Med Surg Fluid Electrolyte Acid-Base Imbalances PDF

Nursing Care of Patient’s with Fluid, Electrolyte, and Acid-Base Imbalances BY: Michelle Melton, BSN, RN  Objective...

Nursing Care of Patient’s with Fluid, Electrolyte, and Acid-Base Imbalances BY: Michelle Melton, BSN, RN  Objectives 1. Identify the purposes of fluids and electrolytes in the body 2. List the signs and symptoms of common fluid imbalances 3. Predict patients who are at the highest risk for dehydration and fluid excess 4. Identify data to collect in patients with fluid and electrolyte imbalances 5. Describe therapeutic measures for patients with fluid and electrolyte imbalances  Objectives 6. Identify the education needs of patients with fluid imbalances 7. Categorize common causes, signs and symptoms, and treatments for sodium, potassium, calcium, and magnesium imbalances 8. Identify foods that have high sodium, potassium, and calcium contents 9. Give examples of common causes of acidosis and alkalosis 10. Compare how arterial blood gases change for each type of acid-base imbalance  Fluid and Electrolyte Balance Body fluids – Components Water and chemicals Electrolytes: substances that carry electrical charge when dissolved in fluid Acids: release hydrogen into fluid Bases: substances bind with hydrogen – Purpose: regulate fluid volume, buffer blood to keep its pH neutral—body’s negative feedback loop; bases bind with hydrogen  Fluid and Electrolyte Balance Body fluid compartments – 60% of body is water – For every 100lbs of body weight, approximately 60lbs is water – 1 lb = 500ml of fluid – For accurate weignt have client weigh the same time each day – Intracellular fluid: fluid located within cells 35%-40% – Extracellular fluid: fluid outside of the cells Interstitial fluid; water between cells 10%-15% Intravascular fluid; plasma 5%  Intake and Output Average fluid intake – Adult: 2500 mL/day (Range: 1800 to 3600 mL/day) – Sources: food and liquids Fluid elimination – Sources Urination, bowel elimination, perspiration, breathing Insensible losses: sweat, exhaled air  Distribution of Fluids and Electrolytes Physiologic process: translocation (movement back and forth) of fluid and exchange of chemicals (electrolytes, acids, bases) is continuous – Five processes Osmosis: movement of water through a semipermeable membrane; tonicity—quantity (concentration) of substances dissolved in water Filtration: promotes movement of fluid according to pressure differences; relocates from area of high pressure to area of low pressure; kidneys Passive and facilitated diffusion; example: insulin facilitates distribution of glucose inside cells Active transport: sodium–potassium pump; requires ATP  Mechanisms of Fluid and Electrolyte Regulation Mechanisms to maintain normal fluid volume and electrolyte concentrations – Types Osmoreceptors: neurons that sense blood concentration; simulate release of ADH; baroreceptors Renin–angiotensin–aldosterone system: chemicals released to increase BP and blood volume Natriuretic peptides: ANP and BNP released; increase urine production  Fluid Imbalances Hypovolemia: low volume of extracellular fluid – Causes: vomiting, diarrhea, wounds, profuse urination; hemoconcentration Dehydration: extracellular and intracellular fluids are reduced. (See Box 6.1) – Assessment Findings: thirst Diagnostic Findings: elevated Hct and blood cell counts, elevated urine specific gravity – Medical Management: restore fluid deficit; oral or IV Nursing Management: 8 to 10 glasses water/day; avoid caffeine & alcoholic beverages; do not restrict sodium  Fluid Imbalances Hypervolemia: high volume of water in intravascular fluid compartment – Causes: excessive oral intake, IV fluids, heart failure, kidney disease, adrenal gland dysfunction; circulatory overload – Assessment Findings: weight gain, elevated BP, pitting or nonpitting edema, dependent edema, moist lung sounds; Review Figure 16-8; grading edema Diagnostic Findings: low Hct and blood cell count, low specific gravity; hemodilution – Medical Management: restrict oral or parenteral fluid; diuretics; limit sodium  Nursing Care Plan: Hypervolemia Nursing diagnosis: Excess Fluid Volume related to intake that exceeds fluid loss – Baseline and daily weights (weight gain 2 lb/24 hours) – Accurate intake and output – Auscultate lung sounds – Measure BP, heart rate, respiratory rate – Inspect skin for edema, cracks, and breakdown – See Nursing Process for Client with Hypervolemia beginning on pg. 55  Question #1 A client is at risk for impaired skin integrity due to compromised circulation related to heart failure. Interventions to maintain intact skin includes: A) Changing the client’s position every 4 hours B) Restricting ambulation C) Applying elastic stockings D) Keeping client’s legs lower than the heart  Answer to Question #1 C) Applying elastic stockings Rationale: Elastic stockings support valves in the veins and prevent fluid from pooling in dependent areas such as the feet and ankles.  Third-Spacing Third-spacing—translocation of fluid from intravascular to tissue compartments – Causes: hypoalbuminemia, burns, severe allergic reactions – Assessment Findings: ascites, generalized edema Diagnostic Findings: hemoconcentration, CVP normal, blood counts borderline – Medical Management: albumin infusion, IV diuretic  Electrolyte Imbalances Electrolyte imbalances occur as deficits and/or excess; accompanied by fluid changes – Causes Deficits: administration of IV fluids, vomiting, diarrhea, diuretics Excess: orally consumed, parenteral administration of electrolytes, kidney failure, endocrine dysfunction, crushing injuries, burns Priority electrolyte imbalances: sodium, potassium, calcium, magnesium  Sodium Imbalances Functions: maintaining normal nerve and muscle activity, regulating osmotic pressure, preserving acid–base balance; principal role is to regulate and distribute fluid volume in the body Hyponatremia—serum level below 135 mEq/L – Causes: profuse diaphoresis, diuresis, loss of GI secretions (suctioning, drains), Addison disease – Assessment Findings: mental confusion, muscular weakness, anorexia, elevated body temperature, tachycardia; In severe cases Na+ < 115 mEq/L associated with lethargy, seizures, increased intracranial pressure, and coma in severe cases – Medical Management: foods high in sodium, IV sodium chloride Each tsp of salt added to food provides approximately 2000mg of sodium Naturally occurring sources of sodium include milk, meats, certain vegetables Refer to Table 6.1 pg 56  Sodium Imbalances Hypernatremia – Causes: diarrhea, excessive salt intake, high fever, excessive water loss, decreased water intake – Assessment Findings: thirst; dry, sticky mucous membranes; decreased urine output; fever, rough and dry tongue, lethargy Diagnostic Finding: >145 mEq/L – Medical Management: water intake, hypotonic IV solution (0.45% NaCl or 5% Dextrose) Nursing Management: I&O; assess vital signs; dietary restrictions or supplements  Potassium Imbalances Function: maintaining normal nerve and muscle activity Hypokalemia – Causes: potassium-wasting diuretics (Lasix, HydroDIURIL), GI tract fluid loss (suctioning, drains, vomiting), corticosteroids, IV insulin and glucose – Assessment Findings: fatigue, weakness, nausea, cardiac dysrhythmias, paresthesias, severe cases result in hypotension, flaccid paralysis, death Diagnostic Finding: 5.3 mEq/L ; ECG changes – Medical management: decreasing K+ intake, administration of insulin and glucose, Kayexalate, peritoneal dialysis or hemodialysis Nursing Management: medications, diet teaching regarding foods sources of potassium including: vegetables, dried peas and beans, wheat bran, banannas, oranges, OJ, melon, prune juice, potatoes, milk Refer to Table 6.2 pg 57  Calcium Imbalances Hypocalcemia Function: blood clotting, smooth, skeletal, and cardiac muscle function; transmission of nerve impulses, regulated by parathyroid gland; Vitamin-D is needed for calcium absorption in the intestines and uptake in the bones – Causes: vitamin D deficiency, hypoparathyroidism, burns, pancreatitis, corticosteroids, blood administration, intestinal malabsorption – Assessment Findings: tingling, circumoral paresthesia, muscle cramps, abdominal cramps, positive Chvostek sign (spasm of facial muscles when the facial nerve is tapped), Trousseau sign (carpopedal spasms), bleeding, tetany, seizures, cardiac arrhythias Diagnostic Finding: serum calcium 11 mg/dL – Medical Management: cause, IV sodium chloride, Lasix, corticosteroids or plicamycin – Nursing Management: diet teaching, fluids, fall safety  Magnesium Imbalances Function: transmission of nerve impulses, activation of enzyme systems including functioning of B vitamins; found in bone cells and specialized cells of the heart, liver, and skeletal muscles Hypomagnesemia – Causes: alcoholism, diabetic ketoacidosis, renal disease, burns, malnutrition, intestinal malabsorption, diuresis, prolonged gastric suction – Assessment Findings: tachycardia, paresthesias, leg and foot cramps, neuromuscular irritability, HTN, mental changes, difficulty swallowing, seizures, positive Chvostek and Trousseau signs – Diagnostic Finding: serum magnesium 2.2 mEq/L. Symptoms usually not present until > 4.0 mEq/L – Medical Management: decreasing oral magnesium or parenteral replacement, hemodialysis, mechanical ventilation Nursing Management: BP and respiratory monitoring  Question #2 Which of the following interventions would be appropriate when caring for a client with hypercalcemia? A) Encourage fluids. B) Promote bed rest. C) Administer calcium supplement tablets. D) Administer antibiotics.  Answer to Question #2 A) Encourage fluids. Rationale: Hypercalcemia is a condition in which serum calcium is elevated. By providing increased amounts of fluid, calcium excretion is promoted and the amount of circulating calcium decreases.  Acid-Base Balance Regulation of normal plasma pH (7.35 to 7.45= normal), Death occurs quickly if plasma pH is outside the range of 6.8 to 7.8 – Carbonic acid (H2CO3) and bicarbonate (HCO3) – Chemical: adding or removing hydrogen ions – Organ: lungs regulate carbonic acid levels and kidneys regulate bicarbonate levels; decompensation Imbalance types – Acidosis: excessive accumulation of acids or excessive loss of bicarbonate in body fluids – Alkalosis: excessive accumulation of bases or loss of acid in body fluids  Acid-Base Imbalances Metabolic Acidosis (pH 7.45) – Causes: excessive bicarbonate-containing drugs, diuretic therapy, vomiting, gastric suctioning, hyperaldosteronism – Assessment Findings: anorexia, nausea, circumoral paresthesias, confusion, hypertonic reflexes, tetany, decreased respirations – ABGs = pH > 7.45, HCO3 > 26, PaCO2 Normal – Medical Management: cause, potassium administration, sodium chloride administration Nursing Management: ABG findings; reports assessment findings – See Table 16-3  Acid-Base Imbalances Respiratory Acidosis (pH 45 – Medical Management: mechanical ventilation, airway suctioning, bronchodilators, IV sodium biocarbonate, and antibiotics Arterial blood gas (ABC): values to determine acid–base balances: pH, HCO3, PaCO2  Acid-Base Imbalances Respiratory Alkalosis (pH > 7.45) – Causes: anxiety, fever, overactive thyroid, ASA poisoning, hypoxemia, mechanical ventilation – Assessment Findings: increased respiratory rate, light- headedness, numbness and tingling of fingers and toes, paresthesias, sweating, panic, dry mouth, convulsions – ABGs = pH 7.45, HCO3 Normal, PaCO2 < 35 – Medical Management: rebreathe expired air (brown bag breathing), sedation Nursing management: report assessment findings, monitor laboratory values  Question #3 Which acid–base disturbance would be most characteristic of a narcotic overdose? A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis  Answer to Question #3 B) Respiratory acidosis Rationale: A narcotic overdose slows the rate and depth of breathing. This leads to retention of carbon dioxide (acid). Hypoventilation problems produce respiratory acidosis.