Chapter 16 Fluid and Electrolyte Imbalances PDF

# Timby's Introductory Medical-Surgical Nursing, 13e ## Chapter 16: Caring for Clients With Fluid, Electrolyte, and Acid-Base Imbalances ## Objectives - List three chemical substances that are components of body fluid. - Name the two main fluid locations in the human body and two subdivisions. - G...

# Timby's Introductory Medical-Surgical Nursing, 13e ## Chapter 16: Caring for Clients With Fluid, Electrolyte, and Acid-Base Imbalances ## Objectives - List three chemical substances that are components of body fluid. - Name the two main fluid locations in the human body and two subdivisions. - Give the average fluid intake per day for adults. - List four ways in which the body normally loses fluid. - Identify five processes by which water and dissolved chemicals are relocated in the body. - Name three mechanisms that help regulate fluid and electrolyte balance. - List two types of fluid imbalance. - Explain the difference between hypovolemia and dehydration. - Explain hemoconcentration and hemodilution. - Identify assessment findings of and nursing interventions for hypovolemia. ## Fluid and Electrolyte Intro - Fluid and electrolyte balance is a dynamic process that is crucial for life and homeostasis. - Necessary to maintain equilibrium in body - The body fluid is made up of water, electrolytes, bases, acids, and other components. - cells, proteins, glucose, and chemicals. - Most common fluid imbalance in older adults is dehydration. - Nursing role: recognize, help prevent, and treat fluid & electrolyte imbalances. ## Fluid and Electrolyte Balance #1 - Body fluids: Includes body's water and all dissolved substances called solutes. - Function: Medium for chemical reactions; carry nutrients and waste out of body, bring nutrients into cells. - Components: - Mainly water and chemicals O2, CO2, H. - 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 or balance. ## Fluid and Electrolyte Balance #2 Body Fluid Compartments - 60% of body is water. - Intracellular fluid: fluid located within cells. - Extracellular fluid: all fluid outside of the cells. - Interstitial fluid: between the cells. - Intravascular fluid: blood vessels = plasma. ## Distribution of Body Water A picture of a person is shown. Inside of the human figure, a blue arrow points to the total body water (60%), which is divided into three compartments. - **Extracellular Fluid (33%)**: Includes 8% Blood Plasma and 25% Interstitial Fluid. - **Intracellular Fluid (66%)**: Found inside cells of every kind of tissue, e.g., blood cells, bone cells, muscle cells and adipose cells. ## Intake and Output - Average fluid intake: - Adult: 2500 mL/day (Range: 1800 to 3600 mL/day). - 100 ml/kg for the first 10 kg of weight, plus. - 50 ml/kg for the next 10 kg of weight, plus. - 15 ml/kg per remaining kg of weight. - Calculate for a person weighing 176 lbs. - Fluid - mostly oral - Fluid - elimination: - Sources: Urination, bowel elimination, perspiration, breathing. - Insensible losses: sweat, exhaled air. ## Fluid Intake and Output A picture of a tube is shown. Fluid enters the top and flows down the tube; fluid is exiting the bottom of the tube. The following fluid intake and output values are shown in a table: **Fluid Intake (mL)** - Ingested water: 1300 - Ingested food: 1000 - Metabolic oxidation: 300 - Total: 2600 **Fluid Output** - Kidneys: 1500 - Skin: Insensible loss: 600-900 - Sensible loss: 0-5000 - Lungs: 400 - Gastrointestinal: 100 - Total: 2600-2900 ## Three Types of Dehydration <start_of_image> Diagrams of cells are shown with varying levels of water and solutes. - **Hypotonic dehydration**: Primarily a loss of electrolytes, sodium in particular. Hypotonic dehydration causes decreased plasma osmolarity. - **Hypertonic dehydration**: Primarily a loss of water. Hypertonic dehydration cause increased plasma osmolarity. - **Isotonic dehydration**: An equal loss of water and electrolytes. Isotonic dehydration will not change plasma osmolarity, but it will reduce overall plasma volume. Isotonic dehydration is the most common type of dehydration. ## Distribution of Fluids and Electrolytes - Physiologic process: translocation of fluid and exchange of chemicals is continuous, by active or passive transport. - Four processes: Three passive and one active. - **Osmosis**: Movement of water through a semipermeable membrane; tonicity (concentration of solutes). - **Filtration**: Promotes movement of fluid according to pressure differences; kidneys (hydrostatic pressure). - **Diffusion**: Passive and facilitated. Example: insulin facilitates distribution of glucose inside cells by transporters against a concentrated gradient. - **Active transport**: sodium-potassium pump; requires ATP transporters (low concentration to higher concentration) Figure 16:4 ## Osmosis A diagram of a cell is shown. The cell is surrounded by fluid. Water moves through the cell membrane, from the area with a low concentration of solutes, to the area with a high concentration of solutes, ## Coffee Cup Analogy Three coffee mugs are shown side-by-side. The first has no solutes and is labeled "osmolarity = 0, hypotonic". The second mug has one solute cube in it and is labeled "osmolarity = 1x, hypertonic/hypotonic". The third mug contains two solute cubes and is labeled "osmolarity = 2x, hypertonic". ## Simple and Facilitated Diffusion A diagram of two beakers is shown, separated by a semipermeable membrane. Solute particles are depicted in one beaker and water particles are depicted in the other beaker. An arrow between the two beakers indicates the direction of the particles moving through the membrane. - Movement of molecules and ions from an area of higher concentration to an area of lower concentration until equilibrium is attained. Need active transport to accomplish this (ATP). - osmosis diffusion filtration ## Sodium - Potassium pump Active Transport A diagram of a cell is shown with depictions of the sodium-potassium pump mechanism. ## Fluid Balance - Maintain plasma osmolarity - ratio of solutes to water in blood plasma. - Intake = thirst stimulation; - Output = urine, perspiration, breathing, bleeding. - Pressure sensors in the vascular system regulate fluid balance. - Primary regulators controlled by: - Renin-angiotensin-aldosterone system. - **Angiotensin II**: Causes vasoconstriction (raises BP). - **Aldosterone**: Concentrates urine and balances levels of Na+ and K+ in body, to be reabsorbed by the kidneys. - **ADH**: Helps conserve water by increasing circulating blood volume. ## Regulation of Fluid Review - Movement of fluid through capillary walls depends on: - Hydrostatic pressure: exerted on walls of blood vessels - blood pressure. - Osmotic pressure: exerted by protein in plasma of fluid movement depends on differences of hydrostatic, osmotic pressure. - **Osmoreceptors**: That senses serum osmolality - stimulate hypothalamus to release ADH. - **Baroreceptors**: Sensitive to changes in blood volume. - **Natriuretic peptides**: Vasodilate vessels by excretion of sodium. - Produced in the heart muscles, ventricles and brain. ## High/Low Osmolarity A diagram of a person is shown with various factors that influence osmolarity. - **High Osmolarity Causes**: - Thirst? Increased water intake. - ADH release? Water reabsorbed from urine. - **Low Osmolarity Causes**: - Lack of thirst?Decreased water intake. - Decreased ADH release? Water lost in urine ## Fluid Imbalances #1 - **Hypovolemia**: Low volume of extracellular fluid. - Causes: vomiting; diarrhea; wounds; profuse urination; hemorrhage; perspiration; diuretics; low intake fluids. - Clients at risk: lethargic, sick, elderly, dementia. - Dehydration: volume of ICF and ECF fluids are reduced. See EBP 16-1. - Assessment Findings: thirst, BP, mentation changes, pulse rapid weak. - Diagnostic Findings: elevated hematocrit; elevated urine specific gravity, electrolyte imbalances; blood clots See Table 16:2. - Nursing Management: hydration measures. - Restore Fluid Volume Deficit: oral or IV NS - Don't restrict sodium, avoid caffeine beverages. - Monitor closely for SS of dehydration Josie King. ## Fluid Imbalances #2 - **Hypervolemia**: High volume of water in intravascular fluid compartment or fluid volume excess. - Causes: excessive oral intake; IV fluids; heart failure; kidney disease; adrenal gland dysfunction; circulatory overload. - Assessment Findings: rapid weight gain, BP, pitting or nonpitting edema, dependent edema, moist lung sounds, jugular venous distention. - Neurologic changes, respiratory changes. - Diagnostic Findings: Hematocrit and blood cell count, low specific gravity; hemodilution. - Medical Management: restrict oral or parenteral fluid; diuretics; limit sodium; watch dehydration. ## Fluid Excess A picture of a person is shown. The person is holding two buckets overflowing with water. The person is sweating and the caption states "Too much fluid going in with failure to eliminate". The picture is meant to depict the symptoms of fluid excess. - **Neurologic**: Changes in LOC, Confusion, Headache, Seizures. - **Respiratory**: Pulmonary congestion. - **Cardiovascular**: Bounding pulse, increased BP, presence of S3, Tachycardia. - **Gastrointestinal**: Anorexia, Nausea. - **Edema**: Dependent, pitting edema. "Sodium concentrations can be decreased, as well as the osmolality, because there is more water than sodium. The hematocrit will be reduced from the dilution of excess water." ## Nursing Care Plan: Hypervolemia - Nursing diagnosis: Excess Fluid Volume related to intake that exceeds fluid loss (Pg 228) and interventions: - Baseline and daily weights (weight gain 2 lb/24 hours). - Accurate intake and output. - Thirst: ice chips, fluid restriction. - Auscultate lung sounds. - Measure BP, heart rate, respiratory rate. - Inspect skin for edema, cracks, breakdown, mucus membranes, tenting. - Manage: Edema - diuretics. - Hematocrit levels. - Elevate lower extremities. ## Pitting Edema A diagram of four legs is shown. Each leg is labeled 1+ to 4+ and has a different level of indentation when pressed. The leg with 1+ pitting edema has a slight indentation when pressed (2 mm) . The leg with 2+ pitting edema has a deeper indentation when pressed (4 mm) . The leg with 3+ pitting edema has a very deep indentation when pressed (6 mm). The leg with 4+ pitting edema has an extremely deep indentation when pressed (8 mm). The final leg has no indentation and the caption states "Brawny Edema: Fluid can no longer be displaced secondary to excessive interstitial fluid accumulation. No pitting. Tissue palpates as firm or hard. Skin surface shiny, warm, moist. " ## Third-Spacing - Third-spacing: translocation of fluid from intravascular to tissue compartments. - Causes: hypoalbuminemia, burns, severe allergic reactions, after surgery (postmastectomy) lymphedema, sepsis syndrome, weak blood vessels. - Assessment Findings: ascites, generalized edema. - Diagnostic Findings: hemoconcentration, CVP below normal, blood counts borderline. - Medical Management: Albumin infusion. Need albumin to pull trapped fluid back into the intravascular space. - Diuretic if become overloaded. - Can lead to hypotension, shock, and circulatory failure. ## Third Spacing A diagram of blood vessels is shown. Liquid is shown leaking out into the space between the cells. Another picture of an arm and leg is shown of someone with swollen legs. ## Nursing Management of Fluid Imbalances - Nursing Management: 16:1 and Guidelines - Restore fluid volume deficit or excess. - Education: 8-10 glasses of water a day. - Avoid caffeine beverages. - Weigh client daily (report loss 2lbs 24 hours). - Mental status changes. - Urine specific gravity of 1.0 or more or dark and has strong odor, BUN. - Monitor BP, Intake and output, Respiratory. - Cognition changes - Edema ## Electrolyte Imbalances Review - Electrolyte imbalances occur as deficits and/or excess; accompanied by fluid changes. - Causes: - Deficits: vomiting, diarrhea, diuretics, kidney failure, deficits of healthy foods, medications. - Excess: orally consumed, parenteral administration of electrolytes, kidney failure, endocrine dysfunction, crushing injuries, burns. - Priority electrolyte imbalances: sodium, potassium, calcium, and magnesium. ## Electrolytes Active chemicals that carry positive (cations) and negative (anions) electrical charges. - **Major Cations**: Sodium, Potassium, Calcium, Magnesium, hydrogen ions. - **Major Anions**: Chloride, Bicarbonate, Phosphate, Sulfate, Proteinate ions. - Major cation in ECF is Na+ and ICF is K+ - Electrolyte concentrations differ in the fluid compartments. - **Fluid and Electrolytes Nursing.com** ## Sodium Imbalances #1 Hyponatremia - Sodium: Responsible for maintaining normal nerve and muscle activity, regulating osmotic pressure, preserving acid-base balance. Regulate fluid volume in body. - **Hyponatremia**: Serum level below 135 mEq/L. - Causes: profuse diaphoresis, diuresis, loss of GI secretions (suctioning, drains), Addison disease, dilution (SIADH). - Assessment Findings: mental confusion, cerebral edema, muscular weakness, anorexia, elevated body temperature, tachycardia and weak pulses. Late signs respiratory arrest, seizures. - Medical Management: foods high in Na, IV fluids, sea salt. - Nursing care watch for early and late signs and symptoms. Monitor fluids, labs, neuro assessments, vital signs, IV solutions with Na+. ## Sodium Imbalances #2 Hypernatremia - **Hypernatremia**: Excess sodium Na+ (serum sodium) blood. - Causes: diarrhea; excessive salt intake; fever; water loss; decreased water intake; severe burns, Cushing's, DI, kidney disease. - Assessment Findings: thirst; dry sticky mucous membranes; decreased urine output; fever, lethargy, comatose. - Diagnostic Finding: Na+ > mEq/L. - Medical Management: Fluids; hypotonic IV solution 0.45% NaCl or 5% Dextrose; pull fluid from ECF to ICF. - Nursing Management: Strict I&O; VS; dietary restrictions on NA+ and teaching (See Nutrition Notes). - Monitor for late and serious signs: Swollen dry tongue, nausea and vomiting and increased muscle tone (very stiff muscles). ## Potassium Imbalances #1 Hypokalemia - Potassium K+ - maintaining normal nerve and muscle activity: Low and slow in hypo. - Causes: potassium-wasting diuretics (Lasix, HydroDIURIL), GI tract fluid loss (suctioning, drains, vomiting), corticosteroids. - Assessment Findings: Fatigue, weakness, nausea, cardiac dysrhythmias, flaccid, paresthesia, leg cramps, lethargic, GI - slow (paralytic ileus). Confusion, slow RR, low BP. - Diagnostic Finding: <3.0 mEq/L of 2.5-5.0. Flat T waves, prominent U Wave. Nerve impulses slowed. - Medical Management: potassium-sparing diuretics (Aldactone), foods high in K+, oral supplements (K-Lor), IV - slowly. - Nursing management: Monitor for EKG changes, oral supplements, BP, Resp, GI, and Neuro. ## Potassium Imbalances # Hyperkalemia - **Hyperkalemia**: Potassium is essential for maintaining cardiac function. - Causes: renal failure, diuretics, supplements, diet sodas, crushing injuries, Addison disease. - Assessment Findings: diarrhea, nausea, muscle weakness, cardiac dysrhythmias, decreased reflexes, tall peaked T-waves, muscle twitches, cramps. Decreased urine output. - Diagnostic Finding: >k+ 5.5 mEq/L, EKG changes. - Medical management: decreasing K+ intake, administration of insulin and glucose, Kayexalate, dialysis. - Nursing Management: medications, diet teaching, IV insulin and glucose (shifts k+ back into cells). Monitor for cardiac changes. ## Hyperkalemia A picture of a person's heart and the word "Murder" is shown. The caption states that "The body CARED too much about K+" and then defines each letter of the word CARED. - **C**: Cellular movement of K+ from intracellular to extracellular (burns, tissue damage, etc). - **A**: Adrenal Insufficiency w/ Addison's Disease. - **R**: Renal Failure. - **E**: Excessive K+ intake. - **D**: Drugs (potassium-sparing drugs: spironolactone, ACE inhibitors, NSAIDS). <start_of_image> - **S & S**: Muscle weakness, Urine output little or none (renal failure), Respiratory failure (due to muscle weakness), Decreased cardiac contractility (weak pulse/ low HR), Early: muscle twitches/cramps, Rhythm changes: Tall peaked T waves, prolonged PR interval. ## Effects of Potassium ECG - Three different ECG waveforms are shown. **A** depicts a normal waveform with the following labels: - P (representing the p-wave) - P-R interval - QRS complex - R (representing the r-wave) - S (representing the s-wave) - T (representing the t-wave) - S-T segment. **B** depicts an ECG waveform with the following labels: - P (representing the p-wave) - Q (representing the q-wave) - R (representing the r-wave) - S (representing the s-wave). - S-T segment depression. - U wave. - Flattened t wave. **C** depicts an ECG waveform with the following labels: - Prolonged P-R interval. - Wide Q-R-S complex. - Tall tented T wave. - S-T segment depression. ## Calcium Imbalances #1 - **Hypocalcemia**: Lack of calcium (CA++) located in bones. - Function: blood clotting; transmission of nerve impulses; muscle contraction; smooth muscle of heart. - Causes: vitamin D deficiency, hypoparathyroidism, burns, pancreatitis, corticosteroids, blood administration, intestinal malabsorption. - Assessment Findings: circumoral paresthesia (tingling around mouth) muscle cramps, positive Chvostek sign, Trousseau sign, bleeding, tetany, bone pain, constipation, weakness, anxiety, laryngospasm. - Diagnostic Finding: serum calcium < 8.8 mg/dL. - Medical Management: oral calcium (calcium gluconate) and vitamin D, IV calcium. ## Trousseau's Sign and Chvostek sign Two pictures are shown. The picture labeled **A** is a woman with her arm under her chin. An arrow points to a woman's cheek and a doctor is shown tapping the woman's cheek with a finger. The picture labeled **B** shows a woman with a blood pressure cuff on her arm. The cuff is partially inflated. ## Calcium Imbalances #2 - **Hypercalcemia**: High levels of (Ca++) in blood. - Causes: parathyroid tumors, multiple fractures, Paget disease, prolonged immobilization, chemotherapy agents, multiple myeloma. - Assessment Findings: deep bone pain, constipation, anorexia, polyuria, pathologic fractures, kidney stones, fatigue, nausea, cardiac arrythmias, muscle weakness; mental changes. - Diagnostic Finding: serum calcium > 10 mg/dL. - Medical Management: Find cause, IV sodium chloride, Lasix, corticosteroids, manage kidney stones, calcitonin. - Nursing Management: diet teaching, encourage fluids, fall safety, restrict calcium, discontinue thiazide diuretics, monitor cardiac arrythmias. ## Hypercalcemia and Hypocalcemia A table is shown with the nervous system (CNS), the cardiovascular system (CVS), and the musculoskeletal system (MSK). Symptoms associated with hypocalcemia and hypercalcemia are listed for each system. **CNS** - **Hypocalcemia**: Irritability & anxiety, Paresthesias, Seizures, Laryngospasm, Bronchospasm. - **Hypercalcemia**: Decreased ability to concentrate, Increased sleep requirement, Depression, Confusion and Coma, Death,. **CVS** - **Hypocalcemia**: Heart failure. - **Hypercalcemia**: Arrhythmias, Bradycardia. **MSK** - **Hypocalcemia**: Muscle cramps. - **Hypercalcemia**: Muscle weakness. ## Magnesium Imbalances #1 Hypomagnesemia - **Hypomagnesemia**: low levels of magnesium found in bone cells and cells of heart, liver and skeletal muscles. - Function: transmission of nerve impulses, activation of enzyme systems including functioning of Vitamins B. - Causes: alcoholism, DKA, renal disease, burns, malnutrition, intestinal malabsorption, diuresis, prolonged gastric suction, chronic alcoholism, low intake of Mg++. - Assessment: tachycardia, paresthesias, neuromuscular, HA irritability, HTN, mental changes, leg cramps, + Chvostek and Trousseaus signs, anxiety. - Diagnostic Finding: serum magnesium < 1.3 mEq/L. - Medical Management: oral or IV magnesium, diet supplements. ## Hypomagnesemia A picture of a person is shown with symptoms of magnesium deficiency. - **Anxiety & Low Mood** - **PMS and Hormonal Imbalances** - **Sore or Aching Joints** - **Headaches and Migraines** - **General Fatigue** - **Muscle Weakness or Cramps** ## Nursing Interventions - Nursing: check for positive Chvostek and Trousseaus signs, dysphagia and seizures, teaching on foods rich in magnesium. Monitor for cardiac, LOC, neuromuscular activity. - Monitor cardiac, GI, respiratory, neuro status. Place on a cardiac monitor (watching for any EKG changes prolonging of PR interval and widening QRS complex). - Administer Magnesium Sulfate IV route. Monitor Mg+ level closely because patient can become magnesium toxic (Watch for depressed or loss of deep tendon reflexes). - Oral forms of Magnesium may cause diarrhea which can increase magnesium loss. - Encourage foods rich in Mg++: green leafy veggies, whole grains, nuts, seafood etc. - Administering Calcium Gluconate - antidote for adverse reaction during administration of Mg ++ sulfate ## Magnesium Imbalances #2 - **Hypermagnesemia**: To mush - calm and quiet. - Causes: renal failure; Addison disease; excessive antacid or laxative use; hyperparathyroidism. - Assessment: flushing, hypotension, lethargy, bradycardia, muscle weakness, coma, (DTR), shallow respirations, hypoactive bowel sounds. - Diagnostic Finding: serum magnesium > 2.1 mEq/L. - Medical Management: decreasing oral magnesium or parenteral replacement, mechanical ventilation. - Nursing Management: BP and respiratory monitoring. - Monitor for bradycardia, lethargy, muscle weakness and depressed respirations. Monitor VS. Calcium gluconate is kept available as an antidote. ## Acid-Base Balance A picture of a balance scale is shown. - **Acidic (Red) side of the scale**: Weighs heavy with numerous red spheres labelled HCO3- - **Basic (Blue) side of the scale**: Weighs very light with one blue sphere labelled H2CO3. - **The numbers** 6.8, 7.35, 7.45, 8.0 are shown on the scale. - **Death** is shown on either end of the scale. - **pH** is shown in a box above the scale. ## Acid-Base Balance - Regulation of normal plasma pH (7.35 - 7.45), death occurs quickly if plasma pH is outside the range of 6.8 to 7.8. - Chemical regulation: Carbonic acid (H2CO3) and bicarbonate (HCO3) buffer system by adding or removing hydrogen ions. - Organ regulation: Lungs regulate H2CO3 by conserving C02. Kidneys regulate acid-base by balancing HCO3. - Referred to as compensation. Fully compensated when pH is in normal range. - **Acidosis**: Excessive accumulation of acids or excessive loss of bicarbonate in body fluids; ketones; carbonic acid. - **Alkalosis**: Excessive accumulation of bases or loss of acid in body fluids. - **https://youtu.be/-Af0Vvrh8Ds** Simple nursing ## Arterial Blood Gases - Four sub-types: Metabolic acidosis, metabolic alkalosis, respiratory acidosis, respiratory alkalosis. - pH 7.3 - 7.45 - normal. - PaCO2 35 - 45 mm Hg. - HCO3 22 - 26 mEq/L. - Assumed average values for ABG interpretation. - PaO2 80 to 100 mm Hg. - Oxygen saturation >94%. - Base excess/deficit ± 2mEq/L. ## Blood Gas Practice A table is shown with four columns. The columns are labelled "Reference", "Problem", "Interpretation", and "Normal Values". The "Reference" column contains the normal values for pH, paCO2, and HCO3. The "Problem" column includes specific values for pH, paCO2, and HCO3. The "Interpretation" column contains the diagnosis, (i.e., metabolic acidosis, uncompensated). The "Normal Values" column contains the following normal ranges: - **pH**: 7.35-7.45 - **PaO2**: 75-100 mmHg - **PaCO2**: 35-45 mmHg - **HCO3-**: 22-26 mEq/L ## Acid-Base Imbalances #1 - **Metabolic Acidosis**: decreased plasma pH; bicarbonate. - Cause: Shock, MI, starvation, DKA, renal failure, aspirin use, loss of intestinal fluid, severe diarrhea. - Assessment Findings: deep and rapid breathing, Kussmaul breathing, nausea, headache, flushing, abdominal pain, weakness; N&V. - **Diagnosis's**: HC03, Anion gap >16; - pH < 7.35. - Anion gap is the Difference between +Na and +K cations, and NaCl and Bi-Carb. - Medical Management: eliminate cause, replace fluids and electrolytes, IV bicarbonate. ## Metabolic Acidosis A picture of a person is shown with symptoms such as headache, decreased BP, hyperkalemia, muscle twitching, warm flushed skin (vasodilation), nausea, vomiting and diarrhea. It shows arrows pointing to the kidney indicating a decrease in its ability to excrete acid or conserve base. It also shows the pH and HCO3 values. - **Causes**: DKA, Severe Diarrhea, Renal Failure, Shock. ## Acid-Base Imbalances #2 - **Metabolic Alkalosis**: (pH > 7.45) and HC03. - Causes: excessive bicarbonate-containing drugs, diuretic therapy, vomiting, gastric suctioning, renal failure. - Assessment Findings: anorexia, nausea, paresthesias, confusion, hypertonic reflexes, decreased respirations. - Medical Management: cause, potassium administration, sodium chloride administration. - Nursing Management: ABG findings; reports assessment findings, - The lungs try to compensate for metabolic acidosis or alkalosis by changing pCO2; they decrease pCO2 in metabolic acidosis and increase pCO2 in metabolic alkalosis. ## Metabolic Alkalosis A picture of a person is shown. The person appears to be anxious and is shown with symptoms such as restlessness, dysrhythmias, tachycardia, compensatory hypoventilation, confusion, nausea and diarrhea. It shows arrows pointing to the kidney and noting a ↑ in acid or ↑ in Base. - **Causes**: Vomiting, excessive GI suctioning, diuretics, excessive NaHCO3. ## Acid-Base Imbalances #3 - **Respiratory Acidosis**: lungs do not remove excess C02 and blood becomes acidic due to Co2 buildup in lungs Due to respiratory problem with inadequate excretion of Co2. more common than metabolic. - Causes: pneumothorax, pulmonary edema, asthma, pneumonia, drug overdose, head injuries. Due to respiratory problem with inadequate excretion of Co2. more common than metabolic. - Assessment Findings: cyanosis, tremors, respiratory insufficiency, <12 beath/min, lethargic: (pH < 7.35). - Medical Management: mechanical ventilation, airway suctioning, bronchodilators, and antibiotics. Arterial blood gas (ABG): values to determine acid-base balances. ## Respiratory Acidosis A picture of a person is shown with symptoms such as hypoventilation, rapid shallow respirations, decreased BP with vasodilation, dyspnea, headache, hyperkalemia, dysrhythmias, drowsiness, dizziness, disorientation, muscle weakness, hyperreflexia. - **Causes**: Decreased respiratory stimuli (anesthesia, drug overdose), COPD, pneumonia, atelectasis. ## Acid-Base Imbalances #4 Respiratory Alkalosis - **Alkalosis**: more bicarbonate in the blood. - Causes: Anxiety, fever, overactive thyroid, ASA poisoning, mechanical ventilation. - Assessment Findings: increased respiratory rate, light-headedness, numbness and tingling of fingers and toes, paresthesias, sweating, panic attacks. - Medical Management: rebreathe expired air (brown bag breathing), sedation. - Nursing management: report assessment findings, monitor laboratory values. - The kidneys try to compensate for respiratory acidosis or alkalosis by changing concentration of HCO3; they increase HCO during respiratory acidosis and decrease HCO3 during respiratory alkalosis. ## Respiratory Alkalosis A picture of a person is shown with symptoms such as hyperventilation, tachycardia, normal BP, hypokalemia, numbness and tingling of extremities, hyperreflexes, muscle cramping, seizures, anxiety and irritability. - **Causes**: Hyperventilation (anxiety, PE, Fear), Mechanical Ventilation. ## 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. ## Tic-Tac-Toe Grid A tic-tac-toe grid is shown. Each square is labelled as follows: - Top left: Acidosis - Top middle: Normal - Top right: Alkalosis ## ABG #1 - **pH**: 7.52 - **PaCO2**: 43 - **HCO3**: 31 - **Interpretation**: ABG Normal Values: - pH: 7.35-7.45 - PaO2: 75-100 mmHg - PaCO2: 35-45 mmHg - HCO3-: 22-26 mEq/L ## ABG #2 - **pH**: 7.45 - **PaCO2**: 30 - **HCO3**: 19 - **Interpretation**: ABG Normal Values: - pH: 7.35-7.45 - PaO2: 75-100 mmHg - PaCO2: 35-45 mmHg - HCO3-: 22-26 mEq/L ## ABG #3 - **pH**: 7.36 - **PaCO2**: 43 - **HCO3**: 22 - **Interpretation**: ABG Normal Values: - pH: 7.35-7.45 - PaO2: 75-100 mmHg - PaCO2: 35-45 mmHg - HCO3-: 22-26 mEq/L ## ABG #5 - **pH**: 7.51 - **PaCO2**: 28 - **HCO3**: 23 - **Interpretation**: ABG Normal Values: - pH: 7.35-7.45 - PaO2: 75-100 mmHg - PaCO2: 35-45 mmHg - HCO3-: 22-26 mEq/L ## ABG #6 - **pH**: 7.35 - **PaCO2**: 65 - **HCO3**: 31 - **Interpretation**: ABG Normal Values: - pH: 7.35-7.45 - PaO2: 75-100 mmHg - PaCO2: 35-45 mmHg - HCO3-: 22-26 mEq/L ## ABG #7 - **pH**: 7.44 - **PaCO2**: 53 - **HCO3**: 31 - **Interpretation**: ABG Normal Values: - pH: 7.35-7.45 - PaO2: 75-100 mmHg - PaCO2: 35-45 mmHg - HCO3-: 22-26 mEq/L