Fluids & Electrolyte New

8/10/2019 Fluids & Electrolyte New

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TOPICS/SUBJECTS

1. FLUIDS

2. ELECTROLYTES3. ABG


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FLUIDSGrace O. Galapia-Magno, RN, MAN


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Coverage of Discussion

1. Regulator

2. Compartments

3. Percentage

4. Movements5. Types

6. Intake and Output

7. Edema8. Hypervolemia

9. Hypovolemia


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What is the most important regulator

of water?

A. Hypothalamus

B. Pituitary Gland

C. ADH

D. ANPE. Aldosterone

F. Renin

G. Colon

H. HeartI. Kidneys

J. Baroreceptors


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ADH on work.

ADH stops urine


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ADH Antidiuretic Hormone

blood volume

ADH

urine output

blood volume

blood volume

ADH urine output

blood volume


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Drill

1. What triggers a ADH?

a. FVE

b. FVD

2. What will be the concentration of urine ifADH is high?

a. Diluted

b. Concentrated


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Man can live 30 45 days without food

But only 10 14 days without water


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Compartment of Fluids.

1. Extracellular Fluids

2. Intracellular Fluids

Transcellular Fluid


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60% of Body Weight is Water

Fluid Compartments:1. ICF Intracellular Fluid =40%

2. ECF Extracellular Fluid =20%

IVF Intravascular Fluid = 5%

Arterial Fluid = 2%

Venous Fluid = 3%

ITF interstitial fluid = 15%

3. Transcellular Fluid

Pleural FluidPeritoneal Fluid

Pericardial FluidCSF

Synovial Fluid


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Drill

Compute the distibution of water to an adult

weighing 90 kg.

1. ICF?

2. ECF?

3. IVF?

1. Arterial Fluid?2. Venous Fluid?

4. ITF?


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Fluids move

thru ACTIVE or PASSIVE transport

mechanism?


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2 Transport Mechanisms

1. Active: solutes from low to high (PISO)

2. Passive: solutes and solvent

Osmosis: solvent

Diffusion: solutes (gas exchange)

Ultrafiltration: solutes and solvent (Dialysis)


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Drill

1. Movement of solvent from low to high

concentration?

A. Osmosis

B. Diffusion

C. Active


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Drill

2. Movement of solute from low to high

concentration?

A. Osmosis

B. Diffusion

C. Active


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3 Types of Fluids

1. Isotonic: 0.9% NaCl,LR(Same Osmotic Pressure)

Raise blood volume

2. Hypotonic: 0.45% NaCl, D5W

Hydrate cells

3. Hypertonic: 10%, 20%, 50% Dextrose in

Water, D5LR, Mannitol

Pull water from the cells


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Composition of Fluids

Saline solutionwater & electrolyte

Dextrose solutionwater or saline & calories

Lactated ringerswater & electrolyte(Na,K,Cl -,Ca++

Balance Isotonicvaries, water & electrolyte some

electrolyte( Na,K,Mg++,Cl-,HCO3,gluconate)

Whole blood & blood component

Plasma Expanderalbumin, dextran, plasma protein


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Drill

1. What IV fluid is indicated to client with

Stroke?

2. What IV fluid will be given in severe burn

injury?

3. What IV fluid will be prepared to a CHF client?

4. What IV fluid is best during DKA?

5. What IV fluid is a substitute for TPN solution?


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IV Fluids Safety

Macrodrip

Microdrip

Soluset IV Infusion Pump


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Drill

1. 1000 mL D5LR to run in 10 hours, DF 20

How many cc/hr?

How many gtts/min?

2. 1000 mL D5LR, 120cc/hr, DF 15

How many hours to consume? How many gtts/min?


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IV Fluid Computation

TVI/cchr = duration in hr

TVI/duration in hr = cc/hour

Cchr/1 = gtts/min (60 DF)



Cchr/5 = gtts/min (12 DF)Cchr/6 = gtts/min (10 DF)


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Intake and Output

2.6

kg

2.6

kg


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The following are typical 24-hour values for an adult.

Intake 2,600 ml/24h

1,500 ml oral fluids

800 ml in food

300 ml in oxidation of food

Output 2,600 ml/24h

1,500 ml urine

200 ml in stool

500 ml through the skin

400 ml through respiration

What is essential and non essential

intake/output?


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Drill

Colostomy Irrigation

350 mL irrigation

150 mL drainage

1. How many mL is the

intake?

2. How many mL is the

output?

3. When do you tally I andO sheet?

4. Can you delegate I andO to NA?

5. When is the best timeto weigh your patient?

6. Give an example of

patient that wouldrequire I and Omonitoring?


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Osmolality

Refers to the concentration of a solution.Hypoosmolality Hyperosmolality


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Drill

1. In FVD what plasmaosmolality may beobserved?

A. Hyperosmolality

B. Hypoosmolality

2. In Polycythemia Verawhat plasma

osmolality may beobserved?

A. Hyperosmolality

B. Hypoosmolality

3. In CRF what plasmaosmolality may beobserved?

A. Hyperosmolality

B. Hypoosmolality

4. In the 2ndstage of ARFwhat plasma

osmolality may beobserved?

A. Hyperosmolality

B. Hypoosmolality


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Causes of EDEMA FORMATION:

1.Ex: CHF, CRF

2.

Ex: proteinuria, negative nitrogenbalance

3. Lymphatic Obstruction

Ex: Filariasis, Hodgkins and NonHodgkins

4. Increased Capillary Permeability


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EXTRAVASATION leakage of a fluid out of its

container

Inflammation: movement of

white blood cells from thecapillaries to the tissuessurrounding them

Malignant cancer: metastasisit refers to cancer cells exitingthe capillaries and enteringorgans


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INFILTRATION

Infiltration is the

accumulation of

substance in a tissues or

cells.

The material collected in

those tissues or cells isalso called infiltration.


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Drill

1. What is a pitting edema?

2. What is a non-pitting edema?

3. Scoring of edema?

4. Generalized edema?

5. Common location of

edema?

FLUID ASSESSMENT


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FLUID ASSESSMENT:

FVE FVD

1. Mucus membrane

2. Skin integrity3. Body weight4. Jugular vein5. BP, PAWP 6-12 mm Hg, PAP

25/15 mm Hg

6. CVP (most accurate) 0-7 mmHg or 5-10 cm of H2O7. I&O8. Pulse9. Lung sound and heart sound10. Urine output

11. Urine SG 1.005-1.03012. Hematocrit 48%13. Plasma osmolality 252-309

mOsml/L14. LOC


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FVE

CAUSE

DX

S/SXCX

MX

IV

H20

IT

H20

ICH20

TCH20


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Water Intoxication


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3rdSpacing or 3RDFLUID SHIFT

Pleural sac = Pleural Effusion

Pericardial sac = Pericardial Effusion

Peritoneal sac = Ascites


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FVD

CAUSE

DX

S/SX

CX

MXIC

H20

ITH20

IV

H20


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Shock

tissue perfusion (H20, 02, glucose)

CHD

ANS

ER situation (CPR)

Modified T.

02 treatment (ETT-Mech Vent.)

IV line or cutdown (Intra Osseous)

Drugs: Epinephrine

Inotropes and Vasopressors

Treat the underlying

cause

Dont be too late!


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Dont be too late!

ORGANS EARLY S/SX

Reversible

LATE S/SX

Irreversible

BRAIN LOC (disorientation) Coma

HEART tachy Brady

KIDNEYS Oliguria (>30mL/H) Anuria (>10mL/H)

LUNGS tachy Brady

SKIN Pallor Cyanosis

GIT Ulceration Ulceration-bleeding

LIVER detoxification Sepsis


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Drill

1. Most common type of Shock?

2. Hct level in a multiple gun shot wound patient?

3. Serum osmolality of a CRF patient?

4. Drug of choice to improve cardiac contraction in

CHF patient?

5. Severe respiratory complication in fluid overload?

6. Early sign of cerebral edema?7. Therapeutic and diagnostic mx in pleural effusion?


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Thank you


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FLUID POST TEST

20 ITEMS


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1. A client who is admitted with malnutrition andanorexia secondary to chemotherapy is alsoexhibiting generalized edema. The client asks the

nurse for an explanation for the edema. Which ofthe following is the most appropriate response bythe nurse?

A. The fluid is an adverse reaction to chemotherapy.

B. A decrease in activity has allowed extra fluid toaccumulate in the tissues.

C. Poor nutrition has caused decreased blood proteinlevels and fluid has moved from the blood vesselsinto the tissues.

D. Chemotherapy has increased your blood pressureand fluid was forced out into the tissues.


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2. A client who has a recent surgery has been

vomiting and becomes dizzy while standing up

to go to the bathroom. After assisting theclient back to bed, the nurse notes that the

blood pressure is 55/30 and the pulse is 140.

The nurse hangs which of the following IV

fluids to correct this condition?

A. D5.45 NS at 50 ml/hr

B. 0.9 NS at a rate of 1,000ml/hr

C. D5W at 125 ml/hr

D. 0.45 NS at open rate.

3 The lient ho has nder one an e plorator


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3. The client who has undergone an exploratorylaparotomy and subsequent removal of a largeintestinal tumor has a nasogastric tube (NGT) inplace and an IV running at 150 mL/hr via an IVpump. Which data should be reported immediatelyto the health care provider?

A. The pump keeps sounding an alarm that the highpressure has been reached.

B. Intake is 1800 mL, NGT output is 550 mL, and Foleyoutput 950 mL.

C. On auscultation, crackles and rales in all lung fieldsare noted.

D. Client has negative pedal edema and an increasinglevel of consciousness.


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4. The client diagnosed with diabetes insipidus

weighed 180 pounds when the daily weight

was taken yesterday. This morning's weight is175.6 pounds. One liter of fluid weighs

approximately 2.2 pounds. How much fluid

has the client lost (in milliliters)?

A. 500 mL

B. 1000 mLC. 2000 mL

D. 4400 mL


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5. The nurse writes the nursing problem of "fluid

volume excess" (FVE). Which intervention

should be included in the plan of care?

A. Change the IV fluid from 0.9% NS to D5W.

B. Restrict the client's sodium in the diet.C. Monitor blood glucose levels.

D. Prepare the client for hemodialysis.

h l h d l f h


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6. The client has received IV solutions for three

(3) days through a 20-gauge IV catheter

placed in the left cephalic vein. On morningrounds the nurse notes the IV site is tender to

palpation and a red streak has formed. Which

action should the nurse implement first?

A. Start a new IV in the right hand.

B. Discontinue the intravenous line.C. Complete an incident record.

D. Place a warm application over the

site.


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7. The nurse and an unlicensed nursing assistant

are caring for a group of clients. Which

nursing intervention should the nurse perform?

A. Measure the client's output from the

indwelling catheter.B. Record the client's vital signs

C. Instruct the client on appropriate fluid

restrictions.D. Provide water for a client diagnosed with

diabetes insipidus.

8 A nurse is reading a physician's progress


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8. A nurse is reading a physician s progress

notes in the client's record and reads that the

physician has documented "sensible fluid loss

of approximately 800 mL daily." The nurse

understands that this type of fluid loss can

occur through:

A. The skin

B. Urinary output

C. Wound drainage

D. The gastrointestinal tract


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9. A nurse is assigned to care for a group of

clients. On review of the clients' medical

records, the nurse determines that whichclient is at risk for deficient fluid volume?

A. A client with a colostomyB. A client with congestive heart failure

C. A client with decreased kidney function

D. A client receiving frequent woundirrigations

10 A i f li t h h b


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10. A nurse caring for a client who has been

receiving intravenous diuretics suspects that

the client is experiencing a deficient fluid

volume. Which assessment finding would the

nurse note in a client with this condition?

A. Lung congestion

B. Increased hematocrit

C. Increased blood pressureD. Increased central venous pressure (CVP)


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12 The nurse is caring for a client with


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12. The nurse is caring for a client withcongestive heart failure. On assessment, thenurse notes that the client is dyspneic and

that crackles are audible on auscultation. Thenurse suspects excess fluid volume. Whatadditional signs would the nurse expect tonote in this client if excess fluid volume ispresent?

A. Weight loss

B. Flat neck and hand veins

C. An increase in blood pressure

D. A decreased central venous pressure (CVP)

13 A nurse is caring for a client with a


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13. A nurse is caring for a client with anasogastric tube. Nasogastric tube irrigationsare prescribed to be performed once every

shift. The client's serum electrolyte resultsindicate a potassium level of 4.5 mEq/L and asodium level of 132 mEq/L. Based on theselaboratory findings, the nurse selects which

solution to use for the nasogastric tubeirrigation?

A. Tap water

B. Sterile waterC. Normal Saline

D. Distilled water

14 O ll b t


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14. Our cells move substances across a

membrane with the use of energy through

ATP because of the ff reasons EXCEPT:

A. The substances may be too large

B.Substances may be difficult to dissolve in a fat

coreC. The substances moves downhill against a

gradient

D. The substances move uphill against agradient

15 The nurse is aware that ascites can be


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15. The nurse is aware that ascites can be

related to a diminished plasma proteins. The

nurse administer albumin to the patient to

assist in:

A. clotting of blood

B. activation of WBCC. formation of RBC

D. development of oncotic pressure

16 Who among the ff clients is most prone to


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16. Who among the ff clients is most prone to

dehydration?

A. A 45 y/o male who had undergonecholecystectomy

B. A 24 y/o female who is experiencing nausea

and vomitingC. A 4 month old infant with diarrhea

D. A 17 y/o male with fever

17 Signs and symptoms of ECF volume deficit


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17. Signs and symptoms of ECF volume deficit

does not include which of the ff?

A. weight loss, poor skin turgorB. thirst, dry mouth and mucous membrane

C. oliguria, dark concentrated urine

D. decreased hematocrit, decreased specificgravity

18 Whi h f th ff i th t t


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18. Which of the ff is the most accurate

indicator of edema?

A. skin turgorB. serum sodium levels

C. weight gain

D. appearance of the skin in the legs

19 Edema occurs because of the ff mechanisms


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19. Edema occurs because of the ff mechanisms

EXCEPT:

A. increased venous hydrostatic pressureB. increased aldosterone secretion

C. decreased ADH secretion

D. decreased colloidal osmotic pressure

20 Solutes move from an area o f higher


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20. Solutes move from an area o f higher

concentration to an area of lower

concentration. The process involves:

A. Diffusion

B. Osmosis

C. FiltrationD. Active transport


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FLUIDS POST TEST KEY ANSWER

1 A li t h i d itt d ith l t iti d


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1. A client who is admitted with malnutrition andanorexia secondary to chemotherapy is alsoexhibiting generalized edema. The client asks the

nurse for an explanation for the edema. Which ofthe following is the most appropriate response bythe nurse?

A. The fluid is an adverse reaction to chemotherapy.

B. A decrease in activity has allowed extra fluid toaccumulate in the tissues.

C. Poor nutrition has caused decreased blood proteinlevels and fluid has moved from the blood vesselsinto the tissues.

D. Chemotherapy has increased your blood pressureand fluid was forced out into the tissues.

2 A client ho has a recent s rger has been


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2. A client who has a recent surgery has been

vomiting and becomes dizzy while standing up

to go to the bathroom. After assisting theclient back to bed, the nurse notes that the

blood pressure is 55/30 and the pulse is 140.

The nurse hangs which of the following IV

fluids to correct this condition?

A. D5.45 NS at 50 ml/hr

B. 0.9 NS at a rate of 1,000ml/hr

C. D5W at 125 ml/hr

D. 0.45 NS at open rate.

3. The client who has undergone an exploratory


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g p ylaparotomy and subsequent removal of a largeintestinal tumor has a nasogastric tube (NGT) inplace and an IV running at 150 mL/hr via an IVpump. Which data should be reported immediatelyto the health care provider?

A. The pump keeps sounding an alarm that the high

pressure has been reached.B. Intake is 1800 mL, NGT output is 550 mL, and Foley

output 950 mL.

C. On auscultation, crackles and rales in all lung fields

are noted.D. Client has negative pedal edema and an increasing

level of consciousness.

4 The client diagnosed with diabetes insipidus


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4. The client diagnosed with diabetes insipidus

weighed 180 pounds when the daily weight

was taken yesterday. This morning's weight is175.6 pounds. One liter of fluid weighs

approximately 2.2 pounds. How much fluid

has the client lost (in milliliters)?

A. 500 mL

B. 1000 mLC. 2000 mL

D. 4400 mL

5 The nurse writes the nursing problem of "fluid


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5. The nurse writes the nursing problem of fluid

volume excess" (FVE). Which intervention

should be included in the plan of care?

A. Change the IV fluid from 0.9% NS to D5W.

B. Restrict the client's sodium in the diet.C. Monitor blood glucose levels.

D. Prepare the client for hemodialysis.

6 The client has received IV solutions for three


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6. The client has received IV solutions for three

(3) days through a 20-gauge IV catheter

placed in the left cephalic vein. On morning

rounds the nurse notes the IV site is tender to

palpation and a red streak has formed. Which

action should the nurse implement first?

A. Start a new IV in the right hand.

B. Discontinue the intravenous line.

C. Complete an incident record.

D. Place a warm application over the

site.

7 The nurse and an unlicensed nursing assistant


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7. The nurse and an unlicensed nursing assistant

are caring for a group of clients. Which

nursing intervention should the nurse perform?

A. Measure the client's output from the

indwelling catheter.B. Record the client's vital signs

C. Instruct the client on appropriate fluid

restrictions.D. Provide water for a client diagnosed with

diabetes insipidus.

8. A nurse is reading a physician's progress


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g p y p g

notes in the client's record and reads that the

physician has documented "sensible fluid loss

of approximately 800 mL daily." The nurse

understands that this type of fluid loss can

occur through:

A. The skin

B. Urinary output

C. Wound drainage

D. The gastrointestinal tract

9 A nurse is assigned to care for a group of


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records, the nurse determines that whichclient is at risk for deficient fluid volume?

A. A client with a colostomyB. A client with congestive heart failure

C. A client with decreased kidney function

D. A client receiving frequent woundirrigations

10 A nurse caring for a client who has been


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10. A nurse caring for a client who has been

receiving intravenous diuretics suspects that

the client is experiencing a deficient fluid

volume. Which assessment finding would the

nurse note in a client with this condition?

A. Lung congestion

B. Increased hematocrit

C. Increased blood pressureD. Increased central venous pressure (CVP)

11 A nurse is assigned to care for a group of


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records, the nurse determines that whichclient is at risk for excess fluid volume?

A. The client taking diureticsB. The client with renal failure

C. The client with an ileostomy

D. The client who requires gastrointestinalsuctioning

12. The nurse is caring for a client with


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congestive heart failure. On assessment, thenurse notes that the client is dyspneic and

that crackles are audible on auscultation. Thenurse suspects excess fluid volume. Whatadditional signs would the nurse expect tonote in this client if excess fluid volume is

present?

A. Weight loss

B. Flat neck and hand veins

C. An increase in blood pressure

D. A decreased central venous pressure (CVP)

13. A nurse is caring for a client with a


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gnasogastric tube. Nasogastric tube irrigationsare prescribed to be performed once every

shift. The client's serum electrolyte resultsindicate a potassium level of 4.5 mEq/L and asodium level of 132 mEq/L. Based on theselaboratory findings, the nurse selects which

solution to use for the nasogastric tubeirrigation?

A. Tap water

B. Sterile waterC. Normal Saline

D. Distilled water


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related to a diminished plasma proteins. The

nurse administer albumin to the patient to

assist in:

A. clotting of blood

B. activation of WBC

C. formation of RBC

D. development of oncotic pressure

16. Who among the ff clients is most prone to


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g p

dehydration?

A. A 45 y/o male who had undergonecholecystectomy

B. A 24 y/o female who is experiencing nausea

and vomiting

C. A 4 month old infant with diarrhea

D. A 17 y/o male with fever

17. Signs and symptoms of ECF volume deficit


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g y p

does not include which of the ff?

A. weight loss, poor skin turgorB. thirst, dry mouth and mucous membrane

C. oliguria, dark concentrated urine

D. decreased hematocrit, decreased specificgravity

18 Which of the ff is the most accurate


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18. Which of the ff is the most accurate

indicator of edema?

A. skin turgorB. serum sodium levels

C. weight gain

D. appearance of the skin in the legs

19. Edema occurs because of the ff mechanisms


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EXCEPT:

A. increased venous hydrostatic pressureB. increased aldosterone secretion

C. decreased ADH secretion

D. decreased colloidal osmotic pressure

20. Solutes move from an area o f higher


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concentration to an area of lower

concentration. The process involves:

A. Diffusion

B. Osmosis

C. FiltrationD. Active transport


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Sonny M. Moreno, RN, USRN, MAN

2012

K P i t


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Key Points

Water

Ionized Electrolytes

Cations and Anions

Hormones

Kidneys

Small Intestine

Wh t i El t l t ?


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What is Electrolyte?

An electrolyte is any substance

containing free ions that make the

substance electrically conductive.

F ti f El t l t


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Functions of Electrolytes

Blood volume regulationMaintains Plasma osmolality

Muscle relaxation

Muscle contractionEnergy formation

Bones and teeth formation

Nutrients metabolismNerve impulse transmission

Buffer system

Ele trol tes Imbalan e


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Electrolytes Imbalance

D ill


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Drill

1. Major IC cations?

2. Major EC cations?

3. Hormone that regulates Na?

4. Hormone that regulates Ca?

5. Hormone that regulates PO4?

6. Electrolytes imbalance during Acidosis?

Sodium Fxn:


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Sodium Maintains plasma osmolality

Important for nerve impulse

transmission (PISO)

Normal value:135-145 mEq/L

RDA:0.52.76.0 gm/day

Source: canned foods, cheese,ketchup

Regulated by Aldosterone

HYPERNATREMIA HYPONATREMIA


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Cause:

Cushings Disease,

DI and FVD

S/sx:

brain activity

Excessive thirst

Seizure

brain activity

Flushed skin

Dx:Hct, plasma osmo

135 mEq/LMngmt:restrict Na and

hydrate (D5W)

Cause:

Addisons Disease,

SIADH and FVE (CRF

& CHF)S/sx:mimics hypogly,

stroke, bells palsy

brain activity

Weakness Abdl spasm

Cerebral edema*

Dx:Hct, plasma osmo

145 mEq/L

Mngmt:restrict H2O andgive Na oral (SodiumTablet )and IV (NaCl)

Drill


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Drill

1. Normal value of serum Na? 135-145 mEq/L2. Severe complication of hyponatremia?addisons Dse

3. Hct level in hypernatremia? Increase

4. Typical manifestation of hypernatremia? restrict Na5. IVF for hypernatremia? D5w

6. IVF that must be avoided in hyponatremia? NaCl

7. High level of aldosterone leads to what electrolytes

imbalance? Sodium8. Best Salt substitute? KCl

Potassium Fxn:


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Potassium Inhibits cardiac excitability

Muscle relaxation

Normal value:3.5-5.0 mEq/L

Source:banana, orange,

potato or any fresh fruitsand raw vegetables, saltsubstitute (KCl)

Mainly excreted by thekidneys

HYPERKALEMIA

RF Addi o HYPOKALEMIA

C hi Di i


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Cause:RF, Addisons ,Tissue Injuries

s/sx:

Muscle: flaccidity toweakness

GIT: diarrhea Heart: brady,

Arrhythmias(peaked T wave)

Dx:5.0 mEq/LMngmt:Kayexalate,

Insulin+Glucose andDIALYSIS

Calcium Gluconate to

improve heart contraction

Cause:

Cushings, Diuretics,Laxatives, Insulin

S/sx:

Muscle: spasticity toweakness

GIT: constipation

Heart: tachy to A andinverted T wave, U waveappearance

Note digoxin toxicity

Dx:3.5. mEg/L

Mngmt:oral K, tablet(Kalium Durule) and IV(KCl)


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l


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Kayexalate

Sodium Polystyrene Sulfonate Resin Exchange (K loss, Na absorption)

Oral and enema administration

Lowers serum K

Calcium Gluconate


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Given to strengthen cardiac contractions Mix with D5W only (titration)

KCl Administration


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KCl Administration

40 mEq/L:1LPNSS

10 mEq/hour (max dose)

Cardiac monitor

Agitate freq.

Drill


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Drill

1. ECG pattern in hypokalemia?2. ER situation in hyperkalemia?

3. Drug of choice in hyperkalemia to improve cardiacoutput? calcium gluconate

4. Maximum concentration of IV KCl? 10 mEq/hour5. Insulin is given during which K imbalance?

hyperkalemia

6. K imbalance during 2ndstage of ARF?

7. GIT disturbance in hypokalemia?constipation8. Which electrolyte must be checked to client taking

Digitalis?

Calcium Fxn:l t ti


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muscle contraction

Helps in blood coagulation (CF

4) Bones and teeth formation

Normal value:

4.5-5.5 mEq/L

8.5-10.5 mg/dl

RDA: 8001200 mg/day

Source:dairy products (milk,cheese, yogurt) and g.l.v.

BINDS with albumin

Requires Active Vitamin Dto beabsorbed from the intestines

Regulated by Parathyroid glands

Active Vitamin D


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Active Vitamin D

Parathyroid Glands


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Parathyroid Glands

Parathyroid Glands


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Parathyroid Glands

HYPERCALCEMIA

Cause:

HYPOCALCEMIA

Hypoparathyhroidism


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HyperparathyhroidismS/sx: 5.5 mEq/L

deep bone pain,lithiasis formationShortened QT interval

HYPOPHOSPHATEMIA(low energy store)

Mngmt:

parathyroidectomy,hydration,prevent fracture,

reduce Ca intake,CalcitoninDIALYSIS

Cause: Hypoparathyhroidism

S/sx: 4.5 mEq/L

TETANY: tingling,trousseau, chvostek and

laryngeal spasm

Lengthened QT interval

Torsades de pointes HYPERPHOSPHATEMIA

(wide calcification)

Mngmt:

Oral Ca, tablet Ca and IV(Calcium Gluconate)

respiratory support forlaryngeal spasm (TT)


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Tetany


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Tetany

Drill


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Drill

1. Normal value of serum Ca? 4.5- 5.5 mEq/L2. Danger sign of tetany?Tingling, Chvostek,

trosseau

3. Aids in Ca absorption?

4. Safety precautions in hypercalcemia?

5. Drug that will push serum Ca into the bones?

6. Early observable signs of Tetany? chvostek

7. Must on the bedside post thyroidectomy?8. 3 targets of PTH?

HYPERPHOSPHATEMIA ( 2.6) Cause:Excessive intake of P,

h idi i h i k

HYPOPHOSPHATEMIA ( 1.8) Cause: diuretics, insulin,

l b i


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Hypoparathyroidism, High risk

(infants fed with cowsmilk)

S/sx:Wide-spread calcification,Visual impairment, Decreased

mental status

Mx:

Treat the underlying causeRestrict all forms of P

supplements

Give phosphate binding agent

(laxative) Aluminum Magnesiumor Calcium Gel, AMPHOGEL,

OSCAL

Dialysis

malabsorption

S/sx: Low energy store (prioritize

the problem), Organ failure Mx:

Treat the underlying cause

Increase P supplements

Oral (eggs, nuts, whole grains

and meat)

IV (KP04 maximum of 10

mEq/hour) or NaP04

Monitor respiratory status

Magnesium


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Magnesium

Function: Aids in nerve impulse

transmission Plays a role for nutrients

metabolism

Positively charged ion(cation)

Normal value:1.5-2.6 mEq/LSource: chocolates, dry

beans, meats, nuts,seafoods Regulated by

Parathormone

Hypermagnesemia

C RFHypomagnesemia


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Cause:RF mostcommon

S/sx: 2.6 mEq/LDTR (0, +1)brain activity,

LOC to comaHYPERCALCEMIA

Mngmt:laxatives,diuretics, DIALYSIS

Cause: laxatives,diuretics, alcoholism

S/sx: 1.5 mEq/L DTR (+3, +4)

brain activity

(seizure)HYPOCALCEMIA

Mngmt:oral Mg,tablet Mg, MgSO4

parenteral

Chloride


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Chloride

Acid by nature

Found in the GIT

98-106 mEq/L

Goes with all electrolytes

Drill


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Drill

1. High serum Cl leads to Acidosis or Alkalosis?

2. DTR in hypomagnesemia?

3. Drug of choice to lower serum PO4?

4. Normal serum level of PO4?

5. Hyperreflexia and DTR of 4 is a sign of

hypermagnesemia or hypomagnesemia?


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Thank you


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ABG

Sonny M. Moreno, RN, USRN, MAN

What is ABG?


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What is ABG?

ABG Indications?


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ABG Indications?

Metabolic Disorders DM

Vomiting and Diarrhea

Renal Failure Shock

Respiratory Disorders

COPD Cardiac Problems

What will happen if there is an

id i b l ?


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acid imbalance?

The Process.
http://www.google.com.ph/imgres?imgurl=http://darktouch.net/wp-content/uploads/2010/09/blood-drive.jpg&imgrefurl=http://darktouch.net/editorial/stewardship/i-give-blood/&usg=__XVb_k6kvh4cWP-mLPw2wKD5LzbU=&h=640&w=453&sz=44&hl=tl&start=3&zoom=1&um=1&itbs=1&tbnid=iNDvgN9LI82a1M:&tbnh=137&tbnw=97&prev=/search?q=blood&um=1&hl=tl&sa=N&biw=1345&bih=540&rlz=1R2ASUS_enPH343&tbm=isch&ei=2yAgToXjBMKKmQXG1fChAwhttp://www.google.com.ph/imgres?imgurl=http://darktouch.net/wp-content/uploads/2010/09/blood-drive.jpg&imgrefurl=http://darktouch.net/editorial/stewardship/i-give-blood/&usg=__XVb_k6kvh4cWP-mLPw2wKD5LzbU=&h=640&w=453&sz=44&hl=tl&start=3&zoom=1&um=1&itbs=1&tbnid=iNDvgN9LI82a1M:&tbnh=137&tbnw=97&prev=/search?q=blood&um=1&hl=tl&sa=N&biw=1345&bih=540&rlz=1R2ASUS_enPH343&tbm=isch&ei=2yAgToXjBMKKmQXG1fChAwhttp://www.google.com.ph/imgres?imgurl=http://darktouch.net/wp-content/uploads/2010/09/blood-drive.jpg&imgrefurl=http://darktouch.net/editorial/stewardship/i-give-blood/&usg=__XVb_k6kvh4cWP-mLPw2wKD5LzbU=&h=640&w=453&sz=44&hl=tl&start=3&zoom=1&um=1&itbs=1&tbnid=iNDvgN9LI82a1M:&tbnh=137&tbnw=97&prev=/search?q=blood&um=1&hl=tl&sa=N&biw=1345&bih=540&rlz=1R2ASUS_enPH343&tbm=isch&ei=2yAgToXjBMKKmQXG1fChAw


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The Process.

1. Buffer system2. Respiratory regulation

3. Renal regulation

Body on work


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Body on work

H2CO3H + HCO3

H2CO3 H2CO3 H2O & CO2

H2OCO

2

Kidneys

Lungs

ABG Collection of Specimen


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f p

Baseline v/s

Allens Test

Heparin

Site care

Allen's test
http://images.google.com.ph/imgres?imgurl=http://www.smithsoem.com/images/pd_arterial_blood_sampling.jpg&imgrefurl=http://www.smithsoem.com/pd_bloodsampling.php&h=368&w=200&sz=11&hl=tl&start=2&tbnid=sd57C6x8uBzdtM:&tbnh=122&tbnw=66&prev=/images?q=arterial+blood+gas&svnum=10&hl=tl&lr=


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Elevate the hand and make a fist for

approximately 30 seconds. Apply pressure over the ulnar and the radial

arteries occluding both (keep the handelevated).

Open the hand which will be blanched.

Release pressure on the ulnar artery and lookfor perfusion of the hand (this takes under 8

seconds). If there is any delay then it may not be safe to

perform radial artery puncture.

Handling of the specimen


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g f p

Label

Bubbles free

Dont agitate

Avoid warm

Site

care?

ABG Interpretation


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p

ABG Normal Values


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pH 7.35-7.45 HC03 22.26 mEq/L

Pa C02 35-45 mm Hg

Pa 02 80-100 mm Hg

FI02 20% Base Excess +/- (2 mmol/L)

7.856.50

NV: 7.35-7.45, 22-26, 35-45


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, ,

HCO3:alkali, CO2:acid

pH = 7.40 N

HCO3 = 20 PaCO2 = 40 N

Simple Metabolic Acidosis

pH = 7.40 N

HCO3 = 28 PaCO2 = 40 N

Simple Metabolic Alkalosis

pH = 7.40 N

HCO3 = 24 NPaCO2 = 48

Simple Respiratory Acidosis

pH = 7.40 N

HCO3 = 24 NPaCO2 = 32

Simple Respiratory Alkalosis

NV: 7.35-7.45, 22-26, 35-45


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, ,

RO-ME (to pH)*

pH = 7.33HCO3 = 20

PaCO2 = 40 NMetabolic Acidosis

pH = 7.47 HCO3 = 28

PaCO2 = 40 NMetabolic Alkalosis

pH = 7.47

HCO3 = 24 N

PaCO2 = 32 Respiratory Alkalosis

pH = 7.33

HCO3 = 24 NPaCO2 = 48

Respiratory Acidosis

NV: 7.35-7.45, 22-26, 35-45


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, ,

HCO3 and CO2 both acids or alkalis (pH)*

pH = 7.33 HCO3 = 20 PaCO2 = 48

Mixed Acidosis

pH = 7.40 NHCO3 = 28 PaCO2 = 32

Mixed Alkalosis

pH = 7.33 HCO3 = 20

PaCO2 = 48 Mixed Acidosis

pH = 7.40 NHCO3 = 28 PaCO2 = 32

Mixed Alkalosis

NV: 7.35-7.45, 22-26, 35-45


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, ,

Observe the arrows of HCO3 and CO2 (pH)* Primary problem will follow the pH*

pH = 7.33 HCO3 = 20 PaCO2 = 32

Uncompensated Metabolic Acidosis

pH = 7.47 HCO3 = 28 PaCO2 = 48

Uncompensated Metabolic Alkalosis

pH = 7.33 HCO3 = 28 PaCO2 = 48

Uncompensated Respiratory Acidosis

pH = 7.47 HCO3 = 20 PaCO2 = 32

Uncompensated Respiratory Alkalosis

NV: 7.35-7.45, 22-26, 35-45 Observe the arrows of HCO3 and CO2 (pH)*


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(p )

Primary problem, check the difference*

Fully (pH:7.40)*

Partially (pH with in normal range)*

pH = 7.40 NHCO3 = 18 PaCO2 = 32

Compensated Metabolic Acidosis

pH = 7.35 NHCO3 = 30 PaCO2 = 48

Compensated Metabolic Alkalosis

pH = 7.40 NHCO3 = 28 PaCO2 = 48

Compensated Respiratory Acidosis

pH = 7.44 NHCO3 = 20 PaCO2 = 32

Compensated Respiratory Alkalosis

Key to ABG Interpretation


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y p

pH is alkali by nature HCO3 is alkali by nature

CO2 is acid by nature

ROME

Opposite () Mixed

Same () () Compensated or

Uncompensated

Drill 5


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pH 7.40 CO2 47

HCO3 29

Fully Compensated Metabolic Alkalosis

Drill 4


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pH 7.47 CO2 34

HCO3 20

Uncompensated Respiratory Alkalosis

Drill 3


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pH 7.39 CO2 46

HCO3 19

Mixed Acidosis

Drill 2


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pH 7.33 CO2 46

HCO3 25

Respiratory Acidosis

Drill 1


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pH 7.32 CO2 33

HCO3 20



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Thank you

Four-Step Guide to ABG Analysis


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1. Is the pH normal, acidotic or alkalotic?2. Are the PaCO2 or HCO3 abnormal? Which

one appears to influence the pH?

3. If both the PaCO2 and HCO3 are abnormal,the one which deviates most from the norm

is most likely causing an abnormal pH.

4. Check the PaO2. Is the patient hypoxic?

http://www.manuelsweb.com/abg.htm

Swearingen's handbook (1990)

To Interpret ABG


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Compensation can be seen when both thePaCO2 and HCO3 rise or fall together tomaintain a normal pH.

Uncompensated occurs when the PaCO2 andHCO3 rise or fall together but the pH remainsabnormal.

Compensated occurs when the PaCO2 and

HCO3 rise or fall together and the pH returnsto normal.

Sample Lab results:


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Simple Metabolic Acidosis Metabolic Acidosis

Mixed Acidosis


Compensated Metabolic Acidosis

Fully

Partially

http://www.manuelsweb.com/abg.htm

Swearingen's handbook (1990)

Once it fails!


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MANIFESTATIONS


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METABOLIC ACIDOSIS

Weakness

Headache

Disorientation

Deep rapid breathing

Nausea and vomiting

Coma

CAUSE: DKA, terminal CA,RF, starvation, DIARRHEA

RESPIRATORY ACIDOSIS

Dyspnea

Irritability

Disorientation

Tachycardia

Cyanosis

Coma

CAUSE: COPD, airwayobtruction, apnea

MANIFESTATIONS


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METABOLIC ALKALOSIS

Muscle hypertonicity(tetany)

Tingling

Tremors Shallow and slow

respiration

Dizziness, confusion

Coma CAUSE: gastric lavage,

gastric suctioning

RESPIRATORY ALKALOSIS

Deep rapid breathing

Lightheadedness

Tingling, numbness

Tinnitus

Loss of consciousness

CAUSE: anxiety, CPR

Role of water?


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-+

EC

IC

Types


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Types

of Ions

CATIONS OR POSITIVE CHARGE1. Magnesium2. Calcium

3. Sodium4. Hydrogen5. Potassium

ANIONS OR NEGATIVE CHARGE1. Chloride2. Bicarbonate

3. Phosphate

What regulates ionized electrolytes?


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Intestine

Circulation

Kidneys

Hormones*

Hormones that regulates ionized electrolytes?


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Na

K

Mg

Ca

PO4

Cl

Endogenous

Exogenous

Key Points!


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Major source: food intake

Excretion: kidneys, GIT, sweat,

Easily disturbed in case of AcidBase Imbalance

Imbalance is usually

i t d ith di


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associated with diseases:

DM

DI and SIADH

BURNS CHF and CRF

DIARRHEA

CUSHINGS and ADDISONS

ACIDOSIS and ALKALOSIS

Also DRUGS: Laxatives, Diuretics

Which is more important in diagnosing

electrolytes imbalance?


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y

IV

IC

URIN

E

IT

RECALL!RDANORMAL V Functions


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1. Mg 1.5-2.6 320-420mg/d2. P 1.8-2.6 700mg/d

3. K 3.5-4.5 200-250mg/d

4. Ca 4.5-5.5 800-1200mg/d

5. Cl 98-106 750mg/d

6. Na 135-145 2,400 mg/d

7. H 7.35-7.45(pH)

8. HCO3 22-26 mEq/L

RDANORMAL V. Functions


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Fluids & Electrolyte New

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