is the pressure that results in
the movement of the fluid and solutes out of a
compartment.
- Hydrostatic pressure is the pressure exerted by a
fluid within a closed system on the walls of the
container in which it is held.
6. Active transport- the movement of solutes across cell
membranes from a less concentrated solution to a more
concentrated one. This process differs from diffusion
and osmosis, which are passive processes, in that
metabolic energy is expended
Regulating Body Fluids
Fluid intake
- average adult drinks about 1200 to 1500 mL/day,
despite the fact that adults need 2500 mL/day for
normal functioning
- additional 1000-mL volume is acquired from foods
and from the oxidation of these foods during
metabolic processes
- Water as a by-product of food metabolism
accounts for most of the remaining fluid volume
required. This quantity is approximately 200
mL/day
- Standard Formula standard formula
o 100ml/kg for the 1st 10 kg of wt, plus
o 50ml/kg for the next 10 kg of wt, plus
o 15ml/kg per remaining kg of wt
Thirst mechanism
- primary regulator of fluid intake. The thirst center
is located in the hypothalamus of the brain.
- Triggered by osmotic pressure of body fluids,
vascular volume, and angiotensin (a hormone
released in response to decreased blood flow to the
kidneys), causing the sensation of thirst and the
desire to drink fluids.
- Thirst is normally temporarily relieved for 15
minutes immediately after drinking a small amount
of fluid, when the ingested fluid dis- tends the
upper gastrointestinal tract, but before the fluid is
actually absorbed from the gastrointestinal tract
- It takes between 30 minutes and 1 hour for fluid to
be absorbed and distributed throughout the body.
Fluid Output
- Average fluid loss amounts to 2500 ml/day
counterbalancing the input to maintain equilibrium
- Routes: (1500ml/day: 30-50ml/hr: 0.5-1ml/kg/hr),
bowel elimination (200ml), perspiration &
breathing
- Urine: major route of fluid output
- Insensible fluid: losses occur through the skin and
the lungs; called insensible because it is usually
not noticeable and cannot be measured. Insensible
fluid loss through the skin occurs in two ways,
diffusion and perspiration.
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Maintaining Homeostasis
Osmoreceptors
- Specialized neurons in the hypothalamus
- Highly sensitive to serum osmolality
- Increased osmolality-osmoreceptors stimulates
hypothalamus to synthesize ADH
- Decreased osmolality-ADH is inhibited
- Triggers thirst promoting increased fluid intake
- Thirsty when ECF volume decreases by approx..
700ml (2% of the body weight)
- Sensitive to changes in BV and BP through the
info relayed by baroreceptors
Kidneys
- regulate the volume and osmolality of ECF by
regulating water and electrolyte excretion.
- control the reabsorption of water from plasma
filtrate and ultimately the amount excreted as urine
- electrolyte balance is maintained by selective
retention and excretion by the kidneys
- play a significant role in acid–base regulation,
excreting hydrogen ion (H+) and retaining
bicarbonate.
Antidiuretic hormone
- regulates water excretion from the kidney
- When serum osmolality rises, ADH is produced,
causing the collecting ducts to become more
permeable to water. This increased permeability
allows more water to be reabsorbed into the blood
- if serum osmolality decreases, ADH is suppressed,
the collecting ducts become less permeable to
water, and urine output increases. Excess water is
excreted, and serum osmolality returns to normal
Renin-angiotensin-aldosterone system
- If blood flow or pressure to the kidney decreases,
renin is released.
- Renin causes the conversion of angiotensinogen to
angiotensin I, which is then converted to
angiotensin II by angiotensin-converting enzyme.
- Angiotensin II acts directly on the nephrons to
promote sodium and water retention.
- Aldosterone also promotes sodium retention in the
distal nephron effect of the renin-angiotensin-
aldosterone system is to increase blood volume
(and renal perfusion) through sodium and water
retention
Atrial natriuretic factor
- released from cells in the atrium of the heart in
response to excess blood volume and stretching of
the atrial walls.
- Acting on the nephrons, promotes sodium wasting
and acts as a potent diuretic, thus decreasing blood
volume.
- also inhibits thirst, reducing fluid intake.
Regulating Electrolytes
Electrolytes- charged ions capable of conducting
electricity present in all body fluids and fluid
compartments. Although concentration of specific
electrolytes differs between fluid compartments, a balance
of cations and anions always exists.
- Sources of electrolytes: food intake/ingested
fluids, medications, IVF, and TPN solutions
- Electrolytes are important for:
- maintaining fluid balance
- contributing to acid-base regulation
- facilitating enzyme reactions
- transmitting neuromuscular reactions
Note: Some electrolytes, such as sodium chloride and
potassium, are not stored by the body and must be
consumed daily to maintain normal levels. Other
electrolytes, such as calcium, are stored in the body
Dynamics Of Electrolyte Balance
1. Distribution
- Na, Ca, Cl concentration = higher in ECF
- K, Mg, PO4 concentrations = higher in ICF
2. Excretion
- Urine, feces, surgical/wound drainage,
pathological conditions
3. Regulation
- Kidneys, GIT, hormones (aldosterone, ANF, PTH,
calcitonin)
Sodium (NA+) 135-145MEQ/L
- Function: Skeletal/ heart muscle contraction, nerve
impulse transmission, Normal ECF osmolality,
Normal ECF volume
- most abundant cation in ECF and a major
contributor to serum osmolality
- functions largely in controlling and regulating
water balance.
Potassium (ECF: 3.5-5.0MEQ/L) (ICF: 140)
- Function: Regulates CHON synthesis, glucose use
& storage, maintains action potentials in excitable
membranes
- major cation in ICF, with only a small amount
found in the ECF
- vital electrolyte for skeletal, cardiac, and smooth
muscle activity. It is also involved in maintaining
acid–base balance, and it contributes to
intracellular enzyme reactions. Potassium must be
ingested daily because the body cannot conserve it
Calcium
- Function: Bone strength & density, activation of
enzymes or reactions, skeletal/ cardiac muscle
contraction, nerve impulse transmission, blood
clotting
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- stored in the skeletal system, with a relatively - Bicarbonate is excreted when too much is present;
small amount in extracellular fluid if more is needed, the kidneys both regenerate and
- vital in regulating neuromuscular function, reabsorb bicarbonate ions
including muscle contraction and relaxation, as - Unlike electrolytes that must be consumed in the
well as cardiac function. diet, adequate amounts of bicarbonate are
- ECF calcium is regulated by a complex interaction produced through metabolic processes.
of parathyroid hormone, calcitonin (a hormone
produced by the thyroid), and calcitriol (a
metabolite of vitamin D)
- With increasing age, the intestines absorb calcium
less effectively, and more calcium is excreted by
the kidneys. Calcium shifts out of the bone
increasing the risk of osteoporosis and fractures of
the wrists, vertebrae, and hips
Magnesium (MG++) 1.3-2.1 MG/DL
- Functions:
o ICF – skeletal muscle contractions, CHO
metabolism, ATP formation, Vit. B-complex
activation, DNA synthesis, CHON synthesis
o ECF – regulates blood coagulation & skeletal
muscle contractility Acid-Base Balance
- Regulated by the kidney & GIT (exact mechanism - An important part of regulating the homeostasis of
are not known) body fluids is regulating their acidity and alkalinity
- found primarily in the skeleton and ICF, where it - Acid: a substance that releases hydrogen ions (H+)
is the second most abundant intracellular cation in solution
Phosphate (P) 2-4 MG/DL (0.97-1.45MMOL/L) - Bases or alkalis: have a low hydrogen ion
- Function: Activating B-complex vitamins, ATP, concentration & can accept hydrogen ions in
assisting in cell division, cooperating in CHO, solution.
CHON & FAT metabolism, acid- base buffering, - pH: measurement of the relative acidity or
calcium homeostasis; balanced & reciprocal alkalinity of a solution which is an inverse
relationship w/ Ca++ reflection of the hydrogen ion concentration
- major anion of ICF - The higher the hydrogen ion concentration, the
- involved in many chemical actions of cells, and is lower the pH; the lower the hydrogen ion
essential for functioning of muscles, nerves, and concentration, the higher the pH.
RBCs - Water: has a pH of 7 and is neutral. Solutions with
- involved in the metabolism of protein, fat, and a pH lower than 7 are acidic; those with a pH
carbohydrate. higher than 7 are alkaline.
- absorbed from the intestine; found in many foods Regulation of Acid-Base Balance
Chloride (Cl) 90-106 MEQ/L - Body fluids are normally maintained within a
- major ECF anion; work with Na+ to maintain ECF narrow range that is slightly alkaline.
osmotic pressure - Normal pH of arterial blood: 7.35- 7.45
- important in the formation of HCL in the stomach - Buffer help maintain acid-base balance by
- participates in chloride shift (exchange between neutralizing excess acids or bases
CL- and HCO3)
Bicarbonate
- primary function is regulating acid–base balance
as an essential component of the body’s buffering
system

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Buffers
- Prevent excessive changes in pH by binding with
or releasing hydrogen ions
- If body fluids become too acidic, meaning excess
hydrogen ions are present in body fluids, buffers
bind with the hydrogen ions. If body fluids
become too alkaline, meaning not enough
hydrogen ions are present in body fluids, buffers
can release hydrogen ions.
- The action of a buffer is immediate, but limited in
its capacity to maintain or restore normal acid–
base balance.
- as long as a ratio of 20 parts of bicarbonate to 1
part of carbonic acid is maintained, the pH
remains within its normal range of 7.35 to 7.45.
- adding a strong acid to ECF can change this ratio
because bicarbonate is depleted in neutralizing
the acid. When this happens, the pH drops, and
the client has a condition called acidosis. The
ratio can also be upset by adding a strong base to
ECF, depleting carbonic acid as it combines with
the base. In this case the pH rises and the client
has alkalosis.
Respiratory Regulation
- The lungs help regulate acid–base balance by
eliminating or retaining carbon dioxide (CO2)
- lungs help regulate acid–base balance by altering
the rate and depth of respirations. The response
of the respiratory system to changes in pH is
rapid, occurring within minutes
Renal Regulation
- Although buffers and the respiratory system can
compensate for changes in pH, the kidneys are
the ultimate long-term regulator of acid–base
balance
Factors Affecting Body Fluid, Electrolytes, and
Acid-Base Balance
Age
- Infants and growing children have much greater
fluid turnover than adults because their higher
metabolic rate increases fluid loss
- In addition, infants’ respiratory rate is much
higher than that of adults, and their body surface
area is proportionately greater than that of adults,
both of which increases insensible fluid losses.
- In older individuals, the normal aging process
may affect fluid balance. The thirst response is
often diminished. Risk of dehydration is
increased
Sex and Body Size
- individuals with a higher percentage of body fat
have less body water than individuals with a
higher percentage of lean muscle
- Women generally have proportionately more
body fat and, there- fore, less body water than
men.
Environmental Temperature
- Fluid losses through sweating are increased in hot
environments as the body attempts to disperse
heat
- Both electrolytes and water are lost through
sweating.
- When only water is replaced, electrolyte
depletion is a risk.
- An individual who is electrolyte depleted may
experience fatigue, weakness, headache, and
gastrointestinal symptoms such as anorexia and
nausea
Lifestyle
- When calorie intake is not adequate to meet the
body’s needs, fat stores are broken down and
fatty acids are released, increasing the risk of
acidosis
- Regular weight-bearing exercise such as walking
or running has a beneficial effect on calcium
balance.
- Stress can increase cellular metabolism, blood
glucose concentration, and catecholamine levels.
- Heavy alcohol consumption increases the risk of
low calcium, magnesium, and phosphate levels
Disturbances in Fluid Volume, Electrolyte, and
Acid-Base Balances
Fluid Imbalances
Isotonic imbalances occur when water and electrolytes
are lost or gained in equal proportions, so that the
osmolality of body fluids remains constant. Osmolar
imbalances involve the loss or gain of only water, so that
the osmolality of the serum is altered.
Fluid Volume Deficit (Hypovolemia=Low ECF)
- Etiology
o inadequate fluid intake, hemorrhage,
prolonged vomiting and diarrhea, profuse
urination or perspiration, Addison’s disease
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- Pathophysiology
o #HR to maintain adequate CO
o BP falls with postural changes, or it may
become severely lowered when blood is
rapidly lost
o Hemoconcentration occurs = #potential
for blood clots, urinary stones
(compromises kidney’s function to
excrete nitrogen wastes)
o Eventually it depletes ICF which can
affect cellular functions = change in
mentation Health Teaching:
- Assessment findings - Respond to thirst because it is an early indication
o Thirst = one of the earliest symptoms of reduced fluid volume
o Weight loss ≥2lb/24 hr - Consume at least 8-10 (8 oz) glasses of fluid each
o Low bp, high T°, rapid & weak thready day, and more during hot, humid weather
pulse, rapid & shallow respiration, scant - Drink water as an inexpensive means to meet
& dark yellow urine, dry & small volume fluid requirements
stool, warm & flushed dry skin, poor skin - Avoid beverages with alcohol & caffeine
turgor “tents”, sunken eyes, clear lungs, - Include a moderate amount of table salt or foods
effortless breathing, weakness, flat containing sodium each day
jugular veins, reduced cognition, sleepy - Rise slowly from a sitting or lying position to
- Restored by: avoid dizziness and potential injury
o Treating its etiology
o Increasing the volume of oral intake
o Administering IVF replacement
o Controlling fluid loses
- Nursing Management:
o Gathers assessment data
o Plans measures to restore fluid balance
o Evaluates the outcomes of interventions
o Provide health teaching
- Isotonic imbalances: occur when water and
electrolytes are lost or gained in equal
proportions, so that the osmolality of body fluids
remains constant.
- Osmolar imbalances: involve the loss or gain of
only water, so that the osmolality of the serum is
altered
- occurs when the body loses both water and
electrolytes from the ECF in similar proportions.
- fluid is initially lost from the intravascular
compartment, so it often is called hypovolemia
Fluid Volume Excess
Third space syndrome (third spacing) (Hypervolemia/Overhydration)
- translocation of fluid from the IV or intercellular - occurs when the body retains both water and
space to tissue compartments and becomes sodium in similar proportions to normal ECF.
trapped and useless - This is commonly referred to as hypervolemia
- can lead to hypotension, shock & circulatory (increased blood volume)
failure; - always secondary to an increase in the total body
- associated with loss of colloids sodium content, which leads to an increase in
(hypoalbuminemia), burns, severe allergy total body water
reaction & cellular membrane permeability - Specific causes of FVE include
- Assessment findings: o excessive intake of sodium chloride;
o s/sx of hypovolemia except weight loss o administering sodium-containing
o enlargement of organ cavities (ascites) infusions too rapidly, particularly to
o anasarca (brawny edema) clients with impaired regulatory
mechanisms; and
- Management:
o disease processes that alter regulatory
o Restoration of colloidal osmotic pressure
mechanisms, such as heart failure, renal
(albumin), then diuretics
failure, cirrhosis of the liver, and
o Nursing care combines the assessment
Cushing’s syndrome.
techniques for detecting both
hypovolemia and hypervolemia - Etiology

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o Excessive oral intake, rapid IV infusion Overhydration
o Hear failure - Hypo-osmolar fluid imbalance, occurs when
o Excessive salt intake water is gained in excess of electrolytes, resulting
o Adrenal gland dysfunction in low serum osmolality and low serum sodium
o Administration of corticosteroids levels
o ESRD - Water is drawn into the cells, causing them to
- Pathophysiology: swell. In the brain, this can lead to cerebral
o Circulatory overload; compromises edema and impaired neurologic function.
cardiopulmonary function - sometimes called water intoxication, often occurs
o The heart compensates:#BP,# force of when both fluid and electrolytes are lost, for
contraction example, through excessive sweating, but only
o Pitting edema develops (if there is 3L water is replaced
excess in IV volume) - can also result from the syndrome of
- Signs and symptoms inappropriate antidiuretic hormone (SIADH), a
o Early signs: weight gain, elevated BP, disorder that can occur with some malignant
o increased breathing effort tumors, AIDS, head injury, or administration of
o Dependent edema (feet, ankles, sacrum, certain drugs such as barbiturates or anesthetics
buttocks)
o Rings, shoes & stockings leave marks in
the skin
o Prominent jugular vein when sitting
o Moist breath sounds (fluid congestion in
the lungs)
- Diagnostic Findings
o Hemodilution hematocrit (low blood cell
count, low hematocrit)
o Low Urine SG CVP (>10 cm H2O) O in
FVD)
- Medical Management
o Treat the underlying cause
o Restriction of oral and parenteral fluid
intake
- Nursing Management
o Implements prescribed interventions such
as limiting Na and water intake
o Administering ordered medications
o Elevates client head, legs, change
position q2, apply elastic stockings
Edema Electrolyte Imbalances
Sodium
- Excess interstitial fluid
- Dependent edema: most apparent in areas where - Hyponatremia is a sodium deficit, or serum
the tissue pressure is low, such as around the sodium level of less than 135 mEq/L, and is, in
eyes, and in dependent tissues where hydrostatic acute care settings, a common electrolyte
capillary pressure is high imbalance.
- Pitting edema: edema that leaves a small - Hypernatremia is excess sodium in ECF, or a
depression or pit after finger pressure is applied serum sodium of greater than 145 mEq/L.
to the swollen area. The pit is caused by Because the osmotic pressure of extracellular
movement of fluid to adjacent tissue, away from fluid is increased, fluid moves out of the cells
the point of pressure. Within 10 to 30 seconds the into the ECF
pit normally disappears as fluid returns to the
Potassium
area.
Dehydration - Hypokalemia is a potassium deficit, defined as a
serum potassium level of less than 3.5 mEq/L.
- Low body fluid in both ECD and ICF
Gastrointestinal losses of potassium through
- hyperosmolar fluid imbalance, occurs when water
vomiting and gastric suction are common causes
is lost from the body, leaving the client with
of hypokalemia, as is the use of potassium-
excess sodium. Because water is lost while
wasting diuretics, such as thiazide or loop
electrolytes, particularly sodium, are retained,
diuretics.
serum osmolality and serum sodium levels
- Hyperkalemia is a potassium excess, defined as
increase
a serum potassium level greater than 5.0 mEq/L.
- Water is drawn into the vascular compartment
Hyperkalemia is less common than hypokalemia,
from the interstitial space and cells, resulting in
and rarely occurs in clients with normal renal
cellular dehydration

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function. It is, however, more dangerous than Acid-Base Imbalances
hypokalemia and can lead to cardiac arrest. Compensation- process wherein healthy regulatory
systems attempt to correct acid case imbalances
Calcium
Respiratory Acidosis
- Hypocalcemia is a calcium deficit, defined as a
total serum calcium level of less than 8.5 mg/dL - Any condition that causes carbon dioxide
or an ionized calcium level of less than 4.5 retention, either due to hypoventilation or
mEq/L. impaired lung function, causes carbonic acid
- Chvostek’s sign: contraction of the facial levels to increase and pH to fall below 7.35, a
muscles in response to tapping the facial nerve in condition
front of the ear; Respiratory Alkalosis
- Trousseau’s sign: carpal spasm in response to
inflating a blood pressure cuff on the upper arm - When an individual hyperventilates, more carbon
to 20 mmHg greater than the systolic pressure for dioxide than normal is exhaled, carbonic acid
2 to 5 minutes levels fall, and the pH rises to greater than 7.45.
- Hypercalcemia is a calcium excess, defined as a Metabolic Acidosis
total serum calcium level greater than 10.5
mg/dL, or an ionized calcium level of greater - When bicarbonate levels are low in relation to the
than 5.5 mEq/L. It most often occurs when amount of carbonic acid in the body, pH fall
calcium is released in excess from the bony Metabolic Alkalosis
skeleton.
- the amount of bicarbonate in the body exceeds
Magnesium
the normal 20-to-1 ratio
- Hypomagnesemia is a magnesium deficiency,
defined as a serum magnesium level of less than
1.5 mEq/L. It occurs more frequently than
hypermagnesemia. Chronic alcoholism is the
most common cause of hypomagnesemia.
- Hypermagnesemia is a magnesium excess,
defined as a serum magnesium level above 2.5
mEq/L, due to increased intake or decreased
excretion. It is often iatro- genic, meaning caused
by medical treatment; usually the cause is over
supplementation with magnesium.
Chloride
- Hypochloremia is a chloride deficit, defined as a
serum chloride level below 95 mEq/L, and is
usually related to excess loss of chloride through
the GI tract, kidneys, or sweating.
Hypochloremic clients are at risk for alkalosis,
and may experience muscle twitching, tremors, or
tetany.
- Hyperchloremia is a chloride excess, defined as
a serum chloride level above 108 mEq/L. Excess
replacement of sodium chloride or potassium
chloride is a risk factor for high serum chloride
levels, as are conditions that lead to
hypernatremia.
Phosphate
- Hypophosphatemia is a phosphate deficit,
defined as a serum phosphate level of less than
2.5 mg/dL.
- Hyperphosphatemia is a phosphate excess,
defined as a serum phosphate level greater than
4.5 mg/dL. It occurs when phosphate shifts out of
the cells into extracellular fluids (e.g., due to
tissue trauma or chemotherapy), in renal failure,
or when excess phosphate is administered or
ingested

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