Student PP Fluids and Electrolytes Spring 2024 PDF

Fundamental Nursing Care Related to Fluids and Electrolytes  Content Learning Outcomes 1. Apply the concepts to nursing practice incorporating key terminology 2. Describe the mechanisms for maintaining fluid and electrolyte and acid-base balance 3. Recognize factors that predispose a patien...

Fundamental Nursing Care Related to Fluids and Electrolytes  Content Learning Outcomes 1. Apply the concepts to nursing practice incorporating key terminology 2. Describe the mechanisms for maintaining fluid and electrolyte and acid-base balance 3. Recognize factors that predispose a patient to fluid and electrolyte and acid-base imbalances 4. Differentiate dehydration, hypovolemia, and hypervolemia 5. Identify the different types of IV fluids and two types of vascular accesses 6. Explain the assessment and care of peripheral IV access and peripherally inserted central catheter (PICC) 7. Compare and contrast the different blood products 8. Implement the steps I transfusion of blood and blood products  Content Learning Outcomes 9. Recognize the manifestations and actions associated with various blood transfusion reactions 10. Differentiate the four acid-base disorders and compensated versus uncompensated 11. Demonstrate knowledge and skills related to history taking and physical examination 12. Analyze patient data/information/findings for the presence of clinical manifestations and evaluate their significance 13. Recognize findings that should be referred to the health care provider 14. Implement various collaborative treatment modalities and nursing skills/actions and describe their related nursing responsibilities 15. Construct a nursing plan of care for patients with fluid and electrolyte and acid- base imbalances using all components of the nursing process 16. Identify tasks appropriate for delegation Content Learning Outcomes 17. Apply pharmacological information to medications Identify pharmacological and therapeutic class Describe the basic mechanism of action Illustrate signs of therapeutic effectiveness Recognize adverse and side effects Employ required nursing actions Fluid and Electrolytes Fluid and electrolyte balance refers to the body’s maintaining of homeostasis of fluid volume and electrolytes by a number of mechanisms that facilitate fluid and electrolyte movement within the body, including organs and body systems, osmosis, diffusion, active transport, and capillary filtration Body Fluid Reminders Water is the primary body fluid. Water content varies with age, sex, and adipose tissue. Water contains solutes. Electrolytes-have an electrical charge when dissolved in water Nonelectrolytes-substances that do not conduct electricity; Glucose, urea Movement of Fluids Reminders Osmosis The movement of water across a membrane from an area of less concentrated solution to an area of more concentration Solute-a substance dissolved in body fluid Crystalloids-solutes readily dissolved i.e.: electrolytes Colloids-larger molecules that do not dissolve readily i.e.: proteins Fluid Intake Primarily through drinking fluids National Academies of Science, Engineering, and Medicine (2004, updated 2018) recommendation 2,700 mL/day women; 3,500 mL/day men 20% from food/metabolism of food Fluid intake regulated by thirst Change in plasma osmolality Hypothalamus Fluid Output Urine: 1,500 mL/day Skin: Perspiration Lungs: Exhalation Feces: 100 to 200 mL/day Insensible loss – skin as perspiration, lungs as water vapor Noticeable loss – skin as sweat Loss through intestines as Fluid Output Minimal obligatory loss 500ml urine in 24hrs 30ml urine in one hour * Less than either require immediate intervention A&P Review: Hormonal Regulation Antidiuretic hormone (ADH)- released from pituitary gland and causes kidney to retain fluid Renin-angiotensin system-when fluid volume decreases, receptors in glomeruli respond to decreased perfusion to kidneys by releasing renin and aldosterone, sodium and water is reabsorbed retained and aldosterone is released When Aldosterone is released, sodium is reabsorbed, and potassium is excreted. With sodium comes water, increasing plasma volume Diagnostic laboratory values: Fluid and Electrolytes – Blood Urea Nitrogen Normal level: 7 and 20 mg/dL (Can vary slightly by lab ranges) Primarily used clinically as an evaluation of the fluid balance within the body (and liver/kidney function) Basic Patho: Liver produces ammonia (which contains nitrogen) after it breaks down proteins used by the cells. It combines with other elements to form the waste product urea which travels to the kidneys where it is filtered and eliminated via the urine When levels rise it is generally indicative of less-than-optimal filtering usually due to low fluid balance (and kidney problems). Can also be high with higher-than-normal protein intake/breakdown Low levels are typically seen in malnutrition due to poor protein intake Diagnostic laboratory values: Fluid and Electrolytes – Creatinine Normal level: 0.6 and 1.2 mg/dL (Varies slightly based on sex) Evaluation of kidneys’ filtering waste from blood. Done to evaluate status and changes due to disorders and/or damage from nephrotoxic agents Basic Patho: Creatinine is a chemical compound left over from energy-producing processes in muscles. Creatinine exits body as a waste product in urine When levels rise it is an absolute indicator of poor kidney function. Note: Small rises in creatinine are a big deal! Acute kidney injury While creatinine clearance tests done in 24-hour urine tests are more specific, serum creatinine is the regular clinical test as it can be done quickly and on a regular basis to monitor for small changes Fluid Volume Imbalances Fluid volume excess (FVE): hypervolemia Fluid volume deficit (FVD): One of the most important nursing diagnoses in care of patients Hypovolemia or Dehydration Clinically, not the same thing Don’t worry about values in the picture Just understand the concept Fluid volume deficit Fluid volume overload  Fluid Volume Excess: Hypervolemia Excess salt intake, kidney or liver disease Diagnosis sometimes used with poor pumping action of heart (although this is a different process and is less about increased fluid and more about heart failure or “Decreased Cardiac Output”) Signs of fluid overload Elevated blood pressure, bounding pulse Edema, Ascites Pulmonary crackles Rapid weight gain Hyponatremia and hemodilution of Hct Managing Fluid Overload Monitor Intake and Output IV fluid regulation Daily Weight Fluid Volume Overload: Interventions Promote rest to avoid overexertion (Activity Intolerance) and/or respiratory compromise Semi-fowlers to High-fowlers position to avoid/treat orthopnea Fluid restriction as prescribed (less than 1-liter to less than 1.5 liters per day) Focus on daily weight: One kg of weight gained, or lost = 1 liter of fluid gained or lost Balanced scale Weigh same time each day With same or similar clothing Same scale Case Vignette The nurse gets report on a patient with an endocrine disorder that has led to a decreased urine output from fluid retention and fluid volume overload. During the assessment, the nurse notes the following Vital signs: T 98, HR 78 and Labs: WBC 8, Hgb 10 / Hct 28, bounding, RR 16, BP 150/90 NA 131, K 3.8 and PO Sat of 97% Weight today 160 lbs. Weight yesterday 158 lbs. Edema of lower extremities Lungs clear, Abdomen slightly (toes to thigh), sacral area round and soft and back Which findings support the nursing diagnosis of fluid volume overload? Fluid Volume Deficit: Dehydration (1025) Inadequate intake and/or slower loss of intracellular fluid (over several days – week) Causes: Inability to take in enough fluids according to needs (excessive heat, changes in mental status, infection) Increased urination from medications like diuretics Sodium level increases as water level decreases (Hemoconcentration) Hct level also increases from hemoconcentration Manifestations: Thirst, decreased skin turgor, dry mucus membranes, thirst, increased pulse, orthostatic hypotension, muscle weakness, and decreased urine output that is concentrated Hypernatremia – sodium greater than 145 Increases in BUN Dehydration Management Prevention! Encourage oral intake (2-3 liters per day) 8-10 eight-ounce glasses of water unless contraindicated When would that be contraindicated? Nutrition Limit sodium intake, avoid sodium rich foods Avoid fluids high in caffeine, sugar, salt or alcohol Monitor Intake and Output Daily Weight IV fluid slow-moderate rate replacement and maintenance Balanced fluids like D5 ½ 0.45% NS Fluid Volume Deficit: Hypovolemia Active loss of extracellular fluid that exceeds intake. Occurs over a shorter period of time (hours – days) Causes: Fluid loss from vomiting, diarrhea, GI suctioning, excessive urination from disorders, surgical losses (fluid and blood) Risk factors: Diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, third space shifts Manifestations: Tachycardia, oliguria, hypotension, cool clammy skin, nausea and signs of decreased perfusion (shock) Laboratory data: Elevated BUN and serum creatinine (as kidneys are damaged), increased hematocrit Hypovolemia Management Early identification of risk and onset with corresponding collaboration with HCP Medical management: Provide enough fluid to overcome losses and meet body’s needs IV replacement at moderate-rapid rates with isotonic fluids like 0.9% NS or Lactated Ringers IV resuscitation with isotonic boluses (fluid challenges) and/or very rapid rates Frequent vital sign checks and monitoring for symptoms of poor perfusion and worsening status Intake and output Measures to minimize fluid loss (Stop vomiting, Stop diarrhea, etc.) Fluid Volume Deficit: Differentiation Vignettes Hypovolemia Dehydration A patient developed C-diff An elderly patient is admitted while in the hospital. They from home where they live with have been having excessive their family. The family reports bowel movements for 2-days the patient was taking (5-8 watery liquid stool per antibiotics prescribed by the day). Today the nurse notes doctor for a urinary tract that the patient is lethargic infection and over the last 2-3 and upon assessment finds days has been sleeping more, the following: HR of 108, BP not really eating or taking in a of 110/60, RR of 24. Patient lot of fluid. They brought them can’t remember the last time to the ER because they were they urinated and then only very weak. The HR is 88, RR is 20 and BP is 130/90. The skin voids 75 ml of dark amber is dry and tenting urine Hypovolemia Case: Think like a nurse The nurse calls the HCP to report the situation. “I’m calling because the patient has lost a lot of fluid from diarrhea and is exhibiting signs of hypovolemia including oliguria, tachycardia and a lower BP” 1. What kind of IV orders can the nurse anticipate the HCP will provide? 2. What assessments should the nurse perform to evaluate whether the prescribed IV fluids are working? (How would you know it is working?) 3. How long after starting the prescribed IV fluids should the nurse expect to see some improvements? Try using the Nursing Process – Create a couple outcomes: In response to the prescribed IV therapy, the patient will: ___________ Nursing Diagnosis for Fluid Volume Alterations Related to Fluid Volume Deficit, Fluid Volume Overload or both? Decreased cardiac Acute confusion Impaired gas output exchange Impaired oral Risk for electrolyte Ineffective tissue mucous membrane imbalance perfusion Impaired skin Risk for injury Deficient integrity knowledge regarding disease management Clicker The nurse gathers the following data: blood pressure (BP) = 150/94 mm Hg; neck veins distended; pulse (P) = 104 beats/min; pulse bounding; respiratory rate (RR) = 20 breaths/min; temperature (T) = 37C (98.6F). What disorder should the nurse suspect? A. Hypovolemia B. Hypokalemia C. Hyperkalemia D. Hypervolemia Fluid Volume Alterations Nursing Interventions Clinical measurements – no MD order Intake and Output Daily weights- each kg of weight gained or lost = 1 liter of fluid gained or lost Balanced scale Weight same time each day With same or similar clothing Same scale Basic IV Therapy Reminders Purpose: Prevent and/or correct fluid and electrolyte disturbances in clients who are ill. Fluids may be replaced through infusion directly into the circulating blood volume in addition to or in place of fluids ingested through the digestive system Crystalloids: Solutions contain various amounts of salt, sugar (crystals) and/or a combination of both suspended in sterile water to make a variety of solutions with different actions and purposes Types of solutions reminder Isotonic Hypotonic Hypertonic Caution: Too rapid or excessive infusion of any IV fluid has the potential to Isotonic, Hypotonic, and Hypertonic Solutions According to whether the fluids’ total osmolality is the same as, less than, or greater than that of blood and whether they will move into the cells, pull fluid out of the cells or not affect the cells (stay in the vascular space) Less concentrated than More concentrated than the blood and moves the blood and pulls fluid into the cells from the cells Balanced with the blood and stays in the vascular space  Hypotonic Isotonic Hypertonic Solution with a lower Solution with a Solution with a greater concentration than concentration close to concentration than normal normal body cells so that water flows into the cells normal body cells and body cells so water is pulled does not cause cells to out of the cells Used to replace cellular shrink or swell True hypertonic are used for fluid Isotonic fluids expand specific purposes Provide free water for the IVF volume 10% dextrose – AKA D10 excretion of body wastes 0.9% sodium chloride 3% sodium chloride (saline) AKA Can cause cells to swell, so there is some AKA hypertonic saline danger of cerebral Normal saline “Fake” hypertonic solutions used edema NS for slow replacement or 0.45% sodium chloride 0.9 “maintenance” solutions AKA Lactated ringers' 5% dextrose and 0.9% sodium half normal saline solution AKA chloride 5% dextrose in water AKA D5.9 LR D5W 5% dextrose in 0.45% sodium chloride D5 and a half Clicker The nurse is assessing a client in the acute care unit. The client’s blood pressure is 80/40 mm Hg, pulse 120 beats/min and thready, has poor skin turgor, and has dry mucus membranes. Which of the following IV fluids would the nurse expect the healthcare provider to prescribe for this client’s condition? A. Lactated Ringer B. Serum albumin C. 0.45% normal saline D. D5W with normal saline  Major Electrolytes Table 38-3 pg. 1021 & Table 38-5 pg 1026/1027 Take out the case study you prepared for today so we can apply new knowledge and concepts We will not cover the basic PP slides, but you are responsible for all information We will cover the pharmacology Electrolyte Imbalances: Value and Function Reminder Sodium (NA): 135-145 mEq/ml Extracellular fluid (ECF) that regulates fluid volume and stimulates nerve conduction Potassium (K): 3.3-5 mEq/ml Intracellular fluid (ICF): that regulates muscle contraction; cardiac conduction and transmits electrical impulses in multiple body systems Calcium (Ca): 8.5-10.5 mg/dL Related to bone health, insufficiency can lead to osteoporosis. Also involved in muscle and cardiac function (electrical and mechanical), essential for blood clot formation Magnesium (Mg): 1.6-2.6 mEq/L Involved in electrical activity in nerves and muscles, cardiac electrical conduction Hyponatremia: < 135 mEq/L Causes: Diuretics, GI fluid loss, excessive administration of hypotonic fluid Manifestations: Anorexia, nausea, vomiting weakness, lethargy confusion, muscle cramping, seizures Medical management: Fluid restriction, use of diuretics to balance water with sodium levels, replacement with saline or use of hypertonic 3% saline in severe cases to replace High Risk Medication that MUST be administered very slowly to avoid severe complications Nursing management: Assessments, I & O, monitor sodium level, increase oral sodium intake Hypernatremia: > 145mEq/L Causes: excess water loss, excess sodium administration, diabetes insipidus, heat stroke, hypertonic IV solutions Signs and symptoms: Thirst; elevated temperature; dry, swollen tongue; sticky mucosa; neurologic symptoms; restlessness; weakness (seizures are possible, but rare with hypernatremia unless extremely high) Note: thirst may be impaired in elderly or the ill Medical management: hypotonic electrolyte solution or D5W Nursing management: assessment and prevention, monitor sodium levels, assess for OTC sources of sodium, offer and encourage fluids to meet patient needs, provide sufficient water with tube feedings Sources of Sodium Sodium and salt are often thought to be the same, but they’re not. Sodium is a mineral that occurs naturally in foods or is added during manufacturing or both. Table salt is about 40% sodium and 60% chloride Recommendation is less than 2,300 mg per day (2-grams or less for cardiac patients) Approximate amounts of sodium in table salt: 1/4 teaspoon salt = 575 milligrams (mg) sodium 1/2 teaspoon salt = 1,150 milligrams (mg) sodium 3/4 teaspoon salt = 1,725 milligrams (mg) sodium 1 teaspoon salt = 2,300 milligrams (mg) sodium OTC medications very often have high levels of sodium (especially cold medicine) Dietary sources are varied but processed foods (and drinks like soda) are the highest Dietary Sources of Sodium: Top 10 Breads and rolls Pizza Sandwiches Cold cuts and cured meats Soups Burritos and tacos Savory snacks (Chips, popcorn, crackers, etc.) Chicken Cheese Eggs and omelets Hypokalemia: < 3.5 mEq/L Causes: GI losses, medications, alterations of acid-base balance, hyperaldosterism, poor dietary intake and eating disorders like anorexia or bulimia Signs and symptoms: Fatigue, anorexia, nausea, vomiting, cardiac dysrhythmias, muscle weakness and cramps, paresthesia, glucose intolerance, decreased muscle strength and DTRs (deep tendon reflexes) Medical management: Increased dietary potassium, oral potassium replacement, IV for severe deficits Nursing management: Severe hypokalemia is life- threatening, monitor ECG Monitoring K levels, dietary potassium teaching, nursing care related to IV potassium administration Potassium Replacement: Pharmacology Administered to prevent (in patients taking certain diuretics) and treat cases of hypokalemia Potassium chloride: Others - Potassium gluconate, Potassium phosphate, Potassium bicarbonate Oral administration: K-Dur, K-Lyte Mix powdered formulations in at least 90 mL to 240 mL of cold water or juice and drink slowly over 5 to 10 min. Effervescent tablets should be dissolved in 90 mL to 240 mL of cold water Take potassium chloride with a meal or at least 8 oz of water to reduce the risk of adverse GI effects Cover next two in Do not to crush or chew extended-release tablets class Potassium Replacement: IV Infusions High Risk Medication – Can be fatal if administered too quickly. Every institution will have strict Policy and Procedure for administration following standards of care and EBP guidelines that every nurse must know and follow Always diluted according to policy. NEVER IVP – Can lead to immediate death from fatal arrhythmia Always use an IV infusion pump to control the infusion rate Max is 40 mEq/L of IV solution per 1000 ml to prevent vein irritation Assess the IV site for local irritation, phlebitis, and respond to patients’ reports of pain Discontinue the IV immediately if infiltration occurs IVPB doses (K-Riders) in significant hypokalemia Max 10 mEq per hour Max 20 mEq per hour IF patient has a central venous access device AND is on a cardiac monitor Monitor potassium levels frequently and I&O to ensure an adequate urine output of at least 30 mL/hr. to avoid toxic accumulation Hyperkalemia: > 5 mEq/L Causes: Impaired renal function, hypoaldosteronism, tissue trauma, acidosis, or treatment related (multiple blood transfusions can lead to > potassium) Signs and symptoms: Cardiac dysrhythmias that can be fatal, muscle weakness with potential respiratory impairment, paresthesia, anxiety, GI manifestations Medical management: Monitor ECG, limitation of dietary potassium, cation-exchange resin sodium polystyrene sulfonate (Kayexalate), IV sodium bicarbonate , IV calcium gluconate, regular insulin and hypertonic dextrose (D50%) IV, -2 agonists, dialysis Nursing management: Severe hyperkalemia is life-threatening, monitor ECG, monitoring K levels Note: Hemolysis of blood specimen may result in false high laboratory result Dietary Sources of Potassium FYI: Women should get 2,600mg and men should get 3,400mg of potassium every day. Most Americans don’t meet that goal Bananas Oranges and other citrus fruits Melons Green leafy vegetables like spinach Broccoli Tomatoes and tomato juice Potatoes and sweet potatoes Beans Milk and yogurt Hypocalcemia: < 8.5 mg/dL Causes: Hypoparathyroidism, malabsorption, pancreatitis, alkalosis, multiple transfusion of citrated blood, renal failure, medications Signs and symptoms: Tetany, circumoral numbness, paresthesia, hyperactive DTRs, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, anxiety Medical management: IV calcium gluconate, calcium and vitamin D supplements; diet Nursing management: Assessment severe hypocalcemia is life- threatening, weight-bearing exercises to decrease bone calcium loss, patient teaching related to diet and medications, and nursing care related to IV calcium administration Note: a low albumin level can make low calcium level seem lower than it is Hypocalcemia: Physical Signs Trousseau's sign Chvostek's sign Carpopedal spasm Twitching of the facial caused by inflating the muscles in response to blood-pressure cuff to a tapping over the area level above systolic of the facial nerve pressure for 3 minutes Calcium Replacement: Pharmacology Administered to prevent and treat cases of hypocalcemia Calcium citrate: Others - Calcium carbonate, Calcium acetate For IV administration: High Risk Medication Calcium chloride and Calcium gluconate Always diluted according to policy. NEVER IVP – Can lead to immediate death from fatal arrhythmia Always use an IV infusion pump to control the infusion rate Monitor calcium levels Hypercalcemia: > 10.5 mg/dL Causes: Malignancy and hyperparathyroidism, bone loss related to immobility Signs and symptoms: Muscle weakness, incoordination, anorexia, constipation, nausea and vomiting, abdominal and bone pain, polyuria, thirst, kidney stones, ECG changes, dysrhythmias Medical management: Treat underlying cause, large amounts of IV fluids, followed by diuretics to flush out of system. Medications such as phosphates, calcitonin, bisphosphonates Nursing management: Hypercalcemic crisis has high mortality Fluids of 3 to 4 liters per day, fiber for constipation, ensure safety Dietary Sources of Calcium FYI: Need about 1000 – 1200 mg per day Dairy products like milk, yogurt, and cheese are rich in calcium and also tend to be the best-absorbed sources Soybeans Dark green leafy vegetables Figs and raisins Certain nuts Beans and lentils Hypomagnesemia: < 1.8 mg/dL Causes: Alcoholism, GI losses, enteral or parenteral feeding deficient in magnesium, medications, contributing causes include diabetic ketoacidosis, sepsis, burns, hypothermia Signs and symptoms: Neuromuscular irritability, muscle weakness, tremors, athetoid (uncoordinated, spastic) movements, ECG changes and dysrhythmias, alterations in mood and level of consciousness Medical management: diet, oral magnesium, magnesium sulfate IV Nursing management: Severe hypomagnesemia can be life- threatening Nursing care related to IV magnesium administration Patient teaching related to diet and medications Magnesium Replacement: Pharmacology Administered to prevent and treat cases of hypomagnesemia Magnesium oxide: Others – Magnesium citrate Oral magnesium act as antacids when administered in a low dose, and as laxatives in certain doses/mixtures For IV administration: High Risk Medication Magnesium sulfate 1-2 grams diluted in 100 ml over 1-2 hours as ordered Special use in obstetrics to treat preeclampsia (Higher doses) Always diluted according to policy. NEVER IVP – Can lead to immediate death from fatal arrhythmia Always use an IV infusion pump to control the infusion rate Monitor Magnesium levels Cover in class Hypermagnesemia: > 2.7 mg/dL Causes: Renal failure, diabetic ketoacidosis, excessive administration of magnesium Signs and symptoms: Flushing, lowered BP, nausea, vomiting, hypoactive DTR, drowsiness, muscle weakness, depressed respirations, ECG changes, dysrhythmias Medical management: IV calcium gluconate, loop diuretics, IV NS or LR, hemodialysis Nursing management: Assessment, patient teaching regarding magnesium containing OTC medications Dietary Sources of Magnesium Green leafy vegetables Nuts and seeds Fatty fish like tuna and salmon Soybeans Avocado Bananas Dark chocolate Brown rice Others Chloride: (Cl) 95-105 mEq/L Production of hydrochloric acid for gastric secretions, acid base balance Increases and decreases in relation to sodium Phosphate / Phosphorus 2.5-4.5 mEq/L Bound with calcium in teeth and bones; inverse relationship with calcium Glucose (Glu): 70-110 Measurement of glucose in the blood Total CO2: TCO2 22-29 mEq/L Total amount of carbon dioxide in venous blood from cellular waste products Done as part of the metabolic “chemistry” lab tests. Overall general reflection of perfusion status Low levels can indicate FVD, poor perfusion and/or metabolic acidosis Take a Moment: Medications that Affect Fluids and Electrolytes: Diuretics Best example is Furosemide which is classified as a loop diuretic Action: Inhibits reabsorption of sodium and chloride from the loop of Henle and distal renal tubules. Increases renal excretion of water, sodium, chloride, magnesium, potassium and calcium Can have a significant impact on fluid balance (leading to dehydration and make hypovolemia worse if not considered) and electrolyte balance Furosemide is indicated for use with edema due to heart failure, hepatic impairment or renal disease. Hypertension Nursing: Monitor daily weight, intake and output and BP Monitor all electrolyte levels especially POTASSIUM – HYPOKALEMIA FYI: Clinical application Often seen in HCP documents Diagnostic laboratory values: Fluid and Electrolytes Urine specific gravity Serum osmolality 1.001-1.029 275-300 mOsm/kg Kidney’s ability to Indicator of the concentrate urine concentration or number Elevated: Dehydration of particles dissolved in or kidney disease the serum Decreased: Fluid Elevated: Fluid volume volume overload or deficit Diabetes insipidus Decreased: Fluid volume overload Acid Base Balance Body’s cellular activities require alkaline medium Alkalinity & acidity are measured by scale called pH pH – measures hydrogen ion concentration Normal pH of ECF is 7.35-7.45 Balance is maintained as long as the ratio of carbonic acid to bicarbonate ions is 1:20 1 H2CO3 (carbonic acid): 20 HCO3 (bicarbonate ions) Acid Base Balance Normal serum pH 7.35 to 7.45 Alkalosis Serum pH above 7.45 Respiratory cause: Blowing off CO2 Metabolic cause: Increase in bicarbonate Acidosis Serum pH below 7.35 Respiratory cause: Retention of CO2 Metabolic cause: Loss of bicarbonate Respiratory Regulation Lungs regulate acid-base balance by the elimination of carbon dioxide (CO2) When the serum pH is too acidic the lungs remove CO2 through rapid, deep breathing (hyperventilation) More CO2 exhaled, more carbonic acid is removed from blood, blood pH becomes more alkaline When the serum pH is too alkaline the lungs try to conserve CO2 through shallow respirations (hypoventilation) Pco2 range 35-45 mmHG Acid Base Balance: Respiratory Acidosis Caused by conditions or medications that may impair ventilation and gas exchange, depressed respiratory rate and depth, anesthesia, or injury to respiratory center in brain Manifestation: Increase pulse, respiratory rate, confusion, decreased LOC, muscle twitching Intervention: Management to improve ventilation such as: Pulmonary hygiene and/or bronchodilators Non-invasive ventilation (CPAP or BiPap masks) or invasive techniques such as intubation and mechanical ventilation. The pH will be below 7.35 and the PCo2 will be greater than 45 Acid Base Balance Respiratory Alkalosis May be caused by hyperventilation, caused by fever, anxiety, sepsis or mechanical ventilation Manifestation: confusion, light headedness, tingling, palpitations Intervention: treat the underlying cause, encourage patient to relax, breath slowly (Anxiety attack - Breathe into a paper bag to rebreathe the exhaled carbon dioxide) pH above 7.45 Pco2 less than 35 Renal Regulation Last line of defense, regulates the concentration of plasma bicarbonate If the serum pH is too acidic, the kidneys conserve bicarbonate to neutralize acid When the serum pH is too alkaline the kidneys excrete bicarbonate to lower the pH HCO3 range 22-26 mEq/L Acid Base Balance: Metabolic Acidosis Caused by retained acid in blood or increased production of acid caused by uncontrolled diabetes (DKA), sepsis, starvation, severe diarrhea, or kidney failure. Can also occur in aspirin toxicity Also associated with hyperkalemia Manifestation: Headache, confusion, weakness, nausea, vomiting Will produce typical deep ventilation known as Kussmaul’ s respirations Treatment correct underlying cause and in severe cases initiate mechanical ventilation (to control other acid – carbon dioxide) Bicarbonate is sometimes prescribed pH less than 7.35 HCO3 less than 22 mEq/L Acid Base Balance: Metabolic Alkalosis Caused by excessive acid loss due to vomiting, gastric suction, excessive bicarbonate intake Also associated with hypokalemia Manifestation: Dizziness, tingling, decreased respiratory rate and depth Intervention: administer sodium chloride solutions, correct underlying cause pH greater than 7.45 HCO3 greater than 26 mEq/L Interpreting Arterial Blood Gases Step 1: Examine the pH. Is it acidotic, alkalotic, or normal? Step 2: Check the amount of carbon dioxide in the blood (PCO2). Is there too little or too much? Step 3: Think about the bicarbonate level (HCO3). Is there too little or too much? Step 4: Is there compensation? If so, is it partially or fully compensated? Interpreting ABG’s Normally arterial blood pH 7.35-7.45 PCO2 – measure of the pressure exerted by carbon dioxide gas dissolved in blood – normal 35-45 mmHg HCO3- (bicarbonate) is major renal component of acid- base regulation. Normal 22-26 mEq/L Interpreting ABG’s Determine acidity or alkalinity of blood from pH Below 7.35 is acidotic (AKA Acidosis) Above 7.45 is alkalotic (AKA Alkalosis) Identify cause of the pH by checking PCO2 and HCO3 Alterations in PCO2 indicate respiratory Alterations in HCO3 indicate metabolic  Compensation Compensation is a response of the body to correct acid- base imbalances. This is done by both the kidneys and lungs In compensated acidosis or alkalosis, kidney and lungs are able to restore the altered ratio of 1:20, thus maintaining a normal pH When body reserves are used up it is uncompensated Ex- in compensated respiratory acidosis the plasma pH is maintained at normal because the kidneys retain bicarbonate even though there is an increase in the carbonic acid Basic Practice: Normal, Acidosis or Alkalosis Cause Respiratory or Metabolic? pH 7.41 CO2 40 HCO3 24 = Normal ABG pH 7.49 CO2 37 HCO3 30 = pH 7.31 CO2 49 HCO3 23 = pH 7.28 CO2 36 HCO3 18 = pH 7.50 CO2 30 HCO3 24 = pH 7.35 CO2 48 HCO3 28 = pH 7.45 CO2 48 HCO3 27 = pH 7.34 CO2 50 HCO3 28 = pH 7.46 CO2 48 HCO3 28 = Interpreting ABG’s Basic competency with this skill is required Must be able to interpret Normal ABG All the basic imbalances Presence or absence of compensation Resources include: Reading from textbook Basic in class lecture Self review of power point On-line video(s) Required article Practice problems ABG Case Study A patient recovering from surgery in the post-anesthesia care unit (PACU) is difficult to arouse two hours following surgery. The nurse in the PACU has been administering Morphine Sulfate intravenously for complaints of post-surgical pain. The respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli! The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! The STAT results come back from the laboratory and show: pH = 7.15 C02 = 68 mmHg HC03 = 22 mEq/L a. Compensated Respiratory Acidosis b. Uncompensated Metabolic Acidosis c. Compensated Metabolic Alkalosis d. Uncompensated Respiratory Acidosis ABG Case Study A patient is 5 days post-abdominal surgery with a nasogastric tube (NGT) that has been draining large amounts for several days. Today the patient is not oriented to person, place, or time. The nurse contacts the attending physician and ABGs are ordered. The results from the ABGs come back from the laboratory and show: pH = 7.45 C02 = 44 mmHg HC03 = 29 mEq/L a. Compensated Respiratory Alkalosis b. Uncompensated Metabolic Alkalosis c. Compensated Metabolic Alkalosis d. Uncompensated Respiratory Alkalosis Clicker A client is admitted to the emergency department in respiratory distress. The initial arterial blood gases (ABGs) results are pH = 7.30; partial pressure of carbon dioxide (PCO2) = 40; bicarbonate (HCO3) = 19 mEq/L; partial pressure of oxygen (PO2) = 80. The nurse evaluates the client’s treatment plan by examining repeat ABGs. The results are pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. The nurse concludes which of the following? A. Respiratory acidosis; the treatment plan is ineffective. B. Metabolic alkalosis; the treatment plan is effective. C. Partial compensation; the treatment plan is ineffective. D. Full compensation; the treatment plan is effective. Clicker A new father begins to hyperventilate as his baby is about to be born; he becomes lightheaded. The nurse instructs him to breathe into the paper bag until his breathing slows down. When he feels better, he asks the nurse why using the paper bag helped him. What is the nurse’s best response? “Breathing into the paper bag allowed you to A. Rebreathe carbon dioxide to correct respiratory alkalosis” B. Reduce carbon dioxide to correct respiratory acidosis” c. Rebreathe carbon dioxide to correct metabolic alkalosis” Types of IV Vascular Access Peripheral intravenous Central venous access devices (CVAD) access Intravenous device inserted into a major Inserted by RN vein by MD RN chooses the location Advantages: Can accommodate highly irritating and hyperosmolar solution and size based on: Can remain in patient longer Type of fluid to be infused Decreased incidence of phlebitis/infiltration less likely Length of treatment Disadvantages: Need patient consent Client condition X ray required after insertion Sites include hand, Strict sterile technique for dressing change forearm, antecubital Risks: sepsis, air embolism, pneumothorax space, upper arm CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION IV SITE Infiltration IV site is cool, clammy, swollen and painful. IV needle or catheter has become dislodged from the vein and is in the subcutaneous space Treatment is RN’s responsibility Discontinue the infusion- remove the catheter and elevate the extremity on a pillow. To promote absorption of excess fluid  IV SITE: Phlebitis Pain, increased skin temperature, erythema along path of vein Phlebitis is inflammation of vein caused by intravenous catheter itself or by chemical irritation of medications and or additives Treatment is RN’s responsibility along with HCP Discontinue IV , elevate the extremity, apply cold and warm moist packs IV Site: Extravasation Vesicants: Medications or highly concentrated IV solutions that can result in tissue necrosis or formation of blisters when accidentally infused into tissue surrounding a vein Blistering, swelling, pain, necrosis STOP infusion immediately Administer antidote to neutralize the extravasated drug Elevate, cold compress RN Responsibility When patient’s have IVs and IV infusions, the nurse must: Know how to initiate an infusion using aseptic technique (IV certification courses) Assess the site for patency, and signs of problems (infiltration, phlebitis and/or extravasation) Confirm that the solution and rate are correct and match the prescribed order Know how to calculate an infusion rate and how to regulate the infusion rate (pump/manual) Must know how to care for the patient and the system: Know what equipment is needed Maintain the system keeping it free from contamination Identify and correct problems Discontinue an infusion Be able to move patients, change hospital gowns, and bathe patients with IVs IVs problems and lack of adequate assessment and care are frequently involved in liability issues  Types of Central Venous Access Devices Three main types Peripherally inserted central catheters (PICC) Centrally inserted catheters Implanted ports Central Venous Access Devices (CVAD) Moment Exemplar: Peripherally General Nursing Care inserted central catheters Assess site every shift and (PICC) document findings Central venous catheter Ensure catheter is secured to inserted into a vein in arm and avoid movement/migration of line further into or out of vein threaded up into the vena (“STAT lock”) cava. Can be single or multi- Flush PICC line according to lumen policy and procedure For patients who need vascular Ensure dressing with site access for 1 week to 6 months chlorohexidine patch is intact Cannot use arm for BP or blood (and dated) otherwise change immediately draw Replacement of Blood and Blood Products Intravenous fluids replace fluid volume Blood products are infused when the patient has: Experienced significant blood lose or is actively losing blood Has diminished oxygen carrying capacity due to blood loss A deficiency in one of the blood components RBC’s, platelets or clotting factors Replacement of Blood and Blood Products Blood type is inherited. Determined by “self-antigen” and antibodies 4 Types of blood  ABO System Type A Type B Type AB Type O RH factor - an additional antigen that is either positive (+) or negative (-) Rh(-) can only receive : Rh(-) Blood Rh(+)can receive both Rh(+) and Rh(-) Blood  A client’s blood group is B. The nurse knows the client can receive blood only from donors with what group of blood? Select all that apply. A. A B. B C. O D. AB E. AO Blood Groups pg 1047 table 38-9 Blood Typing and Cross Matching Typing (Type and Screen) Sample is tested for blood type, Rh factor and any additional antibodies Screening tests for any donor infection: Hepatitis B or C, HIV, viruses and syphilis Blood must be negative for acceptable transfusion Crossmatching Determines the recipient and donor’s compatibility Blood type AB positive = Universal recipient. Can receive blood from any of the other blood types Blood type O negative = Universal donor. O negative blood can be given to anyone in an emergency  Types of Blood Donation Standard donation- people voluntarily donate blood to a service Directed donation – blood donated to a specific patient only Autologous donation- donate one’s own blood before surgery Intraoperative blood salvage- re-transfused during surgery Blood Products Whole Blood: Contains RBC’s, WBCs, and platelets suspended in plasma. Rarely used Packed red blood cells (PRBC): Whole blood with plasma removed. Most frequently ordered Plasma - Fresh frozen plasma (FFP): The liquid portion of blood that contains the clotting factors. Often ordered for bleeding disorders and/or excessive bleeding from anticoagulants Platelets: Platelets removed from other products. Used to assist with clotting when related to platelet disorders White blood cells: Collected from whole blood and used for infection unresponsive to antibiotic therapy (Rare) Plasma derivatives: Include clotting factors (Factor VIII in hemophilia), immunoglobins, and albumin Initiating a Blood Transfusion pg 1052 table 38-8 1: Verify that informed consent has been obtained and is complete 2: Confirm the prescriber's prescription, noting the indication and rate of infusion (not always provided) Is generally given over 2-3 hours or quicker depending on situation Must be completed within 4 hours of initiation or discarded 3: Ensure appropriate size IV catheter 20 gauge is typical, newer 22 gauge can accept blood, 18 gauge or CVAD for rapid transfusions. Confirm patency 4: Obtain infusion pump Initiating a Blood Transfusion 5: Obtain a blood administration set: Y with filter for PRMC and 250 mL bag of IV 0.9% normal saline solution Saline used to prep line and prepare filter for blood In cases of reaction, DO NOT INFUSE THIS NORMAL SALINE – NEED NEW BAG AND TUBING Single blood line with filter for other blood products (no saline prep required) Initiating a Blood Transfusion 6: Obtain the blood from the lab 7: Verify the patient and blood product identification information AT THE PATIENT’S BEDSIDE with another qualified staff member (RN or MD) 8: Begin transfusion, slowly 9: Remain with patient for the first 15 minutes (or per institution policy) 10: Measure vital signs in 5 minutes, 15 minutes and 30 minutes (or per institution policy) 11: Observe and educate patient to immediately report symptoms of transfusion reaction 12: Measure vital signs at completion of transfusion and complete ALL blood slip documentation before returning empty bag and slip to blood bank 13: Document start, ongoing status and completion in the nurses' notes Focus: Blood Verification Completed by two (2) RNs or RN & MD Done at patient’s bedside, NOT AT THE NURSES STATION Verification elements using Patient ID band Blood bag label Blood bag slip Patient identifiers including but not limited to name and date of birth ABO & Rh  blood product & patient Donor number Expiration date Examine blood ports & blood product Any irregularities  blood product is returned to blood bank Transfusion Reactions Assess patient throughout the transfusion. Reactions can occur immediately, hours into the transfusion or later If it occurs, STOP the transfusion immediately and DO NOT INSTILL ANY OF THE SALINE FROM THE BLOOD TUBING! Notify the HCP IMMEDIATELY /or call for Rapid Response Team if unstable Monitor vital signs and patient frequently Obtain new bag of IV 0.9% normal saline with new IV tubing and hang at “keep vein open” rate or faster depending on patient status and HCP orders Re-verify the patient & donor information Notify blood bank Collect remaining blood and blood tubing  blood bank Obtain transfusion reaction specimens, blood and urine Transfusion Reaction: Allergic Sensitivity response to a Nursing Management - Mild component of the blood product Stop transfusion Onset during and up to 24-hours Remove blood tubing after transfusion is completed Infusion 0.9% normal Symptoms saline/new tubing Mild Administer Diphenhydramine Itching Wheezing Nursing Management - Flushing Anaphylactic Anaphylactic – Rare in appropriately Stop transfusion verified blood Remove blood tubing Bronchospasm /Laryngeal edema - Infuse 0.9% normal saline/new Stridor and resp distress tubing Shock Administer Diphenhydramine and other prescribed meds, Transfusion Reaction: Hemolytic Blood infusion is not Nursing Management compatible with the patient’s Stop transfusion blood. Red blood cells are Remove blood tubing destroyed (hemolyzed) as a Infusion 0.9% normal result saline/new tubing Symptoms Monitor VS, Fluid status Chills Blood product & tubing to Fever blood bank Send sample of blood and Lower back pain (flank first voided urine to lab pain=kidneys) Tachycardia & Tachypnea Chest pain/tightening Transfusion Reaction: Circulatory Overload Symptoms Respiratory distress and crackles – Pulmonary Transfusion Edema associated circulator Distended neck veins overload (TACO) Cough Can occur anytime Anxiety during the transfusion Hypertension in patients with poor Tachycardia cardiac function Nursing Management Results from fluid Stop or slow the transfusion volume overload due to Place the client upright fluid shifts from high Monitor vital signs protein content of Notify the provider blood and/or a rate too Use of prophylactic diuretics like Furosemide rapid for the client before, during or after or in at-risk clients or as a response to TACO Transfusion Reaction: Febrile Temperature elevation due Nursing Management to sensitivity to WBC’s Stop transfusion plasma protein, or platelets Remove blood tubing Infusion 0.9% normal Symptoms saline/new tubing Chills Blood product & tubing to Temp increase of one (1) blood bank full degree Treat Symptoms Warm flushed skin Aches Transfusion Reaction: Bacterial Onset during or several hours Nursing Management after transfusion completed Stop transfusion Contaminated blood products Remove blood tubing (Rare) Infuse 0.9% normal Diagnosis saline/new tubing Blood product & tubing to Blood culture results blood bank Symptoms Administer antibiotics FEVER Notify provider Warm, flushed skin Chills Vomiting A client’s vital signs prior to a blood transfusion were: temperature (T) = 97.6°F (36.4°C); pulse (P) = 72 beats/min; respirations (R) = 22 breaths/min; blood pressure (BP) = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the client began complaining of feeling “itchy and hot.” The nurse discovered a rash on the client’s trunk. Vital signs were T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the most appropriate initial intervention? A. Administer an antihistamine medication. B. Flush the blood tubing with D5W immediately. C. Prepare for emergency resuscitation. D. Stop the blood transfusion immediately.