L&E Chapter 003 Lo

Lesson 3.1

Chapter 3

Lesson 3.1

Chapter 3

Fluids, Electrolytes, Acid-Base Balance, and Intravenous Therapy

Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

Learning ObjectivesLearning Objectives

Theory

1. Recall the various functions fluid performs in the body.

2. Identify the body’s mechanisms for fluid regulation.

3. Review three ways in which body fluids are continually being distributed among the fluid compartments.

4. Distinguish the signs and symptoms of various electrolyte imbalances.

5. Discuss why the elderly have more problems with fluid and electrolyte imbalances.

6. Recognize the disorders that cause specific fluid and electrolyte imbalances.

7. Compare the major causes of acid-base imbalances.

8. State correct interventions to correct an acid-base imbalance.

9. Discuss the steps in managing an intravenous infusion.

10. Describe the measures used to prevent the complications of intravenous therapy.

11. Identify intravenous fluids that are isotonic.12. Discuss the principles of intravenous

therapy.

Clinical Practice

1. Assess patients for signs of dehydration.

2. Correctly assess for and identify edema and signs of overhydration.

3. Apply knowledge of normal laboratory values in order to recognize electrolyte imbalances.

4. Carry out interventions to correct an electrolyte imbalance.

5. Determine if a patient has an acid-base imbalance.

6. Carry out measures to prevent the complications of Intravenous therapy.

7. Compare interventions for the care of a patient receiving total parenteral nutrition with one undergoing intravenous therapy.


Functions of WaterFunctions of Water

• Transportation

• Heat regulation

• Maintenance of hydrogen (H+) balance

• Medium for the enzymatic action of digestion


Control of Fluid BalanceControl of Fluid Balance

• Thirst mechanism and osmoreceptors• Antidiuretic hormone (ADH)• Aldosterone and atrial natriuretic peptide

(ANP) • Baroreceptors in the carotid sinus and

aortic arch and the sympathetic/parasympathetic nervous system


Movement of Fluid and Electrolytes

Movement of Fluid and Electrolytes

• Passive transport:– Diffusion – Osmosis– Isotonic, hypertonic, and hypotonic – Osmotic pressure – Filtration and hydrostatic pressure

• Active transport:– Sodium pump and ATP


Fluid Imbalances: Deficient Fluid Volume

Fluid Imbalances: Deficient Fluid Volume

Risk factors• Inability to take in sufficient quantities of fluid

because of impaired swallowing, extreme weakness, disorientation or coma, or the unavailability of water

• Loss of excessive amounts of fluid through prolonged vomiting, diarrhea, hemorrhage, diaphoresis (sweating), excessive wound drainage, or diuretic therapy


Assessment (Data Collection)Assessment (Data Collection)

• Turgor

• Furrowed, dry tongue

• Blood pressure

• Pulse


Nausea and VomitingNausea and Vomiting

• “Sick to my stomach"

• Pallor, mild diaphoresis, cold clammy skin, excessive salivation, and attempts to remain quiet and motionless

• Vomitus odor, color, contents (e.g., undigested food), and amount


Medical TreatmentMedical Treatment

• Antihistamines, sedative-hypnotics, anticholinergics, and phenothiazines

• Complementary and alternative therapy

• NPO, then progressing slowly to a regular diet

• Carbonated drinks


DiarrheaDiarrhea

• Frequent watery bowel movements, abdominal cramping, and general weakness

• Watery stools often contain mucus and are blood‑streaked; frequency could be as high as 15 to 20 liquid stools.

• Acute diarrhea and local irritation• Chronic and prolonged diarrhea in ulcerative

colitis, irritable bowel syndrome, allergies, lactose intolerance, and nontropical sprue


DiarrheaDiarrhea

• Dehydration, malnutrition, and anemia

• Bowel sounds likely to be loud gurgling and tinkling sounds that come in waves and are hyperactive

• Note and record the number of stools during the shift and the characteristics of each stool and associated pain


Acute DiarrheaAcute Diarrhea

• Limit the intake of food• Progress to clear, bland liquids and to solids

with increased calories and high‑protein, high‑carbohydrate content

• Give rehydrating solutions containing glucose and electrolytes

• Avoid iced fluids, carbonated drinks, whole milk, roughage, raw fruits, and highly seasoned foods


Medications for DiarrheaMedications for Diarrhea

• Cause of the disorder and the length of time the conditionMild cases:– Kaolin and bismuth preparations, (e.g., Kaopectate)

• Antispasmodic drugs such as belladonna or paregoric • Bismuth and "traveler's diarrhea" • Codeine, diphenoxylate (Lomotil), or loperamide

(Imodium)• Drugs and causative organisms• Metabolic acidosis and buffer solutions


Nursing ManagementNursing Management

• Provide physical and mental rest, prevent unnecessary loss of water and nutrients, protect the rectal mucosa, and replace fluids

• Maintain a calm and dignified manner, accept and understand the patient's behavior, and provide privacy and a restful environment


Excess Fluid VolumeExcess Fluid Volume

• Hematocrit: – 35% to 54%, depending on age and sex

• Urine concentration: – Specific gravity: 1.003 to 1.030 (average

range is 1.010 to 1.025)


EdemaEdema

• Localized edema and generalized edema

• General causes of edema:– An increase in capillary hydrostatic pressure– A loss of plasma proteins– An obstruction of lymphatic circulation– An increase in capillary permeability

• Dependent edema


TreatmentTreatment

• Correct the underlying cause • Assist the body to rebalance fluid content• Restrict fluids• Give diuretic drugs• Allow bed rest• Provide low-sodium diet• Use elastic stockings or sequential

compression devices


Home Care: Fluid Volume Deficit

Home Care: Fluid Volume Deficit

• Log of intake and output

• Small amounts of liquid every hour while awake

• Emergency department and intravenous fluids


Home Care: Fluid ExcessHome Care: Fluid Excess

• Weigh daily

• Assess edema

• Know when to notify physician


ElectrolytesElectrolytes

• Ions:– Negatively charged anions– Positively charged cations

• Creation of an electrical impulse:– Transmission of nerve impulses– Contraction of muscles– Excretion of hormones and other

substances from glandular cells


Osmolality Osmolality

• Concentration of the solution determined by the number of solutes

• Osmolality controls water movement and the body fluid distribution in the intracellular and extracellular compartments

• Intracellular fluid and potassium• Extracellular fluid and sodium• Normal osmolality: 280 to 294 milliosmoles

per kilogram


Sodium ImbalancesSodium Imbalances

Hyponatremia (below 135 mEq/L)

Signs and symptoms:– Fatigue, lethargy, muscle weakness– Muscle cramps– Abdominal cramps and nausea and vomiting– Headache, confusion, seizures– Decreased blood pressure


Sodium ImbalancesSodium Imbalances

Hypernatremia (above 145 mEq/L)Signs and symptoms:

– Decreased urine output if compensatory ADH is being secreted

– Increased thirst with dry mucous membranes

– Weakness and agitation– Good tissue turgor and firm subcutaneous

tissues


Potassium ImbalancesPotassium Imbalances

Hypokalemia (below 3.5 mEq/L)

Signs and symptoms: – Cardiac dysrhythmias and ECG changes– Muscle weakness and decreased reflexes– Urinary retention and increased urine pH– Abdominal pain, gaseous distention, and

paralytic ileus– Lethargy and confusion


Potassium ImbalancesPotassium Imbalances

Hyperkalemia (above 5.0 mEq/L)

Signs and symptoms: – ECG changes and cardiac dysrhythmias

that may progress to cardiac arrest– Paresthesias and muscle weakness

progressing to paralysis– Fatigue and nausea


Calcium ImbalancesCalcium Imbalances

Hypocalcemia (below 8.4 mg/dL)Signs and symptoms:

– Paresthesia and abdominal cramps– Muscle twitching, carpopedal spasm,

Trousseau sign, and hyperactive reflexes– Chvostek sign – Tetany – Weak heart contractions – Laryngospasm


Calcium ImbalancesCalcium Imbalances

Hypercalcemia (above 10.6 mg/dL)

Signs and symptoms: – Muscle weakness, lethargy, stupor, and

personality change– Anorexia and nausea– Polyuria – Dysrhythmias and cardiac arrest – Decreased bone density


Magnesium ImbalancesMagnesium Imbalances

Hypomagnesemia (below 1.3 mEq/L)

Causes:– Diuretic use– Diabetic ketoacidosis– Hyperparathyroidism– Hyperaldosteronism


Magnesium ImbalancesMagnesium Imbalances

Hypermagnesemia (above 2.1 mEq/L)

Causes:– Renal failure– Overuse of magnesium-containing antacids

and cathartics


Anion ImbalancesAnion Imbalances

Imbalances of chloride, phosphate, and bicarbonate accompany cation imbalances:

• Hypochloremia (below 95 mEq/L) and hyponatremia

• Hyperchloremia (above 103 mEq/L) with hypernatremia and metabolic acidosis


Anion ImbalancesAnion Imbalances

Imbalances of chloride, phosphate, and bicarbonate accompany cation imbalances

• Hypophosphatemia (below 3.0 mg/dL): – Aluminum-containing antacids that bind

phosphate– Vitamin D deficiency– Hyperparathyroidism

• Hyperphosphatemia (above 4.5 mg/dL) and renal failure


Control Mechanisms and pHControl Mechanisms and pH

Buffer pairs – Bicarbonate–carbonic

acid buffer system – Phosphate system– Hemoglobin system– Protein system

Respiratory system – Carbon dioxide– Carbonic acid

Kidneys – Bicarbonate ion


Acid–Base ImbalancesAcid–Base Imbalances

• Respiratory acidosis

• Respiratory alkalosis

• Metabolic acidosis

• Metabolic alkalosis


Arterial Blood Gas AnalysisArterial Blood Gas Analysis

• Partial pressure exerted by oxygen (PaO2) 80 to 100 mm Hg

• Partial pressure of carbon dioxide (PaCO2) 35 to 45 mm Hg

• pH 7.35 to 7.45• SaO2 (also abbreviated O2 Sat) 94% to 100%• HCO3 22 to 26 mEq/L• Base excess or deficit measured in "+" or "−"


Respiratory AcidosisRespiratory Acidosis

An increase in carbon dioxide levels occurs in a variety of disorders

Signs and symptoms:– Complaints of increasing difficulty in breathing– History of respiratory obstruction (acute or chronic)– Dyspnea, weakness, dizziness, restlessness,

sleepiness, and change in mental alertness


Respiratory Acidosis Treatment

Respiratory Acidosis Treatment

Airway:• Tracheostomy and endotracheal tube • Oxygen administration • Mechanical ventilation• Postural drainage, deep‑breathing exercises,

bronchodilators, and antibiotics • Narcotics, hypnotics, and tranquilizers as

respiratory depressants


Metabolic AcidosisMetabolic Acidosis

An excessive loss of bicarbonate ions or an increased production or retention of hydrogen ions

Causes: – Excessive loss of bicarbonate ions from

diarrhea– Renal failure– Diabetic ketoacidosis– Hyperkalemia


Symptoms of Metabolic Acidosis

Symptoms of Metabolic Acidosis

• Weakness, lethargy, headache, and confusion

• Stupor, unconsciousness, coma, and death

• Fruity odor and ketone bodies (ketoacidosis)

• Vomiting and diarrhea


Metabolic Acidosis Treatment Metabolic Acidosis Treatment

• Insulin and diabetic ketoacidosis

• Dialysis and kidney failure

• Severe metabolic acidosis and administration of IV bicarbonate or lactate


Respiratory AlkalosisRespiratory Alkalosis

Causes of

hyperventilation – Anxiety– High fever – Aspirin overdose

Symptoms – Deep, rapid breathing– Tingling of the fingers– Pallor around the

mouth– Dizziness– Spasms of the

muscles of the hands


Treatment for HyperventilationTreatment for Hyperventilation

• Treat the underlying disorder

• Have patient use re-breather mask

• Calm patient’s hysteria and prevent further hyperventilation

• Administer sedatives to calm the patient

• Have patient breathe into a paper sack


Causes of Metabolic AlkalosisCauses of Metabolic Alkalosis

• Vomiting • Extensive gastrointestinal suction • Hypokalemia• Excessive consumption of antacids with

bicarbonate • Other causes

– Drainage from intestinal fistula– Diuresis – Steroid therapy


Signs and Symptoms of Metabolic Alkalosis

Signs and Symptoms of Metabolic Alkalosis

• Irritability, disorientation, lethargy, muscle twitching, tingling and numbness of the fingers, and convulsions

• Slow shallow respirations, decreased chest movements, and cyanosis

• Symptoms of potassium and calcium depletion

• Tetany, seizures, and coma


Treatment of Metabolic Alkalosis

Treatment of Metabolic Alkalosis

• Correcting underlying cause

• Fluid and electrolyte replacement

• Administration of an acidifying solution such as ammonium chloride


Home CareHome Care

• Fluid intake or restriction

• Sodium restriction

• Controlling underlying disorder

• Arterial blood gases

• Oxygen and electrolytes


Intravenous TherapyIntravenous Therapy

• Total parenteral nutrition

• Isotonic, hypotonic, and hypertonic

• Blood‑related fluids

• Plasma expanders


Nursing Responsibilities: Administering IV Fluids

Nursing Responsibilities: Administering IV Fluids

• Venipuncture

• National Patient Safety Goal

• Central intravenous lines

• Subcutaneous infusion and hypodermoclysis

• Intraosseous infusion

• Epidural infusion

L&E Chapter 003 Lo

Health & Medicine

Transcript of L&E Chapter 003 Lo