LD LICEO DE CAGAYAN UNIVERSITY
PASEO DEL RIO CAMPUS
CU
SURGERY
DEFINITION
Is a branch of medicine concerned
with the treatment of diseases,
deformities, & injuries through
manual procedures called
operations
TERMS
EXTOMY- excision or removal
LYSIS- destruction of
ORRAPHY- repair or suture of
OSCOPY- looking into
OSTOMY- creation of opening
PLASTY- repair of scar or tissue
PEXY- fixation, anchor into place
PERIOPERATIVE
NURSING OVERVIEW
PERIOPERATIVE PERIOD
Encompasses a client’s total
surgical experience, including the
preoperative and postoperative
phases.
PERIOPERATIVE NURSING
Refers to activities performed by
the professional nurses during
these phases
PHASES
PREOPERATIVE PHASE
Begins with the decision to
perform surgery and ends the
client’s transfer to operating room
(OR) table.
MedSurg
INTRAOPERATIVE PHASE
Begins with the client is received
in the OR and ends with his
admission to the post anesthesia
recovery room (PARR) or post
anesthesia care unit (PACU)
POSTOPERATIVE PHASE
Begins when the client is admitted
to PARR and extends through
follow-up home or clinic
evaluation
PERIOPERATIVE TEAM
1. The Anesthesiologist or Nurse
Anesthetist
Makes a preoperative assessment
to plan the type of anesthetic to
be administered and to evaluate
the client physical status.
2. The Professional Registered or
Nurse
Makes preoperative nursing
assessment and documents the
intra-operative client care plan
3. The Circulating Nurse
Manages the OR and protects the
safety and health needs of the
client by monitoring the
conditions in the OR
4. The Scrub Nurse
Is responsible for scrubbing for
surgery, including setting up
sterile tables and equipment and
assisting the surgeon and surgical
technicians during the surgical
procedure.
5. The PACU Nurse
Is responsible for caring foe the
client until the client has
recovered from the effects of
anesthesia, is oriented
CONDITIONS
REQUIRING SURGERY
Obstruction or blockage
Perforation
Erosion
Tumor
CATEGORIES OF
SURGICAL
PROCEDURE
According to PUPOSE
According to URGENCY
According to MAGNITUDE or
EXTENT of surgery
PURPOSE
DIAGNOSTIC
Is used to determine the cause
of an illness or disorder
Makes it possible to verify a
suspected diagnosis.
CURATIVE
Tending to overcome disease
and promote recovery
Removal of disease organ or
tissues
RECONSTRUCTIVE
Concerned with restoration,
construction, reconstruction,
or improvement in the shape
and appearance of body
structures that are missing,
defective, damaged, or
misshapen
PALLIATIVE
Affording relief but not cure
PURPOSE
OPTIONAL SURGERY
Is done totally at the clients
discretion
e.g cosmetic surgery
URGENCY
ELECTIVE SURGERY
Refer to procedures that are
schedule at the client’s
convenience
e.g cyst removal, repair of scars, &
simple hernia or vaginal repair
REQUIRED SURGERY
is warranted for conditions
necessitating intervention within a
few weeks.
e.g cataract surgery, thyroid disorder
URGENT OR IMPERATIVE SURGERY
Is indicated for problem requiring
intervention within 4 to 48 hours
e.g some cancers, acute gallbladder
infection appendicitis, kidney stones
EMERGENCY SURGERY
Describe procedure that must be
done immediately to sustain life or
maintain function
MAGNITUDE OR
EXTENT
Major surgery: High Risk;
Extensive; Prolonged; Large
amount of blood loss; Great risk of
complication
Minor surgery: Generally not
prolonged; Leads to few serious
complications; Involves less risk
SURGICAL RISK Hematologic function
Use of medications
1. Age Presence of trauma
2. Obesity
3. Immobility PSYCHOLOGIC
4. Malnutrition Pre-op Defense Mechanism
5. Emergency Regression
6. Endocrine related condition Denial
7. Steroid therapy Intellectualization

MAJOR CAUSES OF Nursing Interventions help relieve

DEATH anxiety
1. Pneumonia Explore feelings
2. Cardiac arrest Allow to speak openly about fears
3. Renal failure Give accurate information
4. Stroke Give emphatic Support
5. Pulmonary emboli
6. Sepsis; peritonitis ASSESSMENT OF ECONOMIC AND
7. Hypovolemic shock DEVELOPMENTAL STATUS

DEGREE OF SURGICAL NURSING PEOPLE

RISK DEPENDS ON: BEFORE SURGERY
1. Nature, location, and duration of Preoperative Preparation: 4 phases
the condition At the physician’s office before
2. Type and classification of surgery admission to health care facility
3. Person’s mental attitudes Upon admission and during days
4. Available professional resources before operation
Night before the surgery
IDENTIFICATION OF Morning of surgery
POTENTIAL RISK
PREOPERATIVE
Elicitation of stress response
ADMISSION
Decreased resistance of infection
Description of the vascular system Depend on the amount of
Disturbance of body image preoperative intervention
Involve family interview
NURSING Thorough assessment of the body
ASSESSMENT system
Patient orientation
PHYSIOLOGIC Verify info on pre-operative
Age Presence of pain testing
Nutritional Status Initiates teaching appropriate to
Fluid and Electrolyte pt’s needs
Infection
Cardiovascular function PSYCHOLOGIC ASPECT
Pulmonary function Fear of the unknown
Renal function Provide information about
Gastrointestinal function hospitals protocols
Liver function Explains procedure of surgical
Endocrine function phases
Neurologic function Explain all nursing intervention
 Allow pt to ask question
Introduce to people who had
successful operation
Arrange occupational therapy on
extended post op
Include significant others in
discussion
LEGAL ASPECT
INFORMED CONSENT
(OPERATIVE PERMIT/
SURGICAL CONSENT)
PURPOSE
To ensure that the client
understand the nature of the
treatment including the potential
complication and disfigurement.
To indicate that the clients
decision was made without
pressure
To protect the client against
unauthorized procedure
To protect the surgeon and
hospital against legal action by a
client who claims that an
unauthorized procedure was
performed.
CIRCUMSTANCES
REQUIRING PERMIT
Any surgical procedure where
scalpel, scissors, suture, hemostat
or electrocoagulation may be used
Entrance into a body cavity- e.g
paracentesis, bronchoscopy,
cystoscopy, colonoscopy, &
proctosigmoidoscopy
General anesthesia, Local
infiltration, Regional block
REQUISITE FOR
VALIDITY OF
INFORMED CONSENT
Written permission is best and is
legally acceptable
Signature is obtained with clients
complete understanding of what
to occur- adult sign their own
operative permit; it is obtained
before sedation
Secured without pressure or
duress
A witness is desirable- nurse,
physician, or other authorized
person.
In an emergency, permission via
telephone or telefax is acceptable
For minor (below 18 yrs.),
unconscious, psychologically
incapacitated, permission is
required from responsible family
members (parent/ legal guardian)
PHYSIOLOGIC ASPECT
Correct dietary deficiencies
Reduce weight
Correct fluid and electrolyte
imbalances
Restore adequate blood volume
Treat chronic disease
treat alcoholic person with
vitamin supplement
IVF fluids if dehydrated
PREOPERATIVE
TEACHING
Preop Exercises
Coughing
Deep breathing- expand
alveoli, prevent atelectasis &
other complication, less pain in
inspiration than expiration
Turning
Moving
Foot and leg exercise
Preoperative teaching Cont.
Incentive spirometer 10-12x
per hour
Early ambulation
PREPARATION ON THE
EVENING BEFORE
SURGERY
4 Major Considerations
Preparing the skin
Awareness of pre-op preparation
protocol of the health care facility
On procedure
Proper technique
Location
Size of areas to be prepared
Specific preferences of the
surgeon
Document observation of the
surgical site
Preparing GIT
Special Preparation of the evening
before surgery
To reduce the possibility of
vomiting
Reduce the possibility of
bowel obstruction
Prevent contamination from
fecal material during intestinal
or bowel surgery
Preparations includes:
Restrict food/fluids
Administration of enema as
needed
Insert gastric tubes/intestinal
tubes
If General Anesthesia
Food and fluids restricted for 8-10
hours before the operations
NPO after midnoc (8-10hrs)
Water be given up to 4hrs before
surgery as ordered
When surgery is not schedule until
late afternoon person may eat
light breakfast in AM if permitted
Extremely debilitated or
malnourished receive IV infusion
amino acid, glucose, plasma till
moment of surgery
ENEMA as ordered
GUIDELINES OF PREOP
FASTING
Preparing for anesthesia
Done evening before surgery to
complete respiratory,
Cardiovascular, neurologic
examination
Determine the type of anesthesia
used during surgery
Discuss type anesthesia planned,
sensation the person will
experience
Address fears. A clam, confident
person undergoes anesthesia
more smoothly than someone who
is nervous is frightened
Promoting rest and sleep
Physically comfortable; mentally
ease; adequately sedated
Measure to reduce sleeplessness
and restlessness, have a well-
ventilated room, comfortable and
clean bed, give back rube, worm
beverage if fluid not
contraindicated.
PREPARATION ON THE
DAY OF SURGERY
A. Early Morning Care
Record vital signs- slight increase
due to anxiety
Check ID band
Skin prep thoroughly/ oral hygiene
Check order if carried out
Identify if not eaten within 4-10hrs
Remove jewelry, hearing aid
prosthesis
Remove colored nail polish
B. Pre-Operative Medication SAFETY MEASURES
To allay anxiety, reduce
pharyngeal secretions, reduce OR tables are securely locked
effect of anesthesia and create Muscles, nerves, and bony
amnesia prominences are positioned or
padded to avoid injury
Before administration anesthesia Heavily sedated patients and the
1. Get the BP and record elderly are moved slowly & gently
2. If given to early-induction is more Ensure tubing are not dislodged or
difficult to administered, put side obstructed
rails up, turn off lights, instruct Straps should not interfere with
not to get up without resistance to blood circulation
prevent dizziness, speak only Sterile team members should not
when necessary, just before the lean on any part of the patient’s
person goes to surgery “ON CALL” body.
if tentative schedule for surgery.
POSITION DURING
C. Transporting the person to surgery SURGERY
Gently move transporting to
DORSAL RECUMBENT
stretcher smooth and gentle to
Hernia repair
prevent Am nausea and vomiting,
Mastectomy
cover with blanket to prevent
Bowel resection
exposure and draft.

INTRAOPERATIVE
PHASE
Goals of Care:
Asepsis
Homeostasis
Safe administration of anesthesia
TRENDELENBURG’S
Basic Rules: Lower abdomen
Only sterile materials may be used Pelvic surgeries
within a sterile field. if there is any
doubt about the sterility of the
item, it’s considered UNSTERILE
Gowns of scrubbed team
members are sterile in the front
from shoulder to waist level and
sleeves 2 inches above the elbow
Draped tables are considered to
be sterile on top only LITHOTOMY
Sterile surface should contact Vaginal Repairs
only sterile areas D&C
Edges of any sterile package or Rectal surgery
container are considered unsterile Abdominal perineal resection
The sterile field should be created
as close to the time it is going to
be used as possible
 REGIONAL
Reduce all painful sensations in
one region of the body without
inducing unconsciousness

LEVELS OF SEDATION AND

ANESTHESIA

PRONE
Minimal Sedation
Spinal surgeries
Cognitive and coordination may
Laminectomy
be impaired, but ventilatory &
cardiovascular functions are not
affected

Moderate Sedation
It depressed the level of
consciousness that does not
impair the patient’s ability to
LATERAL maintain a patent airway and to
Kidney respond appropriately to physical
Chest stimulation and verbal command.
Hip Surgeries
Deep Sedation
A drug induced state during which
patient cannot be easily aroused
but can responds purposefully
after repeated stimulation.

NURSING
RESPONSIBILITIES
Explain the purpose of the
position
Avoid undue exposure
Strap the person to prevent falls
Maintain adequate respiratory and
circulatory function
Maintain good body alignment
TYPES OF
ANESTHESIA
STAGES OF
ANESTHESIA
STAGE 1: ONSET/ INDUCTION
Extends from the administration
of anesthesia to the limit of loss of
consciousness
During this stage, noises are
exaggerated; even low voices or a
low or minor sound seem loud and
unreal. For this reason, the nurse
avoids making unnecessary noises
or motions when anesthesia
begins.

GENERAL ANESTHESIA STAGE 2: EXCITEMENT/ DELIRIUM

Total loss of consciousness and
sensation
Produces amnesia
IV, Inhalation, & rectal
Extends from the time of loss of
consciousness to the time of loss
of lid reflex. It may be
characterized by the shouting
struggling of the client
The pupils dilate but constrict if
exposed to light, the pulse is rapid.
STAGE 3: SURGICAL
Extend from the loss of lid reflex
to the loss of most reflexes.
Surgical procedure is started
Patient is unconscious and lies
quietly at the table
Pupils are small but constrict
when they are exposed to light
Respiration is regular, the pulse
rate and volume are normal, and
the skin is pink or slightly flushed
STAGE 4: MEDULLARY/ STAGE OF
DANGER
It is characterized by
respiratory/cardiac depression or
arrest. It is due to an overdose of
anesthesia
Respirations become shallow,
the pulse is weak and thready
Pupils become widely dilated
and no longer constrict when
exposed to light
Cyanosis develops, and
without prompt intervention,
death rapidly follows
METHODS OF
ANESTHESIA
ADMINISTRATION
Inhalation
May be administered by mixing
the vapor with oxygen or nitrous
oxide-oxygen and the having the
patient inhale the mixture
Administered through a tube or a
mask
It can also be administered using a
laryngeal mask
It can also be administered using the
endotracheal technique
When it is place, the tube seals off the
lung from the esophagus so that if the
patient vomits, the stomach does not
enter the lungs
Intravenous
intravenous anesthetic agents are
non-explosive; they require little
equipment and are easy to
administer
Intravenous anesthesia is useful
for short periods but less often
used for longer abdominal surgery
procedures.
Advantageous because the onset
of anesthesia is pleasant; there is
none of buzzing, roaring, or
dizziness known to follow the
administration of an inhalation
anesthetic
Duration of action is brief, and the
patient awakens with little nausea
or vomiting
Thiopental is the agent of choice,
but it causes powerful respiratory
depressant
REGIONAL
ANESTHESIA
Is a form of local anesthetic in
which an anesthetic agent is
injected around the nerve
The patient is awake and aware of
his or her surroundings unless
medication is given to produce
mild sedation of to relieve anxiety
Nurses must avoid careless
conversation, unnecessary noise
and unpleasant odors.
CONDUCTION BLOCK
AND SPINAL
ANESTHESIA
There are many types of conduction
block
Epidural Anesthesia
Achieved by injecting a local
anesthetic into the spinal canal in
the space surrounding the dura
mater
Block sensory, motor and
autonomic functions
 Are much higher in doses because POTENTIAL
it is not in direct contact with cord INTRAOPERATIVE
or nerve roots
COMPLICATIONS
Advantageous because of the
absence of headaches
Nausea and Vomiting
Disadvantage because of the
Anaphylaxis
greater technical challenge of
Hypoxia and other respiratory
introducing the anesthetic into the
complications
epidural matter than the
Hypothermia
subarachnoid
Malignant Hyperthermia

Spinal Anesthesia
Transport of the client from the OR to
Type of extensive conduction
RR/PACU
nerve block that is introduced into
Avoid exposure
the subarachnoid space at the
Avoid rough handling
lumbar level between L4 and L5
Avoid hurried movement and
Anesthesia of the lower
rapid changes in position
extremities, perineum, and lower
abdomen
POSTOPERATIVE
Nausea, vomiting, & pain may
occur during surgery due to the
PHASE
manipulation of those structures
Maintain adequate body system
Administration of a weak solution
function
of thiopental and inhalation of
Restore homeostasis
nitrous oxide may prevent such
Alleviate pain and discomfort
reactions.
Prevent post-op complications
Headache may be after-effect due
Ensure adequate discharge
to many factors, such as:
planning and teaching
A spinal needle used
The leakage of fluid from the
NURISNG CARE:
subarachnoid space through
the puncture site
IMMEDIATE POSTOP
Patient’s hydration status CARE (PACU/RR)
Use measures to increase the
ASSESSMENT
cerebrospinal pressure of the
Appraise air exchange status and
patient to relieve headache
note skin color
Keep the patient lying flat on
Verify identity, operative
the bed and well-hydrated.
procedure, surgeon
Assess Neurologic status (LOC)
Local Infiltration Anesthesia
Determine VS and skin
Injection of the local anesthetic
temperature (CV status)
into the tissue at the planned
incision site combined with the
NURSING
local regional block.
Local anesthesia is administered ASSESSMENT &
with epinephrine INTERVENTION
Constrict blood vessels and
prevent rapid absorption of Examine the operative site and
anesthetic agent, thus it check dressing
prolongs its effect.
 Perform safety checks:
position for good body
alignment
side rails
restraints for IVF’s, Blood
transfusion
Require briefing on problems
encountered in OR
INTERVENTIONS (RR)
Ensure maintenance of patent airway
and adequate respiratory function:
Lateral position with neck
extended
Keep airway in place until fully
away
*suction secretions
Encourage deep breathing
Administer humidified oxygen as
ordered
ASSESS STATUS OF
CIRCULATORY SYSTEM
Monitor vital signs and report
abnormalities
Observe signs and symptoms of
shock and hemorrhage
Promote comfort and maintain
safety
Continuous, constant patient
surveillance until he is completely
out of anesthesia
PAIN MANAGEMENT
What is Pain?
An “unpleasant, subjective,
sensory and emotional experience
associated with actual or potential
tissue damage or described in
term of such tissue”
PATIENT’S RIGHTS
It is every person’s right to have
their pain appropriately and
aggressively managed
Pain relief is a “basic human right”
It is “not the responsibility of the
patients to prove they are in pain;
it is the nurses’ responsibility to
accept the client’s report of pain”
PAIN ASSESSMENT/
INTERVENTION/ RE-
ASSESSMENT (AIR)
CYCLE INDICATOR
Pain Assessment:
Comprehensive evaluation of pain
How do you assess pain?
Pain Intervention:
Selection and implementation of
various measures to facilitate pain
relief
What nurse interventions could be
used to manage pain?
What non-nursing interventions
could be used to manage pain?
Pain Reassessment:
Subsequent evaluation of the
effectiveness of pain relief
measures following the
interventions
NON-
PHARMACOLOGIC
INTERVENTIONS
What are the Examples of Non-
Pharmacologic/ Nursing
Interventions?
Splinting of a fracture
Immobilization of an inflamed joint
Repositioning
Application of therapeutic heat
Cooling of an area of inflammation
Distraction
Reassurance and psychological
support
Unrelieved pain has serious side
effects, which can result harmful
multisystem effects
TRANSFER OF SURGICAL UNIT-
PATIENTS FROM PACU ASSESSMENT
TO THE SURGICAL CONTINUE
UNIT/WARD
Vital signs
Parameters for discharge from RR Bowel sounds
Activity- able to obey commands, Breath sounds
e.g., deep breathing & coughing Level of consciousness
Respiration- easy, noiseless Wound dressing
breathing Tubings
Circulation- BP is within 20 mmHg
of the preop level
Consciousness- Responsive
Color- Pinkish skin and mucus
membrane
 FLUID & ELECTROLYTES
FLUID BALANCE
Maintain body temperature and
cell shape
Transport nutrients, gases, &
wastes
Body’s major organs work
together to maintain fluid balance
Fluids gained must equal the
amount lost
Insensible losses- fluid losses from
skin & lungs (can’t be measured or
seen)
Sensible losses- fluid losses form
urination, defecation, & wounds (can
be measured)
A typical adult loses 100 to
200ml/day of fluid through
defecation
Severe diarrhea losses may
exceed 5000 ml/day
FLUID AND
ELECTROLYTES, ACIDS
AND BASES
The cells of the body live in a fluid
compartment with an electrolyte
and acid-base concentration
maintained within a narrow range
Changes in the electrolyte
concentration affect the electrical
activity of the nerve and muscle
cells and cause fluid shift from
one compartment to another
Alteration in acid-base balance
disrupts cellular functions
Fluid fluctuation also affects
blood volume and cellular
function
Disturbance in these functions are
common and can be life-
threatening
FLUID AND
ELECTROLYTES
60% of the body consists of fluid
Intracellular space (2/3)
Extracellular space (1/3)
Electrolytes are active ions:
positively and negatively charged
MAJOR FLUID
COMPARTMENTS
Intracellular Fluid (ICF)
found inside the cell
averages 40% of an adult person’s
body weight or 28L
Extracellular fluid (ECF)
found outside the cell
averages 20% of an adult person’s
body weight or 14L
ECF is broken down into three spaces:
Intravascular space- fluid with
blood vessel (plasma)
Interstitial space- fluids that
surround the cell (11-12L/adult)
Transcellular space- smallest
division (CSF, pericardial, synovial,
intraocular & pleural fluids)
Capillary walls and cell
membranes separate the ICF and
ECF
REGULATING BODY
FLUIDS
Specific organs and glands help to
regulate fluid and electrolyte balance
Kidney
perform major regulation
functions
retention and excretion of fluids
regulation of pH and excretion of
metabolic waste & toxic
substances
 secretion of renin as a response to
decreased BP or ECF volume

Heart
maintains the kidney’s perfusion
pressure to regulate water and
electrolyte balance

Lungs
maintain acid-base balance; renin
interacts with angiotensin in the
liver to form angiotensin I, which
converts to angiotensin II

Adrenal glands
secret aldosterone, which alters
fluid balance

MOVEMENT OF FLUIDS
Osmosis
Molecules of a solvent pass from a
low-concentration solution to a
high-concentration solution
through a semi-permeable
membrane

Diffusion
Movement of solute from an area
of greater to lesser concentration

Filtration
Movement of water and solutes
from an area of high hydrostatic
pressure to an area of low
hydrostatic pressure
MAINTAINING FLUID
BALANCE Active transport
Sodium potassium pump
Intake should equal fluid output
Sodium concentration is higher in
intake at 2000 ml
ECF than in ICF
output at 1500 ml
Sodium enters the cell by
Difference within 200-300 ml
diffusion
Potassium exits in cell into ECF
SODIUM-POTASSIUM
PUMP
THE CELL IN SHOCK
FLUID AND
ELECTROLYTE
BALANCE
Volume imbalance:
Net volume gain
hypervolemia
Net volume loss
hypovolemia
Water intoxication
overhydration
WATER INTOXICATION
Excess water in all compartments,
electrolyte disturbance is absent
because all compartmental
volumes increase concurrently
Cause: due to severe stress with
excess production of ADH, &
overhydration
S/Sx: weakness. drowsiness, loss
of muscular control, behavioral
changes, disorientation, skin is
flushed and moist, but excessive
sweating seldom occurs
Management: Water restriction
FLUID VOLUME
EXCESS (FVE)
Intake Exceeds Output
Weight gain-surgery
Pitting edema
Cough
Dyspnea
Cardia palpitations
Decreased urinary output
Output Exceeds Intake
Diarrhea
Diuretics
Vomiting
Gastric suction
Anorexia
Increasing fatigue and weakness
Weight loss
Fever
Excess urine output
Traumatic injury (burn)
Blood loss
FLUID VOLUME
DISTURBANCE
Fluid Volume Deficit (Hypovolemia)
Mild- 2% of body weight loss
Moderate- 5% of body weight loss
Severe- 8% or more of body
weight loss
Pathophysiology
results from loss of body fluids
and occurs more rapidly when
coupled with decreased fluid
intake
Clinical Manifestation
Acute weight loss
Decreased skin turgor
1. Oliguria
2. Concentrated urine
3. Postural hypotension
4. Weak, rapid heart rate
5. Flattened neck veins
6. Increased temperature
7. Decreased central venous
pressure
Nursing Diagnosis & Goal Goal: the client will have
Fluid volume Deficit r/t normal fluid volume within 48
insufficient intake of food or fluids hours
dry mucous membranes, low Decreased weight of 1lb. per
BP, HR (112-122), Na 152, urine day, lung sound clear in all
dark amber; Intake fields, ankles without edema
200ml/Output 450ml over 24
hours Nursing management
Goal: The client will have prevent FVE
adequate fluid volume within detecting and controlling FVE
24 hours: teaching patients about edema
Moist tongue, mucous (raise, massage, reduce salt intake,
membranes, HR WNL, Na 135- moving, and use of compression)
145, Urine clear yellow,
balanced I/O REGULATING
ELECTROLYTES
Nursing Management
Restore fluid by oral or IV Sodium
Treat underlying cause Potassium
Monitor I&O calcium
Daily weight Magnesium
Vital signs Chloride
Skin turgor Phosphate
Urine Concentration Bicarbonate

Fluid Volume Excess (Hypervolemia)

Edema of the ankles and feet

Pathophysiology
may be related to fluid overload or
diminished function of the
homeostatic mechanism

Contributing factors
CHF
Renal Failure
Cirrhosis RISK FACTORS OF
FLUID, ELECTROLYTE
Clinical Manifestation IMBALANCE
edema
Chronic Diseases
distended neck veins
Acute conditions
crackles, tachycardia
Medications
increased blood pressure
Treatments
increased weight
Extremes of age
Inability to access food and fluids
Nursing Diagnosis and Goal
Fluid volume excess r/t excess
sodium intake
weight gain of 6 lb. in 24 hours;
lungs with crackles in bases
bilaterally; 2+ edema in ankles
bilaterally
SPECIFIC ILLNESSES Medical Management
Sodium Replacement
COPD, asthma, Cystic Fibrosis Water Restriction
CHF
Kidney disease Nursing Management
Diabetes Mellitus Detecting and controlling
Cancer hyponatremia
malnutrition Returning sodium level to normal
Gastroenteritis
Bowel obstruction HYPERNATREMIA
Head injury The sodium level is greater than
Fever, draining wounds, fistulas 145 mEq/L
Surgery It can be caused by a gain of
sodium in excess of water or by a
MEDICATIONS TO loss of water in excess of sodium
MONITOR
Pathophysiology
Diuretics Fluid deprivation in patients who
Water depletion cannot perceive, respond to, or
Electrolyte depletion communicate their thirst
Corticosteroids Most often affects very old, very
Water retention young, and cognitively impaired
NSAIDS/Opioids patients
Constipation
Clinical manifestation
TREATMENTS THAT
Thirst
AFFECT FLUID Dry, Swollen tongue
BALANCE Sticky mucous membranes
Flushed skin
Chemotherapy
Postural hypotension
IV therapy or TPN
Nasogastric suction
Medical Management
Enteral Feedings
Nursing Management
Mechanical Ventilation
Preventing Hypernatremia
ELECTROLYTE Correcting Hypernatremia
IMBALANCES
HYPONATREMIA
Sodium level less than 135 mEq/L
may be caused by vomiting,
diarrhea, sweating, diuretics, etc.

Clinical Manifestations
Poor skin turgor
Dry mucosa
Decreased saliva production
Orthostatic hypotension
Nausea/Abdominal cramping
Altered mental status
ALL BOUT Clinical Manifestations:
POSTASSIUM Skeletal muscle
weakness/paralysis
Major Intracellular electrolyte EKG changes- such as peaked T
98% of the boy’s potassium is waves, widened QRS complexes
inside the cells Heart block
Influences both skeletal and
cardiac muscle potassium Medical/Nursing Management
Normal serum potassium Monitor EKG changes- telemetry
concentration- 3.5 to 5.5 mEq/L Administer Calcium solutions to
neutralize the potassium
HYPOKALEMIA
Monitor muscle tone
Clinical Manifestations:
Give insulin and D50W
Muscle weakness, cardiac
Calcium gluconate
arrythmias, increased sensitivity
to digitalis toxicity, fatigue, EKG
Calcium
changes (ST elevation)
99% of the body’s calcium is
located in the skeletal system
Nursing Interventions:
Normal serum calcium level is 8.5
Encourage High-K foods
to 10mg/dl
Monitor EKG results
Needed for transmission of nerve
Dilute KCl- can cause cardiac
impulses
arrest if given IVP
Intracellular calcium is needed for
Administering IV potassium
contraction of muscles
Should be administered only after
Extracellular needed for blood
adequate urine flow has been
clotting
established
Needed for tooth and bone
A decreased in urine volume to
formation
less than 20 ml/h for 2 hours is an
Needed for maintaining a normal
indication to stop the potassium
heart rhythm
infusion
IV K+ should not be given faster
HYPOCALCEMIA
than 20 mEq/h
Serum Calcium level less than 8.5
mEq/L
HYPERKALEMIA
Serum Potassium Greater than 5.5
Causes:
mEq/L
Vitamin D/Calcium deficiency
More dangerous than hypokalemia
Primary/surgical
because cardiac arrest is
hyperparathyroidism
frequently associated with high
Pancreatitis
serum K+ levels
Renal Failure
Causes:
Clinical Manifestations:
Decreased renal potassium
Tetany and cramps in muscles of
excretion as seen with renal failure
extremities
& oliguria
A nervous affection characterized
High potassium intake
by intermittent tonic spasms that
Renal insufficiency
are usually paroxysmal and
Shift or potassium out of the cell
involve the extremities
as seen in acidosis
Chvostek sign
Clinical findings associated with
hypocalcemia
Twitch of the facial muscle that
occurs when gently tapping the
cheek
EKG shows prolonged QT intervals
Medical/Nursing Management
IV/PO Calcium carbonate or
Calcium Gluconate
Encourage increased dietary
intake of Calcium
Monitor neurological status
Establish Seizure precautions
HYPERCALCEMIA
Serum Calcium level greater than
10.5 mEq/L
Causes:
Hyperparathyroidism
Prolonged immobilization
Thiazide diuretics
large doses of Vitamin A and D
Clinical Manifestation
Muscle weakness, nausea and
vomiting
Lethargy and confusion
Constipation
cardiac Arrest (in hypercalcemic
crisis, level 17mg/dl or higher)
Medical/Nursing Management
Eliminate Calcium from the diet
Monitor neurological status
Increase fluids (IV and PO)
Calcitonin
Used to lower serum calcium
level
Useful for pts with heart
disease or renal failure
Reduces bone resorption
Increases deposit of calcium
and phosphorus in the bones
Increase urinary excretion of
calcium and phosphorus
Magnesium
Normal serum magnesium level is
1.5 to 2.5 mg/dl
Helps maintain normal muscle &
nerve activity
Exerts effects on the
cardiovascular system, acting
peripherally to produce
vasodilation
Thought to have a direct effect on
peripheral arteries and arterioles
HYPOMAGNESEMIA
Serum Magnesium level less than
1.5 mEq/L
Cause:
Chronic Alcoholism
Diarrhea, or any disruption in
small bowel function
Clinical Manifestations
Neuromuscular irritability
Positive Chvostek’s and
Trousseau’s Sign
EKG changes with prolonged QRS,
depressed ST segment, and
cardiac dysrhythmias
may occur with hypocalcemia and
hypokalemia
STARVED
a possible cause of
hypomagnesemia
S- seizures
T- tetany
A- anorexia and arrhythmias
R- rapid heart rate
V- vomiting
E- emotional lability
D- deep tendon reflexes increased
Medical/Nursing Management
IV/PO Magnesium replacement,
including Magnesium Sulfate
Give Calcium Gluconate if
accompanied by hypocalcemia
Monitor for dysphagia, give soft
foods
Measure vital signs closely
Foods high in Magnesium: Clinical Manifestations:
Green leafy vegetables Muscle weakness
Nuts Seizures and coma
Legumes Irritability
Seafood Fatigue
Chocolate Confusion
Numbness
HYPERMAGNESEMIA
Serum Magnesium level greater Medical/Nursing management
than 2.5 mEq/L Prevention is the goal
IV Phosphorus for severe
Causes: Prevention of infection
Renal failure Monitor Phosphorus levels
Untreated diabetic ketoacidosis Increase oral intake of phosphorus
Excessive use of antacids and rich foods
laxatives
Foods rich in Phosphorus
Clinical manifestations Milk and Milk products
Flushed face and skin warmth Organ meats
Mild hypotension Nuts
Fish
Medical/Nursing Management Poultry
Monitor Mg levels Whole grains
Monitor respiratory rate
Monitor Cardiac rhythm HYPERPHOSPHATEMIA
Increase fluids Serum phosphorus level greater
than 4.5 mEq/L
Phosphorus
Normal serum phosphorus level is Causes:
2.5 to 4.5 mg/dl Renal failure
Essential to the function of muscle Chemotherapy
and red blood cells, maintenance Hypoparathyroidism
of acid-base balance, and nervous High phosphate intake
system
Phosphate levels vary inversely to Clinical manifestations:
calcium levels Tetany
High Calcium= Low phosphate Muscle weakness
Similar to Hypocalcemia because
HYPOPHOSPHATEMIA of reciprocal relationship
Serum Phosphorus level less than
2.5 mEq/L Medical/Nursing Management
Treat underlying cause
Causes: Avoid phosphorus rich foods
Most likely to occur with
overzealous intake or PROMOTING FLUID AND
administration of simple ELECTROLYTE BALANCE
carbohydrates
Consume 6-8 glasses of water
Severe protein-calorie
daily
malnutrition (anorexia or
Avoid food with excess salt, sugar
alcoholism)
caffeine
Eat well-balanced diet
 Limit alcohol intake
Increase fluid intake before,
during, and after strenuous
exercise
Replace lost electrolytes
Maintain normal body weight
Learn about, monitor, and manage
side effects of medication
Recognize risk factors
Seek professional health care for
notable signs of fluid imbalances
FLUID MANAGEMENT
What are IV Fluids?
Intravenous fluids (IV fluids) are
supplemental fluids used tin
intravenous therapy to restore or
maintain normal fluid volume and
electrolyte balance
Indications
Anesthesia, severe vomiting, &
diarrhea
Dehydration & shock
Hypoglycemia
Vehicle for, e.g., antibiotics &
chemotherapy agents
TPN
Critical problems, e.g.,
anaphylaxis, cardiac arrest, drug
overdose, & poisoning
Advantages
Accurate, controlled, and
predictable way of administration
Immediate response due to direct
infusion
Prompt correction of serious fluid
and electrolyte disturbances
Disadvantages
More expensive, need asepsis, and
under-skilled supervision
Improper selection of type,
volume, rate and technique can
lead to serious problems
Contraindications
Avoided if the patient can take
oral fluids
CHF; Pulmonary edema
Complications
Local
Hematoma
Infusion phlebitis
Systemic
Large volumes can lead to
circulatory overload
Air embolism
Septicemia
Others
Fluid contamination & mixing
incompatible drugs
TYPES OF IV FLUIDS
Crystalloids
small molecules, are cheap, easy
to use, and provide immediate
fluid resuscitation, but may
increase edema.
consist of isotonic saline or
balance electrolyte solutions and
are widely distributed across
extracellular fluid compartments
Colloids
larger molecules, cost more, and
may provide swifter volume
expansion in the intravascular
space, bit may induce allergic
reactions, blood clotting disorder,
and kidney failure
tend to stay in the intravascular
space because these larger
molecules are slower to diffuse
into the extravascular space
ISOTONIC IV FLUIDS
Most IV fluids are isotonic ( the
same concentration of solutes as
blood plasma)
Expand both the intracellular fluid
and extracellular fluid spaces
equally
Isotonic IV fluids do not cause red
blood cells to shrink to swell
0.9% NaCl (Normal Saline)
Th percentage of NaCl dissolved in
the solution is similar to the usual
concentration of Na & Cl in the
intravascular space
Isotonic solution of choice for
expanding ECF volume because it
does not enter the ICF
It is administered to correct
extracellular fluid volume deficit
because it remains within the ECF
It is used alongside the
administration of blood products
(Compatible)
It also replaces large sodium
losses, such as in burn injuries and
trauma
It should not be used for heart
failure, pulmonary edema, renal
impairment, or conditions that
cause sodium retention, as it may
risk fluid volume overload
Dextrose 5% in Water (D5W)
initially, an isotonic solution
becomes hypotonic once dextrose
is metabolized (expanding the ECF
and ICF)
A liter of D5W provides fewer than
200kcal and contains 50g of
glucose
It should not be used for fluid
resuscitation because
hyperglycemia can result
It should also be avoided in clients
at risk for increased intracranial
pressure as it can cause cerebral
edema
Lactated Ringers 5% Dextrose in
Water (D5LRS)
AKA Ringer’s Lactate or Hartmann
solution
Electrolyte content is most closely
related to the composition of the
body’s blood serum and plasma
(physiologically adaptable)
Contains bicarbonate precursors
to prevent acidosis
Correct dehydration & Na
depletion & replace GI tract fluid
losses.
Used in fluid losses due to burns,
fistula drainage, & trauma
Metabolizes in the liver should bot
be given to patients with liver
disease & lactic acidosis
Used with caution for patients
with heart failure and renal failure
Nursing Considerations for Isotonic
IV Solution
Document baseline data
Observe for signs of fluid overload
Monitor manifestations of
continued hypovolemia
Prevent hypervolemia
Elevate the head of the bed at 35
to 45 degrees
Elevate the patient’s legs
Educate patients and families
Close monitoring for patients with
heart failure
HYPOTONIC IV FLUIDS
Contains fewer solutes than
plasma
Cause fluid shifts from the ECF
into the ICF to achieve
homeostasis, causing cells to swell
and may even rupture
IV solutions are considered
hypotonic if the total electrolyte
content is less than 250 mEq/L
Usually used to provide free water
for the excretion of body wastes,
treat cellular dehydration &
replace the cellular fluid
0.45% Sodium Chloride (0.45% NaCl)
AKA as half-strength normal saline
Used for replacing water in
patients who have hypovolemia
with hypernatremia
Excess use may lead to
hyponatremia due to the dilution
of sodium, especially in patients
prone to water retention
Used to treat hypernatremia and
other hyperosmolar conditions
0.33% Sodium Chloride Solution
Used to allow kidneys to retain the
needed amounts of water and is
typically administered with
dextrose to increase tonicity
Used cautiously for patients with
heart failure and renal
insufficiency
0.225% Sodium Chloride (0.225%
NaCl)
Used as a maintenance fluid for
pediatric patients as it is the most
hypotonic IV fluid available
Used together with dextrose
Nursing Considerations for
Hypotonic IV Solution
Document baseline data
Do not administer in
contraindicated conditions
Risk for increased intracranial
pressure (IICP)
Monitor for manifestations of fluid
volume deficit
Warning on excessive infusion
Do not administer along with
blood products
HYPERTONIC IV FLUIDS
Greater concentration of solutes
(375 mEq/L and greater) than
plasma
Cause fluids to move out of the
cells and into the ECF to normalize
the concentration of parties
between two compartments
Causes cells to shrink & may
disrupt their function
AKA as volume expanders as they
draw water out of the intracellular
space, increasing extracellular
fluid volume
3% sodium chloride (35 NaCl)
containing 513 mEq/L of Na and Cl
with an osmolality of 1030
mOsm/L
5% sodium chloride (5% NaCl)
containing 855 mEq/L of Na and Ci
with an osmolality of 1717 mOsm/L
Used in the acute treatment of
sodium deficiency (severe
hyponatremia) and should be used
only in critical situations to treat
hyponatremia
Need to be infused at a very low
rate to avoid the risk if overload
and pulmonary edema
If administered in larger quantities
and rapidly, they may cause an
extracellular volume excess and
precipitate circulatory overload in
fluid excretion
It is also used in patients with
cerebral edema
Dextrose 10% in water (D10W)
Used in the treatment of ketosis of
starvation and provides calories
(380kcal/L), free water, and no
electrolytes
Should be administered using a
central line if possible and should
not be infused using the same line
as blood products as it can cause
RBC hemolysis
Dextrose 20% in Water (D20W)
Causes fluid shifts between
various compartments to promote
diuresis
Dextrose 50% in water (D50W)
Used to treat severe hypoglycemia
and is administered rapidly via IV
bolus
Nursing Considerations for
Hypertonic IV fluids
Document baseline data
Watch for signs of hypervolemia
Monitor and observe the patient
during administration
Verify order
Assess health history
Prevent fluid overload
Do not administer peripherally
Monitor blood glucose closely
COLLOIDS IV SOLUTION
Colloids
Contains large molecules that do
not pass through semipermeable
membranes.
Contains solutes of high molecular
weight that, when infused, exert
an osmotic pull of fluids from
interstitial and extracellular
spaces.
Useful for expanding the
intravascular volume and raising
blood pressure.
Indicated for patients in
malnourished states and patients
who cannot tolerate large
infusions of fluid.
Human Albumin
Solution derived from plasma.
5% Albumin is a solution derived
from plasma and is a commonly
utilized colloid solution.
Used to increase the circulating
volume and restore protein levels
in conditions, e.g., burns,
pancreatitis, and plasma loss
trauma.
ACID-BASE BALANCE
WHAT ABG?
Measure respiratory function
Make changes in treatment
Ventilator settings
Monitor acid-base balance
for example: DKA
HYDROGEN ION (H+)
BALANCE
H+ is found in both the
intracellular and extracellular
fluids
H+ is vital in regulating the
following biochemical and
metabolic activities for proper
cellular function.
25% Albumin is used together
with sodium and water restriction
to reduce excessive edema.
Contraindicated:
Severe anemia, heart failure, or
known sensitivity to albumin.
Other colloids IV Solution
Dextran
Gelatin
Gelofusine
Nursing Considerations for Colloid IV
Solutions
Assess allergy history
Use a large-bore needle (18-gauge)
Document baseline data
Monitor coagulation indexes
Monitor the patient’s response
HYDROGEN ION
Affects the normal distribution of
other ions (e.g., Na & K+) between
the intracellular fluids and the
ECF.
Normal ECF hydrogen ion
concentration is essential for
normal body functions.
DEFINITIONS
Acid
Any substance that releases
hydrogen ions when dissolved in
water
Base PCO2
Any substance that binds
hydrogen when dissolved in water Measurement of carbon dioxide
Controlled by the lungs
Buffer (respiratory)
Any substance capable of binding Carried as carbonic acid H2CO3
or releasing hydrogen ions from Has an inverse relationship with
body fluids pH
If pCO2 up­then pH low
BALANCE Normal ABG: pCO2 35 – 45 mm Hg
< 35 = hyperventilation or base
Kidneys control bicarbonate =
(alkalosis)
Metabolic
> 45 = hypoventilation or acidic
Lungs control carbon dioxide =
(acidosis)
Respiratory

ARTERIAL BLOOD GAS PO2

MEASURES Measures oxygen carried by red
pH bloodcells and dissolved in
7.35-7.45 (percent of H= plasma
Concentration) Normal ABG: P02 80 –100 mm Hg
< 80 is hypoventilation
pCO2 (hypoxia)
35-45 (Pressure of Carbon dioxide)
HCO3
pO2 Measurement of amount of
80-100 (Pressure of Oxygen) bicarbonate in blood
Is the body’s buffer system
SaO2 Controlled by the kidneys
>95% (Oxygen Saturation) (metabolic)
Normal ABG:HCO3 21 – 28 mEq/L
BE < 21 = acidic (acidosis)
-2 to +2 (Base Excess) > 28 = base (alkalosis)

HCO3 BASE EXCESS

21-28 (Bicarbonate)
PH
How acidic or alkaline a substance
is
Normal ABG: pH 7.35 – 7.45
< 7.35 is acidic (acidosis)
> 7.45 is base (alkalosis)
7.40 considered exactly normal
when determining compensation
Indication of how much extra base
is available to the body
Normal ABG: -2 to +2
< -2 = acidic (metabolic
acidosis)
> +2 = base (metabolic
alkalosis)
pH- measures hydrogen ion
concentration in the blood; shows
blood acidity or alkalinity
PaCO2 – It is the partial pressure
of CO2 that is carried by the blood
for excretion by the lungs; known
as the respiratory parameter
 PaO2- it is the partial pressure of
O2 that is dissolved in the blood; it
reflects the body’s ability to pick
up O2 from the lungs
HCO3 – known as the metabolic
parameter, reflects the kidney’s
ability to retain and excrete
bicarbonate

ACID-BASE RESPIRATORY
IMBALANCES IMBALANCES
Respiratory acidosis 1. Respiratory Acidosis
Respiratory alkalosis The PH is down
Metabolic acidosis The PCO2 is up
Metabolic alkalosis 2. Respiratory Alkalosis
The PH is up
ARTERIAL BLOOD GASES The PCO2 is down
ACIDOSIS COMPENSATION
Blood pH < 7.35
Abnormal ­in H+ in the body due to The goal is to try to maintain
accumulation of acid or loss of normal pH
base If problem is with lungs then
Effects: kidneys try to compensate
Severe CNS depression If problem is with kidneys then
pH <7.0 =coma & death lungs try to compensate
If the compensation occurs fully,
ALKALOSIS the pH returns to normal: full
Blood pH > 7.45 compensation
Abnormal decrease in H+ in the If the compensating organ cant
body due to accumulation of base work hard enough to compensate,
or loss of acid the pH will still be abnormal:
Effects: partial compensation
CNS stimulation
Tetanus - sustained muscular HOW THE BODY
contraction COMPENSATES
Convulsions
Death from respiratory arrest Body attempts to maintain normal
pH through the:
Lungs
Very sensitive and can
compensate quickly by
changing respiratory rate
But tires easily so cant
continue long term
low pH (acid) =
respiratory rate (high) ­-
to blow off CO2 (acid)
 Kidneys
More powerful but slower
(hours to days)
Changes the amount of
hydrogen excreted and
bicarbonate retained
(low) pH (acid) = kidneys
excrete more H+ and
retain more
bicarbonate so HCO3
(high)
RESPIRATORY ACIDOSIS
Caused by the failure of the
respiratory system to remove CO2
from body fluids as rapidly as it is
produced in the tissues.
CO2 retention, increased carbonic
acid, decreased pH
A decrease in the pulmonary
ventilation rate will increase the
PaCO2 of the ECF, causing an
increase in H2CO3.
Due to:
Depressed ventilation
Pulmonary disease
CNS depression
Restriction of thoracic movement
Airway obstruction
WHAT TESTS SHOW?
Uncompensated
pH <.35
PaCO2 >45
HCO3 Normal
Compensated
pH Normal
PaCO2 >45
HCO3 >26
How it’s treated?
Bronchodilator to open
constricted airways
Supplemental oxygen as needed.
Antibiotic to treat infection.
Chest physiotherapy to remove
secretions from the lungs
Removal of a foreign body from
the patient’s airway, if needed.
If hypoventilation can’t be
corrected, expect the patient to
have an artificial airway inserted
and then be placed on mechanical
ventilation. Be aware that
bronchoscopy may be needed to
remove retained secretions.
RESPIRATORY
ALKALOSIS
Respiratory alkalosis is caused by
the loss of carbon dioxide from
the lungs faster than it is
produced in the tissues.
Excessive CO2 excretion,
increased pH
This leads to a decrease in arterial
PaCO2 below 35 mm Hg
(hypocapnia), with a pH greater
than 7.45.
How it happens?
Any clinical condition that
increases respiratory rate or
depth can cause the lungs to
eliminate, or “blow off,” CO2.
Because CO2 is an acid,
eliminating it causes a decrease in
PaCo2 along with an increase in
pH –alkalosis.
Due to:
Hyperventilation (anxiety)
Mechanical ventilation
CNS disease
Fever
WHAT TEST SHOW?
Uncompensated
pH >7.35
PaCO2 (mmHg) <35
HCO3 (mEq/L) Normal
Compensated
pH Normal
PaCO2 (mmHg) <35
HCO3 (mEq/L) <22
How it’s treated?
Treatment focuses on correcting
the underlying disorder by
removing the causative agent, e.g.,
salicylate or other drug, or taking
steps to reduce fever & eliminate
the source of sepsis.
If Acute Hypoxemia is the cause –
oxygen therapy is initiated.
If anxiety is the cause, the patient
may receive a sedative or an
anxiolytic.
Hyperventilation can be
counteracted by having the
patient breathe into a paper bag
or into cupped hands, which
forces the patient to breathe
exhaled CO2, thereby raising the
CO2 level.
METABOLIC
IMBALANCES
1. Metabolic Acidosis
The pH is down
the HCO3 is down
2. Metabolic Alkalosis
The Ph is up
The HCO3 is up
METABOLIC ACIDOSIS
Caused by an increase in H+
production and is characterized
by a pH below 7.35 and HCO3 level
below 22 mEq/L.
This disorder depresses the CNS.
It may lead to ventricular
arrhythmias, coma and cardiac
arrest.
Some causes:
Alcohol consumption
(metabolized to Acetic Acid)
Acid ingestion
(asa)
Diabetes mellitus or starvation
(ketoacids produced)
Lactic acid
Renal disease
(unable to eliminate excess H+)
How it happens?
Loss of HCO3 from ECF, an
accumulation of metabolic acids,
or a combination of the two.
Gain in acids or a loss of bases
from the plasma.
Overproduction of ketones
bodies.
Fatty acids are converted to
ketone bodies when glucose
supplies have been used, and the
body draws on fat stores for
energy (DKA). Causes:
Excessive GI loss from the GI tract
WHAT TEST SHOW? Diuretic therapy
Uncompensated Cushing disease
pH >7.35 Organic acidosis
PaCO2 (mmHg) Normal Kidney disease
HCO3 (mEq/L) <22 Certain drugs like corticosteroids
and antacids that contain sodium
Compensated bicarbonate can lead to metabolic
pH Normal alkalosis
PaCO2 (mmHg) <35
HCO3 (mEq/L) <22 WHAT TEST SHOW?
Uncompensated
How it’s treated? pH >7.45
Insulin PaCO2 Normal
Sodium bicarbonate HCO3 >26
Fluids
Dialysis Compensated
Prepare for intubation pH Normal
Maintain Patent I.V. line for PaCO2 <45
emergency drugs HCO3 >26

METABOLIC ALKALOSIS How it’s treated?

Decreased in H+ production,
characterized by a blood pH above
7.45 and HCO3 level above 26
mEq/L.
IV administration of ammonium
chloride
Thiazide diuretics and NG
suctioning are discontinued
Antiemetics
Acetazolamide (Diamox)

INFORMATION NEEDED:
pH tells whether an imbalance
exists or not
Normal values 7.35 - 7.45
PCO2 tells whether the cause
respiratory
Normal values 35 - 45
HCO3- Tells whether the cause is
metabolic
Normal values 22-29
 STEPS TO ANALYZE
ABG’S
PH NEVER LIES!
Points to Remember:
In acidosis PH IS DOWN
In alkalosis PH IS UP
Respiratory indicator is PCO2
Metabolic indicator is HCO3
BURNS
DEFINITION
Burns are wounds produced by
various kinds of agents that cause
cutaneous injury and destruction of
underlying tissue
TYPES OF BURNS
Thermal injury
Scald- spillage of hot liquids
Flame burns
Flash burns due to exposure of
natural gas, alcohol,
combustible liquids
Contact burns- contact with
hot metals/objects/materials
Electrical injury
Chemical burns- acid/alkali
Cold injury- frost bite
Ionizing radiation
Sun burns
THE RULES!
1. Look at the pH - (7.25) Is it normal,
acidotic, or alkalotic? The pH is
acidotic!
2. Look at the PCO2. (PCO2 72)
Normal? Does it indicate
respiratory acidosis or respiratory
alkalosis?
3. Look at the HCO3- (HCO3 33) Is it
normal? Does it indicate metabolic
acidosis or metabolic alkalosis?
4. Choose whichever of #2 or #3
agree with the pH. This is the
condition. If the third variable is
normal the condition is not
compensating. If it is abnormal it is
compensating.
CLASSIFICATION OF
BURNS
Depending on the thickness of skin
involved
First degree:
Epidermis is red and painful
No blisters
Heals rapidly in 5-7 days
By epithelialization without
scarring
Second degree:
Mottled, red, painful, with
blisters
Heals in 14-21 days
Superficial burn heals, causing
pigmentation
Deep burn heals, causing
scarring, and pigmentation
Third degree:
Charred, painless and
insensitive
Thrombosis or superficial
vessels
It requires grafting
 Eschar
Charred, denatured,
insensitive, contracted full
thickness burn
These wound must heal by
re-epithelialization from
wound edge
Fourth degree:
Involves the underlying tissues-
muscles, bones
Depending on thickness of skin
involved
Partial thickness burns:
It is either first or second
degree burn which is red and
painful, often with blister
Full thickness burns:
It is third degree burns which is
charred, insensitive, deep
involving all layers of the skin
Depending of the Percentage of Burns
Mild (Minor):
Partial thickness burns <15% in
adults or <10% in children
Full thickness burns less than
2%
can be treated on outpatient
basis
Moderate:
Second degree of 15-25%
burns (10-20% on children)
Third degree between 2-10%
burns
Burns which are not involving
eyes, ears, face, hand, feet,
perineum
Severe (major):
Second degree burns more
that 25% in adults, in children
more than 20%
All third degree burns of 10%
or more.
Burns involving eyes, ears,
feet, hands, perineum
All inhalation and electrical
burns
Burns with fractures or major
mechanical trauma
ASSESSMENT OF BURNS
WALLACE’S RULES OF NINE
It is sued for early assessment
Burn Central Referral
partial thickness burns greater
than 10% of total body surface
area
Full thickness burns
Burns of the face, hands, feet,
genitalia, or major joints
Chemical burns, electrical, or
lighting strike injuries
Significant inhalation injuries
Burns in patients with multiple
medical disorders
Burn in patients with associated
traumatic injuries
THE LUNG AND BROWDER CHART
Better method for assessing the
burns wound
here each part of the body is
individually assessed
RULE OF PALM
Patient’s entire hand area is 1%
Clean piece of paper is cut to the
size of hand and through that
percentage of burns is assessed
Clinical Features
History of burn
Pain, Burning, anxious status,
tachycardia, tachypnoea
In severe degrees features of
shock
Tolerable temperature to human skin
is 40C for brief period
PATHOPHYSIOLOGY GIT
Burns to mucosal atrophy to
decreased absorption & increased
intestinal permeability to
increased bacterial translocation
to septicemia
Acute gastric dilation which
occurs in 2-4 days
Paralytic ileus
Curling’s ulcer
Acute acalculous cholecystitis,
acute pancreatitis
Abdominal Compartment
syndrome

IMMUNE SYSTEM

MASSIVE EDEMA Decreased function of T and B

lymphocytes and macrophages to
increased infection rate

METABOLIC
Hypermetabolic rate (BMR)
Negative nitrogen balance
Electrolyte imbalance
Deficiencies of vitamins and
essential elements
RENAL Metabolic acidosis due to hypoxia
Diminished blood flow and cardiac and lactic acid
output leads to decreased renal
blood flow and GFR
Toxins released from the wound
along with sepsis causes acute
tubular necrosis
Myoglobin released from muscles
(in case of electric injury or often
from eschar) is most injurious to
kidneys
Earlier resuscitation decreases
renal failure and improves
associated mortality

LUNGS
Altered ventilation-perfusion ratio
Pulmonary oedema due to burn
injury, fluid overload
ARDS
Aspiration
Septicaemia
SUMMARY OF INFECTIONS
PATHOPHYSIOLOGY Streptococci (Beta haemolytic-
most common)
Pseudomonas
Staphylococci
Other gram-negative organisms
Candida albicans