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OXYGENATION

FLUID AND ELETROLYTENUTRITION AND METABOLISM

ENDOCRINE FUNCTION

H ANG IL KANG

NCM 103

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OXYGENATION

occurs when oxygen molecules (O2) enter thetissues ofthe body. For example, blood is

oxygenated in the lungs, where oxygen

molecules travelfrom the airand into the

blood. Oxygenation iscommonlyused toreferto medical Oxygen Saturation.

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THE PROCESS OF OXYGENATION

Deliveryofoxygen to the body

Dependsupon the interplayofpulmonary, hematologicand

cardiovascularsystem

Processes involvedare ventilation, alveolargas exchange, oxygen

transport andcellularrespiration.

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I. VENTILATION

First step in the processofoxygenationMovement ofair intoandout ofthe lungsfor the purpose of

deliveringfresh air in the alveoli

Regulated by the respiratorycenters in the ponsand medulla

oblongata.

Rate anddepth dependson the concentratinghydrogen ion andcarbon dioxide (CO2) in bodyandfluid

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MECHANICS OF VENTILATION

1. Air Pressure VariancesAirflowsfrom region ofhigher pressure toaregion oflower

pressure.During inspiration, movement of

diaphragm andother musclesofrespiration enlarge the thoracic

cavityand therebylower the pressure inside the

thorax toalevel below that ofthe atmospheric pressure.

Duringthe normal expiration, the diaphragm relaxesand the

lungsrecoil. The alveolar pressure then exceeds

atmospheric pressure, andairflowsfrom the lungs into the

atmosphere.

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2. ALVEOLAR GAS EXCHANGE

Once fresh airreaches the lungsalveoli,oxygen movesfrom areaofhigher

concentration (alveoli) tolower

concentration (pulmonarycapillary blood).The same way that CO2 diffusesfrom

the blood to the alveolarspace.

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3. OXYGEN TRANSPORT

Once the diffusion ofoxygen across the alveolar-capillarymembrane occurs, the CO2 moleculesare dissolved in

the blood plasma. Plasma is not able tocarry enough

dissolvedoxygen to meet the metabolic needsofthe

body. Oxygen carryingcapacityofthe blood isgreatly

enhanced by the presence ofhemoglobin in theerythrocytes. Once oxygen is bound to hemoglobin, the

oxygen isdelivered to the cellofthe body by

circulation

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HEMOGLOBIN

RBCs majorcomponent which contains heme, acomplex molecule of iron gives

blood itscolorandglobin, asimple protein

Hemoglobin Test Measures the gramsof

hemoglobin in a 100mlofwhole blood.

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NORMAL VALUES

Males 14.0 17.4 g/dL

Females 12.0 16.0 g/dL

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MEASUREMENT OF OXYGEN IN BLOOD

SAMPLES

1) Partial Pressure ofOxygen (PaO2) measuresoxygen dissolved in plasma.

Normal Value: 80 100 mmHg

2) Oxygen Saturation (SaO2)

measures the percentage ofhemoglobinsaturated with oxygen. Normal Value: 95 100 %

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IV. CELLULAR RESPIRATION

Gas exchange at the cellularlevel takesplace viadiffusion in response to

pressure gradient. Oxygen diffusesfrom

the blood to the tissues while carbondioxide movesfrom the tissues to the

blood. Blood isreoxygenated.

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FACTORS AFFECTING OXYGENATION

1. Age: adultsoften exhibit barrelchestandrequire increased effort to expand

the lung. Theyare also

susceptible torespiratory infection duebecause ofdecreasedactivity which is

an effective defense mechanism.

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2. ENVIRONMENTAL AND LIFESTYLE

FACTORS

Clients whoare exposed todust, animaldander, asbestosor toxicchemicalsare at an increasedriskfor

alterations in oxygenation. Smokersas wellas those exposed to

it should be questionedas to the type,

frequencyofsmoking.

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3. DISEASE PROCESSES

ASSESSMENT OF CLIENT WITH RESPIRATORYD

ISORD

ERS(HEALTH HISTORY )

Identify the chiefreason forseekinghealth care

Nurse determines when the health problemsstarted, how longit

lasted, if it wasrelievedany time, and how reliefwasobtained.

Collects information about precipitatingfactors, duration, severity

andassociatedfactorsorsymptoms

Assessriskfactorsandgeneticfactors that contribute to the

condition

Assess the impact ofsign andsymptomson the patientsability to

perform activitiesofdailyliving

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SIGNS AND SYMPTOMS

Dys

pnea

d

iff

icul

tyor

la

bor

ed

bre

athin

g,

sh

ortne

ssof

bre

ath t

oa

ny

constantlyrecurringirritant

Cough resultsfrom the irritation ofmucous membrane anywhere

in the respiratory tract. It mayarise from infectious

processandfrom airborne irritantssuch assmoke, dust andgas

Sputum Production reaction oflungs toanyconstantlyrecurringirritants

Chest Pain sharp, stabbingand intermittent or may be dull,

achingand persistent

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Wheezing high pitched musicalsound heard mainlyon expiration.

(bronchoconstriction orairway narrowing)

ClubbingFingers found in clients with chronic hypoxiccondition, chroniclunginfection and malignanciesofthe lungs. It

isdescribedassponginessofthe nail bedandlossofnail bed

angle

Hemoptysis expectoration ofbloodfrom respiratory tract. A

symptom ofboth pulmonaryandcardiacdisorder

Cyanosis bluish discoloration ofthe skin. It isalate sign ofhypoxia

(can lead toshockordeath). Cyanosisappearsof

there is 5 g/dL ofunoxygenated hemoglobin

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PHYSICAL ASSESSMENT OF UPPER

RESPIRATORY STUCTURES

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1.NOSE AND SINUSES

inspect the external nose forlesions, asymmetryor inflammation

examine the internalstructure forswelling, color, exudatesor

bleeding

inspect forseptum deviation, perforation or bleeding

palpate the frontaland maxillarysinusesfor tenderness. Usingthe

thumb the nurse appliesgentle pressure in an upwardfashion at

the supraorbitalridges (frontalsinuses) and in the cheekarea

adjacent to the nose (maxillary). Tendernesssuggests

inflammation

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2. PHARYNX AND MOUTH

Instruct the client toopen mouth and takedeep breath

Inspect structuresforcolor, symmetryandevidence ofexudates, ulceration or

enlargement

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3. TRACHEA

Place thumb and indexfingerofone handon eitherside ofthe tracheajust above

the sternal notch. It is normally in the

midline as it enters the thoracic inlet

behind the sternum.

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CONCEPTS OF FLUID BALANCE

Functionsofbodyfluids

Fluidcompartments

Electrolytes

Movement offluidsand electrolytes

Regulation offluid balance

Problemsoffluid balance

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FUNCTIONS OF BODY FLUIDS

Body needs: 1500 mL daily

700 mL from food we eat

300 mL from oxidation offood

Functions Makes halfthe body weight

Transports nutrientsand wastes toandfrom cells

Actsassolvent for electrolytesand nonelectrolytes

Facilitatesdigestion and elimination

Maintainsacid-base balance

Lubricatesjointsandother body tissues

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FLUID COMPARTMENTS

Intracellularfluidcompartment Contain 70% ofbodyfluids

Fluidlossat cellularlevelaffects entire body

Extracellularfluidcompartment

Contain 30% ofbodyfluids

Intravascularfluids

Interstitialfluids

Transcellularfluids

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ELECTROLYTES

ElectrolyteElectrolyte Normal Plasma ValueNormal Plasma Value

SodiumSodium 135 to 145 mEq/L135 to 145 mEq/L

PotassiumPotassium 3.5 to 5.0 mEq/L3.5 to 5.0 mEq/L

CalciumCalcium 4.5 to 5.5 mg/dL4.5 to 5.5 mg/dL

MagnesiumMagnesium 1.5 to 2.5 mg/dL1.5 to 2.5 mg/dL

ChlorideChloride 98 to 106 mEq/L98 to 106 mEq/L

PhosphorusPhosphorus 1.2 to 3.0 mg/dL1.2 to 3.0 mg/dL

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MOVEMENT OF FLUIDS AND

ELECTROLYTES

Osmosis

Hypotonic

Hypertonic

Diffusion

Active transport

Filtration

Colloidosmotic pressure

Hydrostatic pressure

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REGULATION OF FLUID BALANCE

Thirst Intake offluids

Lymphaticsystem Spongingup

Neuroendocrine system Hormones

Gastrointestinalsystem Absorbssecretesreabsorbs

Renalsystem Works with neuroendocrine system toregulate volume

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PROBLEMS OF FLUID BALANCE

Deficient fluidvolume Hypovolemia

Dehydration

Excessfluidvolume

Hypervolemia Water intoxication

Electrolyte imbalance

Deficit or excessofone or more electrolytes

Acid-base imbalance

Respiratoryacidosisandrespiratoryalkalosis

Metabolicacidosisand metabolicalkalosis

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Lifestyle factors

Nutrition

Exercise

Stress

Physiologicalfactors Cardiovascular

Respiratory

Gastrointestinal

Renal

Integumentary Trauma

Developmentalfactors

Infantsandchildren

Adolescentsand middle-agedadults

Olderadults

Clinicalfactors Surgery

Chemotherapy

Medications

Gastrointestinal intubation

Intravenous therapy

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FACTORS AFFECTING FLUID

BALANCE

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ASSESSMENT OF FLUID BALANCE

GeneralFocusedassessment fordeficient fluidvolume

Focusedassessment for excessfluidvolume

Focusedassessment forassociated problems

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Health history

Chiefcomplaint

Past historyofillnesses

Physical examination Standardclinical

measurements

Weighingthe client

Input andoutput

Assessingedema

Diagnostic tests

Plasmasodium

Plasmaosmolality

Urine osmolality

Hematocrit

Bloodurea nitrogen (BUN)

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FOCUSED ASSESSMENT FOR DEFICIENT

FLUID VOLUME

Definingcharacteristics

Extracellular

Intracellular

Relatedfactors

The acutenessofthe loss

The severityofthe loss

The clientsage andstate ofhealth

The degree to which the client combats the deficit

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FOCUSED ASSESSMENT FOR EXCESS

FLUID VOLUME

Definingcharacteristics

Extracellular

Intracellular

Relatedfactors

Any increase in fluid intake

Any increase in sodium intake

Increase in capillary permeability

Protein loss

The clientsresponse tofluid excess

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FOCUSED ASSESSMENT FOR

ASSOCIATED PROBLEMS

Electrolyte imbalances Fluid imbalancesrarely exists without electrolyte imbalance

Anticipate the riskfor imbalance

Metabolicacidosis

End-stage renaldisease Severe diarrhea

Hypoxia

Hyperglycemia

Metabolicalkalosis

Consumption ofexcessive bicarbonate products Lossofexcessive potassium and hydrochloricacid

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DIAGNOSIS

Deficient fluid volume orRisk for deficient fluid volume

Excess fluid volume orRisk for excess fluid volume

Related nursingdiagnoses Fatigue

Anxiety

Ineffective health maintenance

Imbalanced nutrition

Impaired skin integrity

Impaired tissue perfusion

Impaired gas exchange

Constipation

Impaired oral mucous membranes

Disturbed sleep pattern

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PLANNING

Deficient fluid volume

Increase in fluid intake

Moist mucous membranes

Absence oftongue furrows

Excess fluid volume

Decrease in peripheral edema

Weight loss

Decrease in fatigue and weakness

Associated problems

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INTERVENTIONS

Toreduce the riskofdeficient fluidvolume Teachingclient about fluid needs

Preventingexcessive fluiddeficits

Restoringlost fluids

To increase fluidvolume

Restoringfluid balance Preventingfurtherloss

Institutingrehabilitative care

Administeringintravenous therapy

Todecrease fluidvolume Restoringfluid balance

Preventingcomplications

Institutingrehabilitative care

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INTERVENTIONS

To balance electrolyte levels General interventions

o Nutrition is the key

Sodium imbalance: hyponatremiaor hypernatremia

Potassium imbalance: hypokalemiaor hyperkalemia

Calcium imbalance: hypocalcemiaor hypercalcemia Magnesium imbalance

Phosphate imbalance

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Typesof intravenous (IV)solutions

Categorized byosmolality:how solution affectsotherfluids

Isotonic

Hypotonic

Hypertonic

Sitesfor IV therapy

Potentialcomplications

Infiltration

Phlebitis

Infection

Air embolism

Allergicreaction

Circulatoryoverload

Care of IV site

Peripheral

Central

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INTRAVENOUS THERAPY

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EVALUATION

The time frame forevaluatingfluidor electrolyte imbalance

varies with the urgencyofthe

imbalance.

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NUTRITION

is the provision, tocells andorganisms, ofthe materials necessary (in the form of

food) tosupport life. Manycommon

health problemscan be preventedor

alleviated with ahealthydiet.

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NUTRIENTS

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There are six majorclassesofnutrients: carbohydrates,

fats, minerals, protein, vitamins, andwater.

These nutrient classescan be categorizedas either

macronutrients (needed in relativelylarge amounts) or

micronutrients (needed in smaller quantities). The

macronutrients include carbohydrates, fats, fiber,

protein, and water. The micronutrientsare minerals

andvitamins.

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CALORIES

Carbohydratesand proteins provide 17 kJapproximately (4 kcal) ofenergy pergram,

while fats provide 37 kJ (9 kcal) pergram

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Nutrients Deficiency Excess

Macronutrients

Calories Starvation, MarasmusObesity, diabetes mellitus,

Cardiovasculardisease

Simple carbohydrates nonediabetes mellitus, Obesity,

Cardiovasculardisease

Complexcarbohydrates micronutrient deficiencyObesity, Cardiovasculardisease (high

glycemic indexfoods)

Protein kwashiorkorRabbit starvation, Ketoacidosis (in

diabetics)

Saturatedfat none Obesity, CardiovascularDisease

Transfat none Obesity, CardiovascularDisease

Unsaturatedfat fat-soluble vitamin deficiency Obesity, Cardiovasculardisease

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Micronutrients

Vitamin A Xerophthalmia and Night Blindness Hypervitaminosis A (cirrhosis, hairloss)

Vitamin B1 Beri-Beri

Vitamin B2 Skin and Corneal Lesions

Niacin Pellagradyspepsia, cardiacarrhythmias, birth

defects

Vitamin B12 Pernicious Anemia

Vitamin C Scurvy diarrhea causingdehydration

VitaminD RicketsHypervitaminosisD (dehydration,

vomiting, constipation)

Vitamin E neurologicaldiseaseHypervitaminosis E (anticoagulant:

excessive bleeding)

Vitamin K Hemorrhage

Omega 3 Fats CardiovascularDiseaseBleeding, Hemorrhages, Hemorrhagic

stroke, reducedglycemiccontrol

amongdiabetics

Omega 6 Fats none CardiovascularDisease, Cancer

Cholesterol none CardiovascularDisease

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Macrominerals

Calcium

Osteoporosis, tetany, carpopedal

spasm, laryngospasm, cardiac

arrhythmias

Fatigue, depression, confusion,

nausea, vomiting, constipation,

pancreatitis, increasedurination,

kidneystones

Magnesium HypertensionWeakness, nausea, vomiting, impaired

breathing, andhypotension

Potassium Hypokalemia, cardiacarrhythmias Hyperkalemia, palpitations

Sodium hyponatremia Hypernatremia, hypertension

Trace minerals

Iron Anemia Cirrhosis, Hepatitis C, heart disease

Iodine Goiter, hypothyroidism Iodine Toxicity (goiter, hypothyroidism)

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METABOLISM

is the set ofchemicalreactions that happen in living

organisms to maintain life. These processesallow

organisms togrow andreproduce, maintain their

structures, andrespond to their environments.

Metabolism isusuallydivided into twocategories.

Catabolism breaksdown organic matter, for exampleto harvest energy in cellularrespiration.Anabolism

uses energy toconstruct componentsofcellssuch as

proteins andnucleicacids.

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ENDOCRINE SYSTEM

isasystem ofglands, each ofwhich secretesatype ofhormone directly into the bloodstream

toregulate the body. The endocrine system is

in contrast to the exocrine system, which

secretes itschemicalsusingducts. It derivesfrom the Greek words endo meaninginside,

within, andcrinisforsecrete.

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HORMONES

are substances (chemical mediators) releasedfrom endocrine tissue into the bloodstream

where they travel to target tissue andgenerate

aresponse. Hormonesregulate various

human functions, includingMetabolism,growth anddevelopment, tissue function, and

mood.

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8 MAJOR GLANDS

Hypothalamus

Pituitary gland

Parathyroid gland

Thyroid gland

Adrenal glands

Pancreas

Ovaries (in female body)

Testes (in male body)

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HYPOTHALAMUS

A collection ofspecializedcells that are located in the

lowercentral part ofthe brain iscalled the

hypothalamus. The hypothalamus is the main link

between the endocrine system and the nervous

system. The nerve cellsofthe hypothalamuscontrol

the pituitarygland bystimulatingorsuppressingthehormone secretions.

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PITUITARY GLAND

The pituitarygland islocatedat the base ofthe brain just below the hypothalamus.

The pituitarygland is the most important part in the endocrine system. Thepituitaryglandsecrete hormoneson the basisofthe emotionalandseasonal

changes. The hypothalamussends information that issensed by the brain to

pituitary triggeringproduction hormones. The pituitarygland isdivided into two

parts: the anteriorlobe and the posteriorlode. The anterior lobe ofthe pituitary

glandregulated the activityofthe thyroid, adrenals, and the reproductive glands.

The anteriorlobe also produces hormoneslike:

Growth Hormone: Tostimulate the growth ofthe bonesand tissues. It also playsa

role in the body'sabsorption ofnutrientsand minerals.

Prolactin: Toactivate the production ofmilk in lactatingmothers

Thyrotropin: Tostimulate the thyroidgland to produce thyroid hormones

Corticotropin: Tostimulate the adrenalglands to produce certain hormones.

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THYROID GLAND

The thyroidgland issituated in the front part ofthe lower neck that

isshapedlike a bow tie or butterfly. The production and

secretionsofthe hormonesofthe thyroidglandsare controlled

by thyrotropin secreted by the pituitarygland. Thyroid produces

thyroxine and triiodothyronine, that control the rate at which the

cellsuse up energyfrom foodfor production ofenergy. The

thyroid hormonesare very important a they help in growth ofbonesand the development andgrowth ofthe brain and nervous

system in children. Overorundersecretion ofthyroid hormones

leads toa numberofthyroid problems in the body.

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ADRENAL GLANDS

On each ofthe twokidneys, there are two triangular

adrenalglandssituated. The adrenalgland isdivided

into two parts. The outer part called the adrenal

cortex producescorticosteroids, that influence and

regulate the salt and waterlevels. Theyare also

helpful in the body'sresponse tostress, metabolism,immune system and the function anddevelopment of

sexualorgans.

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REPRODUCTIVE GLANDS OR GONADS

The gonadsare present in malesandfemalesandare

the main organs producingsex hormones. In men, the

gonadsare related totestes. The testesare located in

the scrotum andsecrete androgens. The most

important hormone for men testosterone issecreted

from the testes. In women, ovaries are the gonadsthat are located in the pelvisregion.

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PANCREAS

These glandsare associated with the digestive system of

the human body. Theysecrete digestive enzymesand

two important hormonesinsulin andglucagon. These

hormones work together to maintain the levelof

glucose in the blood.

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PINEAL

The pinealgland islocated in the centerofthebrain. Melatonin issecreted by thisgland that

helpsregulate the sleepingcycle ofa person.

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RISK FACTORSAFFECTING ENDOCRINE

SYSTEM

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AGING

hormone production andsecretion

hormone metabolism (how quickly excess hormonesare broken

down andleave the body, for example, through urination)

hormone levelscirculatingin blood

biologicalactivities

target cellor target tissue response to hormones

rhythms in the body, such as the menstrualcycle

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ILLNESS

Illness mayaffect endocrine system function inseveral ways. Acute orchronicconditions may

change endocrine functions.

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CHRONIC/ACUTE CONDITIONS

Hormonesare clearedfrom bloodduringtheircirculation to the target tissues. The liverand

kidneysare primarilyresponsible forclearing

hormones. Severalclearance processes

become alteredorslowed in individuals whohave chronic heart, liver, orkidneydisorders.

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ENDOCRINE PATHOLOGIES

congenital (birth) orgeneticdefects (see section on

Genetics below)

surgery

traumatic injuries

cancerousand non-cancerous tumorsinfection

autoimmune destruction (the immune system turns

against the body'sown organsandcausesdamage)

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STRESS

trauma (severe injury) ofany typesevere illnessor infection

intense heat orcold

surgical procedures

seriousdiseases

allergicreactions

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EXTERNAL FACTORS

disruptedsexualdevelopment

decreasedfertility

birth defects

decreased hatchingin animals

reduced immune response

neurologicaland behavioralchanges, includingreducedstress

tolerance

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GENETICS

Portionsofyour endocrine system can beaffected bygenes. Genesare unitsof

hereditary information passedfrom parent to

child. Genescontain the instructionsfor the

production ofproteins, which are some oftheessentialcomponentsofthe body. Genesare

contained in chromosomes. The normal

numberofchromosomes is 46 (23 pairs).

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CYCLES OF HORMONE RELEASE

Cortisol buildsup early in the day, decreases toward evening, risesagain

toward the endofsleep, and peaksduringthe morninghours.

Thyroid-stimulatinghormone (TSH) peaksduringsleep andreaches itslow

point three hoursafteran individualawakens.

Levelsofgrowth hormone (GH) are high 90 minutesaftersleep begins. GH

typically increasesduringthe first 2 hoursofdeep sleep. It also

increases ifa person is hypoglycemic (low bloodsugar), starving,exercising, excitedor isavictim ofsevere injury.

There isaverydefinite rise-and-fall pattern to both estrogen and

progesterone activityduringa woman's menstrualcycle, which lastsan

average of28 days.

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