CNUR 203 Introductory Lecture: General Assessments & Fluid Balance PDF

CNUR 203 INTRODUCTORY LECTURE: GENERAL ASSESSMENTS AND FLUID BALANCE INTRODUCTION OBJECTIVES  Demonstrate proper assessment techniques and vital signs techniques (Review Powerpoint & in Lab)  Demonstrate the ability to perform a pain assessment (Review Powerpoint & in Lab)  Understand t...

CNUR 203 INTRODUCTORY LECTURE: GENERAL ASSESSMENTS AND FLUID BALANCE INTRODUCTION OBJECTIVES  Demonstrate proper assessment techniques and vital signs techniques (Review Powerpoint & in Lab)  Demonstrate the ability to perform a pain assessment (Review Powerpoint & in Lab)  Understand the pathological processes, risks and complications for a patient with fluid and electrolyte, and acid-base imbalances.  Identify problems and prioritize nursing interventions for a patient with fluid and electrolyte imbalances.  Understand the different types and uses of intravenous fluid replacement therapy.  Interpret and analyze abnormal lab values.  Understand the basic concepts of Anemia  60 SECOND ASSESSMENT HEAD TO TOE NEEDS TO BE PAIN ASSESSMENT SYSTEMATIC HEALTH HISTORY AND ORGANIZED VITAL SIGNS SYSTEMS ASSESSMENT LAB VALUES  What is included in a general survey?  Physical appearance  age, sex, LOC, skin colour, facial features  Body structure GENERAL  stature, nutrition, symmetry, posture, position, body build, contour SURVEY  Mobility  Gait, range of motion  Behaviour  Facial expression, mood and affect, speech, dress, personal hygiene SUBJECTIVE DATA VERSUS OBJECTIVE DATA  Subjective Data  What YOU observe… assessment using your senses  They say it  Systems assessment  What the client tells you  Lab values  Health history  Imaging reports  Objective Data HEALTH HISTORY  Biographical data  Reason for seeking care  Present health or history of present illness  Past health history (childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalizations, operations, obstetrical history, immunizations, last examination date, allergies, current medications, health of immediate relations)  Review of systems  Self-care abilities  Activities of daily living HEALTH HISTORY: PAIN ASSESSMENT **In addition to the Health history data , also include a detailed pain assessment** Review Chapter 11 in Jarvis Two types of Pain: 1. Nociceptive – caused by damage tissue 2. Neuropathic – nerve pain caused by associated conditions HEALTH HISTORY: PAIN ASSESSMENT (OPQRSTUV) Jarvis Pg 188  Onset  Provocation/palliation  Quality  Radiation  Severity  Treatment/timing  Understanding of pain  Value HEALTH HISTORY: PAIN ASSESSMENT  The BEST indication of how much pain the client is in is – What the client TELLS you!  PAIN is Subjective  Once you have completed a subjective assessment of pain, you can also look at other non-verbal/objective factors… NON-VERBAL PAIN ASSESSMENT  Cardiac  GU  Tachycardia, elevated BP,  Urinary retention, Spasm increased CO  MSK  Respiratory  joint Stiffness  Hypoventilation, Hypoxia  Immune  GI  Impaired wound healing  Nausea, Vomiting, Ileus PACSLAC VITAL SIGNS  Once you have completed a general  SpO2 survey  How to take Vital signs was taught in and a health history, including a pain year 1- please review your notes. assessment…  Do a set of Vital signs:  Additional review is available in Jarvis  Temperature on pages 158-175  Pulse  Blood pressure  Respiratory rate ALTERATIONS IN VITAL SIGNS  Understanding how to interpret vital signs is a crucial component of a thorough assessment  Ensure you are familiar with the normal parameters, and what actions to take if vital signs are abnormal. ALTERATIONS IN VITAL SIGNS: TEMPERATURE Oral: 35.8 – 37.3 ° C Axillary: 0.6 C lower than oral Rectal: 0.4 – 0.5 higher than oral Tympanic Terms: Febrile or Afebrile +/- 0.2 to oral Temp 38.1: Mrs. N is.......... ALTERATIONS IN VITAL SIGNS: TEMPERATURE- ALGORITHM Asses The Please note: Infection s Environment Geriatric clients Dehydration Anesthesia may not show Blood transfusion Cold fluids/ ice an elevation. reaction False reading Do Recheck No action Stop Blood reading needed transfusion Notify RN Notify RN WHAT ARE THE FOUR TYPES OF ASSESSMENT TECHNIQUES THAT NURSES USE TO EXAMINE A CLIENT?  Inspection  Palpation  Percussion  Auscultation Fluids and Electrolytes FLUID, ELECTROLYTE AND ACID-BASE IMBALANCES  Fluids and electrolytes are important to the maintenance of homeostasis – the state of equilibrium maintained within the internal environment of the body.  The body produces many acids during normal metabolism, altering the internal environment and must be regulated to maintain homeostasis.  Many diseases, or treatments for disease, alter fluid and electrolytes or acid-base balance.  Nurses play a role in recognition of risks for, or signs and symptoms of imbalances. They can then intervene with appropriate actions. WATER PERCENTAGE OF THE BODY WEIGHT IN DIFFERENT LIFE STAGES REVIEW  Water accounts for approximately 60% of adult body weight.  On average we have 40 liters of body fluid (40,000 ml) (42 liters in a 70 kg man)  Two major fluid compartments are:  Intracellular – (inside the cells) approximately 2/3 of total water (approximately 25 liters or 40% of weight)  Extracellular (outside the cells) consists of primarily interstitial fluid and intravascular fluid (plasma) (20% of weight)  It is important to remember that these amounts may change with age, gender, and body size FLUID BALANCE  Under normal circumstances, the kidney can adjust water and electrolyte excretion to maintain fluid homeostasis.  Osmolality  Is the concentration of solutes per weight of water.  Affects cells by playing a key role in fluid balance.  Is used to evaluate concentration of solutes for plasma, urine and body fluids  Sodium, glucose and urea are key ingredients for osmolality calculation  Urine osmolality.  Serum osmolality FLUID GAIN AND LOSS  One liter of fluid weighs 1 kg  Body weight change is an excellent indicator of overall volume loss or gain  Examples-  A patient who is fasting for surgery could lose 0.5 to 1 kg per day  A patient receiving a diuretic drug (therapeutic action is to increase urine production) who loses 2 kg in two days has experienced a fluid loss of 2 liters.  Doctors often order daily weights to help determine fluid balance  Fluid loss of 20% can be fatal and a fluid loss of 10% is dangerous  MOVEMENT OF FLUID IN THE BODY  Osmosis – movement of water between two compartments separated by a semipermeable membrane – (water moves but not solute)  Diffusion – movement of molecules from an area of high to low concentration. Examples include gases (oxygen, C02) and urea (main product of protein metabolism)  Hydrostatic pressure – force within a fluid compartment. E.g in blood vessels it is the blood pressure generated by contraction of the heart  Oncotic pressure – osmotic pressure exerted by colloids in solution. Major colloid in the vascular system is protein (albumin). Protein molecules pull fluid from tissue space into vascular space. ELEMENTS CARRIED BETWEEN BLOOD AND CELLS  Oxygen and carbon dioxide  Nutrients and cell waste products  Electrolytes (K+, Na++, etc.) FLUID MOVEMENT  Fluid normally moves between capillaries and the interstitial space. This water or body fluid is the vehicle by which electrolytes and nutrients are transported into and out of cells.  Capillary hydrostatic pressure, plasma oncotic pressure, interstitial hydrostatic pressure, and interstitial oncotic pressure determine the amount and interaction of movement  If capillary or interstitial pressures are altered fluid shifts occur resulting in edema or dehydration. REGULATION OF FLUID BALANCE  Hypothalamic regulation  Pituitary regulation  Adrenal cortical regulation  Renal regulation  Cardiac regulation  Gastro-Intestinal regulation  Insensible water loss FLUID SPACING  Term used to describe the distribution of fluids in the body  First spacing is normal distribution between ICF and ECF compartments  Second spacing is an abnormal accumulation of interstitial fluid (edema)  Third spacing occurs when fluid is accumulated, trapped, and unavailable for functional use. Examples are fluid in the abdomen associated with peritonitis or edema associated with burns, trauma, or sepsis. FLUID SHIFTS: PLASMA TO INTERSTITIAL FLUID  Increasing venous hydrostatic pressure inhibits fluid movement back into the capillary. Causes include fluid overload, heart or liver failure, obstruction of venous return to the heart by tourniquets, blood clots, or restrictive clothing or venous insufficiency.  Decrease in plasma oncotic pressure occurs when plasma protein content is low. This occurs in burns, malnutrition, liver disease and renal disease  Elevation of interstitial oncotic pressure occurs with damage to capillary walls. This can occur with inflammation, burns, and trauma.  Increased capillary permeability caused by allergies, inflammation or burns cause both water and solutes to move out into the tissues.  Lymph obstruction causes fluid and protein to be retained in interstitial spaces. FLUID SHIFTS: INTERSTITIAL FLUID TO PLASMA  Fluid is drawn into the plasma space whenever there is an increase in plasma osmotic or oncotic pressure. Administration of colloids (e.g. albumin), dextran, mannitol, or hypertonic IV solutions all draw fluid from the interstitium into the vascular space.  Increasing tissue hydrostatic pressure also causes a fluid shift. Wearing elastic compression gradient stockings is an example of a therapeutic application. INTRAVENOUS FLUIDS: REVIEW Crystalloids Colloids Contain small molecules (solutes) that are Contain large molecules, can’t pass through easily dissolved in a solution semi-permeable membranes (capillaries) Solutes may be electrolytes (Na+, K+) or non- Remain in intravascular space (inside the electrolytes (glucose) vessel) Move easily across semi-permeable Expand intravascular volume membranes Example: Ringer’s Lactate Exert oncotic pressure to “pull” fluid into vascular space Example: Albumin First choice for fluid resuscitation Protein solutions INTRAVENOUS SOLUTIONS CONTINUED Hypotonic Isotonic Hypertonic Concentration of dissolved Osmotic pressure inside & Concentration of dissolved particles is lower than outside of cells remains particles is higher than plasma. constant intracellular fluid & plasma Lowers osmotic pressure within the vascular space. Hydrates cells but also Remain in extracellular Infusion increases osmotic decreases volume in space & distributed between pressure in vascular space. intravascular space – can intravascular and interstitial Draws fluid from intracellular worsen hypotension compartments to extracellular space Have potential to cause Ideal fluid replacement for a Useful in treatment of cellular swelling patients with ECF deficit hypovolemia & hypernatremia Pulls fluid into cells Doesn’t affect size of cells Pulls fluid out of cells Often used for maintenance Contraindicated in lactic Primary use is in provision of fluids acidosis because body calories unable to convert lactate to EFFECTS OF WATER STATUS ON RED BLOOD CELLS  ASSESSMENT OF FLUID AND ELECTROLYTE BALANCE IN THE HOSPITALIZED PATIENT Extracellular Assessment findings Extracellular Assessment findings Fluid Volume Deficit Fluid Volume Deficit Fluid Volume Excess Fluid Volume Excess Hypovolemia – low circulating Vital signs: tachycardia, Hypervolemia – fluid overload Vital signs: full bounding pulse, blood volume hypotension, increased RR due to increased BP, jugular venous decreased perfusion distension Caused by vomiting, diarrhea, Dry mucous membranes, cool Caused by heart, liver, renal Respiratory: crackles, SOB, diuretics, wounds etc. skin, failure etc. dyspnea Poor tissue turgor Treatment: Fluid & electrolyte Irritability, confusion Treatment: Fluid restriction, Weight gain replacement Weight loss sodium restriction, diuretics etc. IV bolus or continuous infusion, Decreased urine output oral or enteral replacement Flat neck veins, weak pulse, Mental status changes reduced capillary refill HOW DO WE KNOW FVE HAS RESOLVED?  Stable CV status with  BP  Diuresis  Balanced intake & output, weight loss  Decreasing edema  Improving lung sounds (↓ crackles, ↑ AE)  Improved mental status  Stabilizing bloodwork Serum Proteins & Electrolytes PLASMA PROTEINS (PRIMARILY ALBUMIN)  Protein 64-83 g/L  Albumin 35-50 g/L  Affects serum osmolarity (The pressure exerted by proteins on the blood vessels).  The main negatively charged intravascular fluid anions.  Pull water into the vascular space and keep it there.  Too big to cross the semipermeable capillary wall so the concentration is highest in the vascular space.  Plasma proteins create colloid osmotic pressure which pull water in and holds it in the vascular bed. PROTEIN IMBALANCES Causes Assessment findings Treatment (Do) Teaching Decreased food intake Edema – caused by Provide a high Teach about reasons decreased oncotic carbohydrate, high for breakdown of Starvation pressure protein diet and protein dietary protein Elevated basal Liver disease Slow healing supplements metabolic rates Catabolic states Massive burns Anorexia Enteral nutrition (tube fever feeding) or total infection Loss of albumin in Fatigue parenteral nutrition malignancies renal disease may be used if patient Anemia cannot meet protein Protein is needed for Major infection needs orally cell growth and repair Muscle loss – results GI disease from breakdown of (malabsorption) body tissue to meet the body’s need for Etc. protein ELECTROLYTES What do they do What happens if What are they? that makes them there is an so important? imbalance? Positive and negative Produce energy Negative effects on all electrically charged Help with electrical body systems ions/salts dissolved in conduction Our cells will not function body fluids and dispersed Help your nerves and without them throughout the body into muscles to function all compartments. Regulate acid-base balance Help to regulate the extracellular and intracellular fluid balance MAIN ELECTROLYTES Extracellular Intracellular  Sodium  Potassium  Chloride  Magnesium  Calcium  Phosphorus ELECTROLYTE BALANCE  Potassium is the dominant particle in intracellular fluid (ICF)  Sodium is the dominant particle in extracellular fluid (ECF)  Osmolarity (total solute concentration) is the same in ECF and ICF even though the numbers of each of the electrolytes (solutes) differs.  Osmolarity is higher when there are more electrolytes in solution  Three factors govern osmolarity: electrolytes (especially sodium Na+), glucose and urea, plasma proteins (albumin) ELECTROLYTES / LIVER PANEL / RENAL PANEL NORMAL VALUES IN ADULTS  Potassium (K): 3.5-5.0 mmol/L  Sodium (Na): 135-145 mmol/L  Chloride (Cl): 98-106 mmol/L  Bicarbonate (HC03- ): 21-28 mmol/L  Magnesium (Mg2+ ): 0.74-1.07 mmol/L  Calcium (Ca2+): 2.25-2.75 mmol/L  Phosphate (P04-3): 0.97-1.45 mmol/L  Protein Total: 64-83 g/L  Albumin: 35-50 g/L NA+ SODIUM  Most abundant electrolyte in extracellular fluid. Very common electrolyte disorder!  Na+ attracts water and plays a major role in fluid balance.  Sodium imbalance usually means a fluid imbalance.  Absorbed in intestines/ excreted by kidneys  Works with potassium to maintain electrolyte balance between ICF and ECF ( sodium potassium pump)  Primary acute clinical manifestations are neurological. CELL CHANGES WITH SODIUM IMBALANCES As water shifts – either into or out of the cells - neurological changes are the most common clinical manifestations. Water follows sodium. Cells will either shrink or swell.  HYPONATREMIA NORMAL 135-145 MML/L CRITICAL VALUE < 120 MML/L Causes Assessment findings Treatment (Do) Teaching Sodium Loss: Decreased ECF volume (sodium Accurate intake and output Teach about commercially GI losses: diarrhea, vomiting, loss) Intake includes oral, IV, tube available oral rehydration fluids fistulas, NG suction Irritability, confusion feedings, any retained containing electrolytes to Renal losses: Hypotension irrigation fluids prevent sodium loss in cases of Diuretics, adrenal insufficiency, Tachycardia Output includes urine, excess diarrhea and vomiting. Skin losses: burns, wound Nausea and vomiting perspiration, wound or tube drainage Dry mucous membranes drainage, vomiting and Teach patients with heart Weight loss diarrhea failure to monitor weight daily Water gain: (sodium dilution) Tremors, seizures, coma Monitor vital signs and observe and report sudden increase. SIADH (syndrome of trends inappropriate antidiuretic Fluid restriction is often all that hormone secretion) Normal or increased ECF is needed. Heart failure volume (water gain) Daily weights Excessive IV or oral fluids Skin assessment and care Headache, apathy Safety Considerations: Weakness, confusion Administer IV fluids as ordered. Nausea and vomiting Hypertonic saline solution (3% Weight gain or 5%) can be used for a Increased BP limited time and requires very Muscle spasms, seizures, coma close monitoring. Rapid correction of hyponatremia can cause permanent brain damage – osmotic demyelination  HYPERNATREMIA NA+ 135 -145 MMOL/L CRITICAL VALUE > 160 MMOL/L Causes Assessment findings Treatment (Do) Teaching Hypernatremia (water deficit) Decreased ECF (water loss) Treat the underlying cause Teach older adults to drink Increased insensible water loss Intense thirst; dry, swollen In primary water deficit: water regularly. or perspiration (high fever, tongue Replace fluid orally or with heat stroke) Restlessness, agitation, isotonic 0.9% sodium chloride Explain treatment goals to Diabetes insipidus twitching For sodium excess – dilute patients Osmotic diuresis (seen in type Seizures, coma sodium concentration with salt 1 diabetes) Weakness free IV fluids e.g 5% Dextrose Postural hypotension in water (hypotonic) Sodium gain Weight loss Promote excretion of sodium IV hypertonic NaCl with diuretics IV sodium bicarbonate Normal or increased ECF Salt water near-drowning (sodium gain) Safety considerations: Intense thirst Na + Levels must be reduced Restlessness, agitation, gradually twitching Older adults or cognitively Seizures, coma impaired individuals are at high Flushed skin risk. Regular administration of Weight gain oral fluids must be Peripheral and pulmonary incorporated in the plan of care edema Increased BP K+ - POTASSIUM Critical values: < 3.3 mmol/L or > 6.0 mmol/L Many cellular and metabolic functions Transmission & conduction of nerve impulses Maintenance of normal cardiac rhythms Skeletal and smooth muscle contraction Promotes cellular growth Kidneys are primary route for K+ loss Diet is source of K+  HYPOKALEMIA K+ < 3.5 MMOL/L CRITICAL VALUE < 3.3 MMOL/L Causes Assessment findings Treatment (Do) Teaching Deficient dietary intake Weak, irregular pulse Administration of K+ Signs & symptoms of supplements orally or IV (oral hypokalemia ECG changes – ventricular route preferred) Importance of increasing dysrhythmias, flattened T Dilute liquid in water or juice dietary K+ if taking thiazide wave, presence of U wave, Give pills with food or loop diuretics bradycardia etc. For patient taking K+ GI losses ( diarrhea, vomiting, Skeletal muscle weakness, Safety Considerations: sparing diuretics explain NG suction) fatigue IV K+ is irritating to the that salt substitutes and Lethargy vein assess IV site hourly foods with high K+ content Low, shallow respirations for phlebitis and infiltration should be avoided If taking K+ supplements Diuretics – especially in Leg cramps – K+ can cause necrosis & sloughing take as directed with a full patients with high aldosterone Limp muscles glass of H20 K+ given IV must be diluted levels If taking digoxin or at high Never IV push Skin losses - diaphoresis May be asymptomatic IV bags should be inverted risk of hypokalemia serum several times to ensure K+ levels should be even distribution monitored regularly Never add K+ to a hanging IV bag to avoid a bolus dose **Think slow and low POTASSIUM RICH FOODS  HYPERKALEMIA K+ > 5.1 MMOL/L CRITICAL VALUE > 6.0 MMOL/L Causes Assessment findings Treatment (Do) Teaching Failure to eliminate K+ Irregular pulse Mild: Explain rationale for treatment Renal disease Cardiac standstill if Eliminate oral and IV K+ intake and provide teaching about K+ sparing diuretics hyperkalemia sudden or severe medications. Adrenal insufficiency Moderate: ACE inhibitors ECG changes – tall peaked T Increase elimination of Reinforce self-management of wave, loss of P wave, potassium renal insufficiency – dietary ventricular fibrillation, etc. Diuretics (furosemide) restrictions etc. Dialysis Irritability/anxiety Ion-exchange resins (Kayexalate) Weakness of lower extremities Increased fluid intake Shift of K+ out of cells: Severe (ECG changes) Acidosis Paresthesia Force potassium from ECF Tissue catabolism (e.g. to ICF fever, sepsis, burns) Abdominal cramping/diarrhea Give IV insulin (along with Crush injury glucose) Tumour lysis syndrome Administer sodium Excess potassium intake bicarbonate if acidosis Excessive or rapid IV present Reverse membrane effects administration K+ containing drugs of elevated ECF K+ by Potassium containing salt administering calcium substitute gluconate IV  CA –CALCIUM NORMAL VALUE 2.25 – 2.75 MML/L  Obtained from diet  More than 99% combined with phosphorus and concentrated in the skeletal system.  Calcium and phosphorus have inverse relationship – as one increases the other decreases  Functions: transmission of nerve impulses, myocardial contractions, blood clotting, formation of teeth and bone, and muscle contractions.  Present in serum in 3 forms: free or ionized; bound to albumin; and complexed with phosphate, citrate, or carbonate. Ionized form is biologically active. Total calcium includes all three forms  Calcium balance is controlled by parathyroid hormone and vitamin D.  HYPERCALCEMIA CA ++ 2.25 – 2.75 MML/L CRITICAL VALUE > 2.75 MMOL/L Causes Assessment findings Treatment (Do) Teaching Increased total calcium Lethargy Basic treatment is promotion of Teach about medications and Malignancies (1/3 of cases) Weakness excretion by administration of why they are being Prolonged immobilization Decreased memory a loop diuretic and hydration administered. Hyperparathyroidism (2/3 of Confusion/personality changes with isotonic saline solutions cases) Anorexia, nausea vomiting Mobilization with weight- Vitamin D overdose Bone pain, fractures bearing activity Thiazide diuretics Polyuria, dehydration Synthetic calcitonin to lower Nephrolithiasis (kidney stones) Ca++ levels Stupor, coma In cases of malignancy the Increased ionized calcium drug of choice is pamidronate acidosis ECG changes which inhibits the activity of osteoclasts Safety considerations: Careful monitoring when giving IV saline as fluid overload can occur in patient who cannot excrete excess sodium due to renal insufficiency. Consider fall risk and safety  HYPOCALCEMIA CA++ 2.25- 2.75 MMOL/L CRITICAL VALUE < 2.25 MMOL/L Causes Assessment findings Treatment (Do) Teaching Decreased total calcium Easy fatigability Aimed primarily at correcting Teach about risk for fractures Chronic renal failure Depression, anxiety, confusion cause Vitamin D deficiency Numbness & tingling in Increase calcium in diet Teach about need for dietary Primary extremities and around mouth Vitamin D supplementation changes or about hypoparathyroidism Hyperreflexia supplementation with oral Elevated phosphorus Muscle cramps If severe: calcium if prescribed. Loop diuretics Chvostek’s sign IV calcium Chronic alcoholism Trousseau’s sign Multiple blood transfusions Safety considerations: Laryngeal spasm Etc. Tetany, seizures Any patient undergoing ECG changes thyroid or neck surgery should be observed closely in the post-op period for manifestations of hypocalcemia because of the proximity of surgery to parathyroid glands TESTS FOR HYPOCALCEMIA  Chvostek’s sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear  Trousseau’s sign is a carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes. (carpal spasms become evident within 3 minutes if hypocalcemia is present) MAGNESIUM IMBALANCE Not commonly seen unless kidneys are not functioning normally. Magnesium plays an important role in essential cellular processes. It is a co-factor in many enzyme systems. Muscle contraction and relaxation, normal neurological function, and neurotransmitter release depend on Mg++  Primary clinical manifestations are neuromuscular and cardiac.  HYPOMAGNESEMIA - MG++ 0.74-1.07 MMOL/L Causes Assessment findings Treatment (Do) Teaching Diarrhea Resembles hypocalcemia If asymptomatic – oral Teach about increasing dietary Vomiting Neuromuscular manifestations magnesium supplements intake of magnesium or oral Chronic alcoholism are common: supplements if ordered. Impaired GI absorption Muscle cramps Cardiac or neurological Prolonged malnutrition Tremors symptoms Large urine output Hyperactive deep tendon IV Mg sulfate administered NG suction reflexes slowly Hyperaldosteronism Chvostek’s sign Safety considerations: Trousseau’s sign Neurological manifestations: Monitor vital signs when Confusion administering magnesium IV Vertigo Seizures Use infusion pump because rapid administration can lead to hypotension, cardiac, and respiratory arrest.  HYPERMAGNESEMIA - MG++ 0.74-1.07 MMOL/L Causes Assessment findings Treatment (Do) Teaching Usually only occurs with an Initial manifestations: Initially: avoidance of oral Teach about decreasing dietary increase in magnesium Hypotension magnesium intake intake of magnesium. intake accompanied by Facial flushing renal insufficiency or failure Lethargy If renal function is adequate, If renal function is adequate (Maalox, Milk of Magnesia Urinary retention increased fluids and diuretic teach about increasing fluids are high in Mg++) Nausea & vomiting promote urinary excretion Can develop in pregnant Later: Dialysis is required in patients women who receive MgSO4 Deep tendon reflexes are lost with impaired renal function for management of Muscle paralysis and coma eclampsia. Respiratory and cardiac arrest If symptomatic – calcium gluconate administered IV opposes effects of excess magnesium on cardiac muscle  PHOSPHATE: 0.97-1.45 MMOL/L CRITICAL VALUE < 0.32 MMOL/L Essential to function of muscle, RBCs and nervous system Stored in the bones Excreted through the kidneys Calcium and phosphate influence each other in opposite ways. For example, when calcium levels increase; phosphate levels decrease Can result in cardiac dysrhythmias, muscle weakness, CNS dysfunction etc.  HYPER & HYPOPHOSPHATEMIA - PO4 0.97 – 1.45 MMOL/L CRITICAL VALUE < 0.32 MMOL/L Hyperphosphatemia:Causes Assessment findings Hypophosphatemia: Causes Assessment findings Main Cause: Hypocalcemia Malabsorption syndrome Remember the word: “BROKEN” B- Breathing problems due to Renal failure Glucose administration muscle weakness Muscle problems, tetany Total parenteral nutrition R- Rhabdomyolysis- rapid Other causes: Alcohol withdrawal necrosis of skeletal muscles Excess Vitamin D intake Deposition of calcium, Phosphate binding antacids which leads to renal failure. Renal failure occurs as a result of Excessive ingestion of milk or phosphate precipitates in skin, Recovery from diabetic myoglobin being released into phosphate containing soft tissue, joints, blood ketoacidosis the blood due to muscle death. laxatives, vessels etc. Respiratory alkalosis Myoglobin is toxic to the kidneys O- Osteomalacia (softening of the chemotherapy bones); cardiac Output is decreased K- Kills the immune systems with immune suppression and decreased platelet aggregation (increased risk of bleeding) E- Extreme weakness, ecchymosis due to decreased platelets. N- Neuro changes (irritability, confusion, seizure, coma) Acid Base Balance  ACID-BASE IMBALANCE PH 7.35 – 7.45  Normally there is a steady balance between acids produced during metabolism and bases that neutralize and promote excretion of acids.  Vomiting and diarrhea cause loss of acids and bases  Renal insufficiency results in inability to compensate for acid load so older adults are often at risk  Older adults have decreased respiratory function which impairs the body’s ability to compensate for acid base imbalance  Lung diseases such as COPD cause retention of carbon dioxide, an acidic gas  All seriously ill patients are at risk for acid-base imbalance  ARTERIAL BLOOD GASES – NORMAL VALUES  pH – 7.35- 7.45  PC02 – 35-45 mm Hg  Bicarbonate level – HC03 – 21 -28 mmol/L  P02 – 80-100 mm Hg  ACIDOSIS PH < 7.35 ALKALOSIS PH > 7.45 Respiratory Respiratory Metabolic Acidosis Metabolic Alkalosis Acidosis Alkalosis Causes: Causes: Causes: Causes: COPD Hyperventilating Diabetic ketoacidosis Severe vomiting Overdose Stimulated respiratory Lactic acidosis Excess gastric suctioning Severe pneumonia center (sepsis, brain Starvation Potassium deficit Pathophysiology: injury etc.) Severe diarrhea Pathophysiology: C02 retention by lungs Pathophysiology: Renal failure Loss of strong acid or due to hypoventilation Increased C02 excretion Shock gain of base Lab findings: by lungs Pathophysiology: Lab findings: Decreased pH Lab findings: Gain of fixed acid, Increased pH Increased paC02 Increased pH inability to excrete acid Increased HC03 Etc. Decreased PaC02 or loss of base Lab findings: Decreased pH Decreased HC03 LAB VALUES Blood is the body fluid most frequently analyzed in the lab Used to assess many body processes and disorders Usual reasons for blood work: To establish a medical diagnosis ( e.g. renal failure) To rule out a clinical problem (e.g. hypokalemia) To monitor therapy (e.g. insulin or anticoagulant) To establish a prognosis (decreasing CD4 counts in HIV) To screen for disease (PSA levels. FIT test) To determine effective drug dosage and prevent toxicity (i.e., digoxin, phenytoin…) LAB VALUES  An important part of patient assessment  “Blood work” contains valuable information about nutritional, hematologic, metabolic, immune and biochemical status of patient  3 general methods used: venipuncture (venous blood), arterial, and skin or capillary puncture COMMON TESTS  Complete Blood Count and Differential : CBC and Diff  Electrolyte Panel (K+, Mg, Ca, Cl, Na…)  Liver Function Tests/ Liver Panel  Renal Panel  Lipid Panel (LDL, HDL, TG, TC)  Coagulation Screening (PT, PTT, INR) CBC  Red blood cell (RBC) count  Hemoglobin  Hematocrit  RBC indices  White blood cell (WBC) and differential count  Blood smear  Platelet count  Mean platelet volume RED BLOOD CELL INDICES  Red blood Cell Indices provide information about the size, colour and hemoglobin content of the RBC. Useful in classifying anemias.  Includes: Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH), Mean Corpuscular Hemoglobin Concentration (MCHC), Red Blood Cell Distribution Width (RDW) RED BLOOD CELL COUNT Normal findings in adults: Male: 4.3-5.7 x 1012/L (SHA- 4.7-6.1 x 1012/L ) Female: 3.8-5.1 x 1012/L (SHA- 4.2-5.4 x 1012/L)  Repeated serially in patients with ongoing bleeding  Low values have many causes: hemorrhage, hemolysis, dietary deficiency (iron or B12),bone marrow failure, chronic illness, ingestion of drugs affecting RBCs, other organ failure CBC - HEMATOCRIT  Hematocrit is the percentage of total blood volume that is composed of RBCs.  Helpful in diagnosing and assessing blood diseases, nutritional deficiencies and hydration status  Male: 0.39--0.50 L/L (SHA- 0.42-0.52L/L volume fraction 40-50%)  Female: 0.35-0.47 L/L (SHA-0.37-0.47 L/L volume fraction 37-47%) HEMOGLOBIN (HGB) Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. The hemoglobin molecule contains iron Normal findings: Adult male: 132-173g/L (SHA 140-180 g/L) Adult female: 117-160g/L (SHA120-160g/L) If hemoglobin falls too low the CV system is strained leading to risk of angina, MI, heart failure and stroke. If too high – risk of stroke and organ infarction CBC - HEMOGLOBIN  Decisions concerning need for blood transfusion are usually based on hemoglobin or hematocrit.  In an otherwise healthy person transfusion is not generally considered if hemoglobin > 80 CBC - WHITE BLOOD CELLS AND DIFFERENTIAL WBC and differential provide two elements of information A total count of WBCs per liter of peripheral blood. The differential count – the percentage of each type of leukocyte Normal value: 4.0-10.0 x 109/L Clinical significance High: infection; inflammation; burns; trauma; heart attack; surgery; leukemia Low: Bone marrow disorders or damage; lymphoma; autoimmune disorders (ie.., lupus); disease of immune system (i.e., HIV); aplastic anemia; chemo/radiation therapy DIFFERENTIAL Neutrophils: 2.5 – 7.5 x 109/L Watch for Bands Lymphocytes: 1.0 -- 4.0 x 109/L Monocytes: 0.1 -- 0.7 x 109/L Eosinophils: 0.00–0.5 x 109/L Basophils: 0.02 -- 0.05 x 109/L Determination of whether each kind of WBC is present in proper proportion. CBC - PLATELET COUNT NORMAL VALUE: 150-400 X 109/L Platelet activity is essential to blood clotting. Platelets circulate in the bloodstream and bind together to form a clot over a damaged blood vessel. Determining platelet count is vital in assessing patients for tendencies of bleeding and thrombosis Counts lower than 150 x 109/L are considered to indicate thrombocytopenia. Thrombocytosis is diagnosed when counts exceed 400 x 109/L CBC - PLATELETS Thrombocytopenia (decreased levels) found in: Idiopathic thrombocytopenia; hemorrhage; bone marrow disorders; viral infection; certain drugs; metastasized cancer to the bone marrow; leukemia; Lupus; cancer treatment… etc. Thrombocytosis (increased levels) found in: Acute infection; cancers of lung, GI, ovarian, breast or lymphoma; myelodysplastic disorder such as chronic myeloid leukemia; polycythemia vera; postsplenectomy syndrome; inflammatory conditions (RA; inflammatory bowel disease); iron deficiency anemia; chronic pancreatitis; cirrhosis, chronic granulocytic leukemia;..etc. ANEMIA A reduction in one or more of the major red blood cell (RBC) measurements obtained as a part of the complete blood count (CBC): *RBC; hematocrit (Hct); hemoglobin(hgb) Normal ranges of hemoglobin/Hct may not apply to certain populations One of the most common problems seen in clinical practice Not a disease, it is a symptom of underlying pathophysiological process In many cases, the cause is not readily apparent and multiple conditions may be related to anemia ANEMIA-CLINICAL MANIFESTATIONS Caused by the body’s response to tissue hypoxia Depends on the severity of anemia and the types of anemia Severity of anemia is determined by hemoglobin levels Mild: 100-120 g/L Moderate: 60-100 g/L Severe: