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Fluid and Electrolytes Jan Bazner-Chandler CPNP, CNS, MSN, RN.

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1 Fluid and Electrolytes Jan Bazner-Chandler CPNP, CNS, MSN, RN

2 Alteration in Fluid and Electrolyte Status Normal routes of fluid excretion in infants and children. Lungs Skin Urine & feces Ball & Bender

3 Developmental and Biological Variances Infants younger than 6 weeks do not produce tears. Infants younger than 6 weeks do not produce tears. In an infant a sunken fontanel may indicate dehydration. In an infant a sunken fontanel may indicate dehydration. Infants are dependant on others to meet their fluid needs. Infants are dependant on others to meet their fluid needs. Infants have limited ability to dilute and concentrate urine. Infants have limited ability to dilute and concentrate urine.

4 Developmental and Biological The small the child, the greater the proportion of body water to weight and proportion of extracellular fluid to intracellular fluid. The small the child, the greater the proportion of body water to weight and proportion of extracellular fluid to intracellular fluid. Infants have a larger proportional surface are of the GI tract than adults. Infants have a larger proportional surface are of the GI tract than adults. Infants have a greater body surface area and higher metabolic rate than adults. Infants have a greater body surface area and higher metabolic rate than adults.

5 Developmental and Biologic Because of immature kidney function, children lack ability to adjust to major changes in sodium and other electrolytes. Because of immature kidney function, children lack ability to adjust to major changes in sodium and other electrolytes. Normal urine output is 1 mL / kg / hr. Normal urine output is 1 mL / kg / hr. More prone than adults to conditions that affect fluid and electrolyte status (diarrhea, vomiting, high fever. More prone than adults to conditions that affect fluid and electrolyte status (diarrhea, vomiting, high fever.

6 Water Balance Regulated by Anti-diuretic Hormone ADH. Regulated by Anti-diuretic Hormone ADH. Acts on kidney tubules to reabsorb water. Acts on kidney tubules to reabsorb water. The young infant is highly susceptible to dehydration. The young infant is highly susceptible to dehydration.

7 Increased Water Needs Fever Fever Vomiting and Diarrhea Vomiting and Diarrhea High-output in renal failure High-output in renal failure Diabetes insipidus Diabetes insipidus Burns Burns Shock Shock Tachypnea Tachypnea

8 Decreased Water Needs Congestive Heart Failure Congestive Heart Failure Mechanical Ventilation Mechanical Ventilation Renal failure Renal failure Head trauma / meningitis Head trauma / meningitis

9 Assessment Focused Health History Focused Health History Focused Physical Assessment Focused Physical Assessment

10 Focused Health History Recent fluid intake including type of fluid ingested Recent fluid intake including type of fluid ingested How many voids in past 12 to 24 hours. How many voids in past 12 to 24 hours. Recent weight loss Recent weight loss

11 Focused Physical Assessment How does the child look? How does the child look? Skin: Skin: TemperatureTemperature Dry skin and mucous membranesDry skin and mucous membranes Poor turgor, tenting, dough-like feelPoor turgor, tenting, dough-like feel Sunken eyeballs; no tearsSunken eyeballs; no tears Pale, ashen, cyanotic nail beds or mucous membranes.Pale, ashen, cyanotic nail beds or mucous membranes. Delayed capillary refill > 2-3 secondsDelayed capillary refill > 2-3 seconds

12 Loss of Skin Elasticity Loss of skin elasticity Due to dehydration.

13 Cardiovascular Pulse rate change: Pulse rate change: Note rate and quality: rapid, weak, or thready Note rate and quality: rapid, weak, or thready Bounding or arrhythmias Bounding or arrhythmias Tachycardia #1 sign that something is wrong Tachycardia #1 sign that something is wrong Increased HR may be first subtle sign of hypovolemia Increased HR may be first subtle sign of hypovolemia Blood Pressure Blood Pressure Note increase or decrease (remember it takes a 25% decrease in fluid or blood volume for change to occur) Note increase or decrease (remember it takes a 25% decrease in fluid or blood volume for change to occur)

14 Respiratory Change in rate or quality Change in rate or quality Dehydration or hypovolemia Dehydration or hypovolemia Tachypnea Tachypnea Apnea Apnea Deep shallow respirations Deep shallow respirations Fluid overload Fluid overload Moist breath sounds Moist breath sounds Cough Cough

15 Diagnostic Tests Make sure free flowing specimen is obtained, a hemolyzed or clotted specimen may give false values. Make sure free flowing specimen is obtained, a hemolyzed or clotted specimen may give false values.

16 Hemoglobin and Hematocrit Measures hemoglobin, the main component of erythrocytes, which is the vehicle for transporting oxygen. Measures hemoglobin, the main component of erythrocytes, which is the vehicle for transporting oxygen. Hgb and hct will be increased in extracellular fluid volume loss. Hgb and hct will be increased in extracellular fluid volume loss. Hgb and hct will be decreased in extracellular fluid volume excess. Hgb and hct will be decreased in extracellular fluid volume excess.

17 Electrolytes Electrolytes account for approximately 95% of the solute molecules in body water. Electrolytes account for approximately 95% of the solute molecules in body water. Sodium Na+ is the predominant extracellular cation. Sodium Na+ is the predominant extracellular cation. Potassium K+ is the predominant intracellular cation. Potassium K+ is the predominant intracellular cation.

18 Potassium High or low values can lead to cardiac arrest. High or low values can lead to cardiac arrest. With adequate kidney function excess potassium is excreted in the kidneys. With adequate kidney function excess potassium is excreted in the kidneys. If kidneys are not functioning, the potassium will accumulate in the intravascular fluid If kidneys are not functioning, the potassium will accumulate in the intravascular fluid

19 Potassium Adults: 3.5 to 5.3 mEq /L Adults: 3.5 to 5.3 mEq /L Child: 3.5 to 5.5 mEq / L Child: 3.5 to 5.5 mEq / L Infant: 3.6 to 5.8 mEq / L Infant: 3.6 to 5.8 mEq / L Panic Values Panic Values 7.0 mEq / L 7.0 mEq / L

20 Hyperkalemia Defined as potassium level above 5.0 mEq / L Defined as potassium level above 5.0 mEq / L Significant dysrhythmias and cardiac arrest Significant dysrhythmias and cardiac arrest Adequate intake of fluids to insure excretion of potassium through the kidneys. Adequate intake of fluids to insure excretion of potassium through the kidneys.

21 Causes of Hyperkalemia Acute renal failure Acute renal failure Chronic renal failure Chronic renal failure Glomerulonephritis Glomerulonephritis

22 Diagnostic tests: Serum potassium Serum potassium ECG ECG Bradycardia Bradycardia Heart block Heart block Ventricular fibrillation Ventricular fibrillation

23 Hypokalemia Potassium level below 3.5 mEq / L Potassium level below 3.5 mEq / L Before administering make sure child is producing urine. Before administering make sure child is producing urine. A child on potassium wasting diuretics is at risk – Lasix A child on potassium wasting diuretics is at risk – Lasix

24 CM: Hypokalemia Neuromuscular manifestations are: neck flop, diminished bowel sounds, truncal weakness, limb weakness, lethargy, and abdominal distention. Neuromuscular manifestations are: neck flop, diminished bowel sounds, truncal weakness, limb weakness, lethargy, and abdominal distention.

25 Causes of Hypokalemia Vomiting / diarrhea Vomiting / diarrhea Malnutrition / starvation Malnutrition / starvation Stress due to trauma from injury or surgery. Stress due to trauma from injury or surgery. Gastric suction / intestinal fistula Gastric suction / intestinal fistula Potassium wasting diuretics Potassium wasting diuretics Ingestion of large amounts of ASA Ingestion of large amounts of ASA

26 Foods high in potassium Apricots, bananas, oranges, pomegranates, prunes Apricots, bananas, oranges, pomegranates, prunes Baked potato with skin, spinach, tomato, lima beans, squash Baked potato with skin, spinach, tomato, lima beans, squash Milk and yogurt Milk and yogurt Pork, veal and fish Pork, veal and fish

27 Monitor Potassium Levels A child with a nasogastric tube in place that is set to suction, needs to have potassium levels monitored.

28 Sodium Sodium is the most abundant cation and chief base of the blood. Sodium is the most abundant cation and chief base of the blood. The primary function is to chemically maintain osmotic pressure and acid-base balance and to transmit nerve impulses. The primary function is to chemically maintain osmotic pressure and acid-base balance and to transmit nerve impulses. Normal values: 135 to 148 mEq / L Normal values: 135 to 148 mEq / L

29 Hyponatremia Reflects an abnormal rate of sodium to water and is defined as a serum sodium concentration less than 135 mEq/L. Reflects an abnormal rate of sodium to water and is defined as a serum sodium concentration less than 135 mEq/L. Results from retention of water secondary to impairment in free water excretion. Results from retention of water secondary to impairment in free water excretion.

30 Pathophysiology When sodium levels drop in the fluids outside the cells, water will sweep into the cells in an attempt to balance the concentration of salt outside the cells. When sodium levels drop in the fluids outside the cells, water will sweep into the cells in an attempt to balance the concentration of salt outside the cells. Cells will swell as the result of the excess water. Cells will swell as the result of the excess water. Brain cells cannot accommodate – symptoms of hyponatremia result from brain swelling Brain cells cannot accommodate – symptoms of hyponatremia result from brain swelling

31 Early Manifestations Anorexia, nausea, lethargy and apathy Anorexia, nausea, lethargy and apathy More advanced symptoms: disorientation, agitation, seizures, depressed reflexes, focal neurological deficits More advanced symptoms: disorientation, agitation, seizures, depressed reflexes, focal neurological deficits Severe: coma and seizures: sodium concentration less than 120 mEq/L Severe: coma and seizures: sodium concentration less than 120 mEq/L

32 Hypernatremia Serum sodium greater than 150 mEq/L is caused by conditions that produce an excessive gain of sodium or excessive loss of water that is greater than the loss of sodium. Serum sodium greater than 150 mEq/L is caused by conditions that produce an excessive gain of sodium or excessive loss of water that is greater than the loss of sodium.

33 Clinical Pearl Most infant with severe dehydration have a history of lethargy, listlessness, and decreased responsiveness; those with hypernatremia dehydration tend to be irritable and fussy. Most infant with severe dehydration have a history of lethargy, listlessness, and decreased responsiveness; those with hypernatremia dehydration tend to be irritable and fussy.

34 Hypernatremia Inadequate fluid intake – 75% Inadequate fluid intake – 75% Gastrointestinal losses – 44% Gastrointestinal losses – 44% Occurs primarily in infants with diarrhea dehydration Occurs primarily in infants with diarrhea dehydration Diabetes insipidus was major reason for excessive urinary output Diabetes insipidus was major reason for excessive urinary output Loss from high fever, environmental temperatures and hyperventilation Loss from high fever, environmental temperatures and hyperventilation

35 Primary Sodium Excess Improperly mixed formula or re-hydration solution Improperly mixed formula or re-hydration solution Ingestion of sea water Ingestion of sea water Hypertonic saline IV Hypertonic saline IV High breast milk sodium High breast milk sodium

36 Primary Water Deficit Diabetes Insipidus Diabetes Insipidus Diabetes Mellitus Diabetes Mellitus Gastroenteritis (water loss greater than solute loss) Gastroenteritis (water loss greater than solute loss) Inadequate breast feeding Inadequate breast feeding Withholding of water: handicapped Withholding of water: handicapped Increased insensible loss – premature infant Increased insensible loss – premature infant

37 Additional Lab Values Arterial blood gas to determine acid-base status Arterial blood gas to determine acid-base status Urine specific gravity: measures kidneys ability to dilute and concentrate urine. Urine specific gravity: measures kidneys ability to dilute and concentrate urine. normal values 1.001 to 1.020 normal values 1.001 to 1.020 Low specific gravity may indicate fluid excess of kidney disease. Low specific gravity may indicate fluid excess of kidney disease. High specific gravity may indicate fluid deficit. High specific gravity may indicate fluid deficit.

38 Treatment Modalities Peripheral IV with IV house.

39 Intraosseous Therapy Intraosseous needle in place for emergency vascular access.

40 Central Venous Catheter

41 Total Parental Nutrition Whaley & Wong A tunneled catheter should have An occlusive dressing in place.

42 Complications of TPN Sepsis: infection Sepsis: infection Liver dysfunction Liver dysfunction Respiratory distress from too –rapid infusion of fluids Respiratory distress from too –rapid infusion of fluids

43 TPN Therapy TPN provides complete nutrition for children who cannot consume sufficient nutrients through gastrointestinal tact to meet and sustain metabolic requirements. TPN provides complete nutrition for children who cannot consume sufficient nutrients through gastrointestinal tact to meet and sustain metabolic requirements. TPN solutions provide protein, carbohydrates, electrolytes, vitamins, minerals, trace elements and fats. TPN solutions provide protein, carbohydrates, electrolytes, vitamins, minerals, trace elements and fats.

44 TPN: care reminder caREminder: The TPN infusion rate should remain fairly constant to avoid glucose overload. The infusion rate should never be abruptly increased or decreased. The TPN infusion rate should remain fairly constant to avoid glucose overload. The infusion rate should never be abruptly increased or decreased.

45 Dehydration Significant depletion of body water. Signs and symptoms include thirst, lethargy, dry mucosa, decreased urine output, and as the degree of dehydration progresses, tachycardia, hypotension, and shock. Significant depletion of body water. Signs and symptoms include thirst, lethargy, dry mucosa, decreased urine output, and as the degree of dehydration progresses, tachycardia, hypotension, and shock.

46 Cause of Dehydration Most common cause is fluid loss in the GI tract from vomiting, diarrhea or both. Most common cause is fluid loss in the GI tract from vomiting, diarrhea or both. Hypovolemic Shock = second most common cause of cardiac arrest in infants / children Hypovolemic Shock = second most common cause of cardiac arrest in infants / children Loss of Fluids Loss of Fluids Loss of blood volume Loss of blood volume

47 Diarrhea Most common cause of diarrhea in infant / child is Rotovirus Most common cause of diarrhea in infant / child is Rotovirus WHO recommends immunization against Rotovirus to decrease infant deaths world wide. WHO recommends immunization against Rotovirus to decrease infant deaths world wide.

48 3 Types of Dehydration Isotonic Dehydration Isotonic Dehydration Hyponatremic Dehydration Hyponatremic Dehydration Hypernatremic Dehydration Hypernatremic Dehydration

49 Isotonic Dehydration Sodium and water are lost in proportional amounts Sodium and water are lost in proportional amounts Reduction in circulating blood volume Reduction in circulating blood volume

50 Hyponatremic Dehydration Hypotonic dehydration: results from water retention or sodium loss. Hypotonic dehydration: results from water retention or sodium loss. Two causes: Two causes: Formula is diluted with water beyond manufacturer recommendation Formula is diluted with water beyond manufacturer recommendation Fluid loss is replaced with electrolyte-free water. Fluid loss is replaced with electrolyte-free water.

51 Hypernatremic Dehydration Marked by elevated sodium levels Marked by elevated sodium levels

52 Dehydration

53 General Assessment Loss of weight Loss of weight Level of consciousness Level of consciousness Alert to irritable Alert to irritable Restless to lethargic Restless to lethargic Lethargic to coma Lethargic to coma

54 Vital Signs The heart rate is the most sensitive indicator of dehydration / hypovolemia. The heart rate is the most sensitive indicator of dehydration / hypovolemia. HR will be elevated in an attempt to compensate for fluid loss. HR will be elevated in an attempt to compensate for fluid loss. Blood pressure will only drop as child is severely dehydrated (>10%). Blood pressure will only drop as child is severely dehydrated (>10%).

55 Skin Turgor In moderate dehydration the skin may have a doughy texture and appearance. In moderate dehydration the skin may have a doughy texture and appearance. In severe dehydration the more typical tenting of skin is observed. In severe dehydration the more typical tenting of skin is observed.

56 Skin Turgor

57 Weight CaREminder; one kilogram of body weight equals the weight of 1 L of water, thus, the amount of fluid gain or loss can be calculated from weight gain or loss. CaREminder; one kilogram of body weight equals the weight of 1 L of water, thus, the amount of fluid gain or loss can be calculated from weight gain or loss. Nursing intervention: compare daily weight with previous measurement and note trends. Nursing intervention: compare daily weight with previous measurement and note trends.

58 Urine Output Normal urine output is 1-2 mL/kg/hr Normal urine output is 1-2 mL/kg/hr In mild dehydration urine output may be low – parent may report decrease in voiding In mild dehydration urine output may be low – parent may report decrease in voiding Moderate dehydration urine output would be low and concentrated (oliguric) with elevated specific gravity. Moderate dehydration urine output would be low and concentrated (oliguric) with elevated specific gravity. Severe dehydration would by (anuric) very low – very concentrated urine with high S.G. Severe dehydration would by (anuric) very low – very concentrated urine with high S.G.

59 Treatment of Mild to Moderate ORT – oral re-hydration therapy ORT – oral re-hydration therapy 50 ml / kg every 4 hours 50 ml / kg every 4 hours Increase to 100 ml / kg every 4 hours Increase to 100 ml / kg every 4 hours No carbonated soda, jell-o, fruit juices or tea. No carbonated soda, jell-o, fruit juices or tea. Commercially prepared solutions are the best. Commercially prepared solutions are the best.

60 Re-hydration Therapy Increase po fluids if diarrhea increases. Increase po fluids if diarrhea increases. Give po fluids slowly if vomiting. Give po fluids slowly if vomiting. Stop ORT when hydration status is normal Stop ORT when hydration status is normal Start on BRAT diet Start on BRAT diet Bananas Bananas Rice Rice Applesauce Applesauce Toast Toast

61 Teaching / Parent Instruction Call PMD Call PMD If diarrhea or vomiting increases If diarrhea or vomiting increases No improvement seen in childs hydration status. No improvement seen in childs hydration status. Child appears worse. Child appears worse. Child will not take fluids. Child will not take fluids. NO URINE OUTPUT NO URINE OUTPUT

62 Moderate to Severe Dehydration IV Therapy needed

63 Fluid Resuscitation Crystalloid Solution: used for volume resuscitation to expand the interstitial volume rather that the plasma volume. Crystalloid Solution: used for volume resuscitation to expand the interstitial volume rather that the plasma volume. Isotonic Saline is the prototype crystalloid fluid. 0.9% NaCl or normal saline. Isotonic Saline is the prototype crystalloid fluid. 0.9% NaCl or normal saline. Lactated Ringers contains potassium and calcium. Lactated Ringers contains potassium and calcium.

64 Fluid Replacement Standard Orders: Standard Orders: Normal Saline or 0.9% NaCl at 20 mL / kg Normal Saline or 0.9% NaCl at 20 mL / kg Followed by Dextrose 5% in 0.45 normal saline Followed by Dextrose 5% in 0.45 normal saline Followed by Dextrose 5% in 0.45 normal saline with 20 mEq KCL per 1000 mL Followed by Dextrose 5% in 0.45 normal saline with 20 mEq KCL per 1000 mL Potassium is only added to the IV when there is documentation of voiding. Potassium is only added to the IV when there is documentation of voiding.

65 Nursing Interventions Assess childs hydration status Assess childs hydration status Accurate intake and output Accurate intake and output Daily weights Daily weights most accurate way to monitor fluid levels most accurate way to monitor fluid levels Hourly monitoring of IV rate and site of infusion. Hourly monitoring of IV rate and site of infusion. Increase fluids if increase in vomiting or diarrhea. Increase fluids if increase in vomiting or diarrhea. Decrease fluids when taking po fluids or signs of edema. Decrease fluids when taking po fluids or signs of edema.

66 Care Reminder A severely dehydrated child will need more than maintenance to replace lost fluids. 1 ½ to 2 times maintenance. A severely dehydrated child will need more than maintenance to replace lost fluids. 1 ½ to 2 times maintenance. Adding potassium to IV solution. Adding potassium to IV solution. Never add in cases of oliguria / anuria Never add in cases of oliguria / anuria Urine output less than 0.5 mg/kg/hourUrine output less than 0.5 mg/kg/hour Never give IV push Never give IV push Double check dosage Double check dosage

67 Over hydration Occurs when child receives more IV fluids that needed for maintenance. Occurs when child receives more IV fluids that needed for maintenance. In pre-existing conditions such as meningitis, head trauma, kidney shutdown, nephrotic syndrome, congestive heart failure, or pulmonary congestion. In pre-existing conditions such as meningitis, head trauma, kidney shutdown, nephrotic syndrome, congestive heart failure, or pulmonary congestion.

68 Signs and Symptoms Tachypnea Tachypnea Dyspnea Dyspnea Cough Cough Moist breath sounds Moist breath sounds Weight gain from edema Weight gain from edema Jugular vein distention Jugular vein distention

69 Safety Precautions Use small bags of fluid or buretrol to control fluid volume. Use small bags of fluid or buretrol to control fluid volume. Check IV solution infusion against physician orders. Check IV solution infusion against physician orders. Always use infusion pump so that the rate can be programmed and monitored. Always use infusion pump so that the rate can be programmed and monitored. Even mechanical pumps can fail, so check the intravenous bag and rate frequently. Even mechanical pumps can fail, so check the intravenous bag and rate frequently. Record IV rate q hour Record IV rate q hour

70 Acid – Base Imbalances Acidosis: Respiratory acidosis is too much carbonic acid in body. Respiratory acidosis is too much carbonic acid in body. Metabolic Acidosis is too much metabolic acid. Metabolic Acidosis is too much metabolic acid.Alkalosis. Respiratory alkalosis is too little carbonic acid. Respiratory alkalosis is too little carbonic acid. Metabolic alkalosis is too little metabolic acid. Metabolic alkalosis is too little metabolic acid.

71 Respiratory Acidosis Carbonic acid excess: CO2 is retained and pH decreases Carbonic acid excess: CO2 is retained and pH decreases Caused by the accumulation of carbon dioxide in the blood. Caused by the accumulation of carbon dioxide in the blood. Acute respiratory acidosis can lead to tachycardia and cardiac arrhythmias. Acute respiratory acidosis can lead to tachycardia and cardiac arrhythmias.

72 Causes of Respiratory Acidosis Any factor that interferes with the ability of the lungs to excrete carbon dioxide can cause respiratory acidosis. Any factor that interferes with the ability of the lungs to excrete carbon dioxide can cause respiratory acidosis. Aspiration, spasm of airway, laryngeal edema, epiglottitis, croup, pulmonary edema, cystic fibrosis, and Bronchopulmonary dysplasia. Aspiration, spasm of airway, laryngeal edema, epiglottitis, croup, pulmonary edema, cystic fibrosis, and Bronchopulmonary dysplasia. Sedation overdose, head injury, or sleep apnea. Sedation overdose, head injury, or sleep apnea.

73 Assessment Respiratory distress Respiratory distress CNS depression: disorientation, coma CNS depression: disorientation, coma Hypoxia: restlessness, irritability, tachycardia, arrhythmias Hypoxia: restlessness, irritability, tachycardia, arrhythmias Muscle weakness Muscle weakness

74 Medical Management Correction of underlying cause Correction of underlying cause Bronchodilators: asthma Bronchodilators: asthma Antibiotics: infection Antibiotics: infection Mechanical ventilation Mechanical ventilation Decreasing sedative use Decreasing sedative use

75 Respiratory Alkalosis Carbonic acid deficit; not enough CO2 is retained, and pH increases. Carbonic acid deficit; not enough CO2 is retained, and pH increases. Excess carbon dioxide loss is caused by hyperventilation. Excess carbon dioxide loss is caused by hyperventilation.

76 Causes of hyperventilation Hypoxemia Hypoxemia Anxiety Anxiety Pain Pain Fever Fever Salicylate poisoning: ASA Salicylate poisoning: ASA Meningitis Meningitis Over-ventilation Over-ventilation

77 Assessment Dizziness Dizziness Numbness or paresthesias of fingers and toes Numbness or paresthesias of fingers and toes Tetany Tetany Convulsions Convulsions Unconsciousness Unconsciousness

78 Management Stress management if caused by hyperventilation. Stress management if caused by hyperventilation. Pain control. Pain control. Adjust ventilation rate. Adjust ventilation rate. Treat underlying disease process. Treat underlying disease process. Have child slow respirations, breathe into paper bag Have child slow respirations, breathe into paper bag

79 Metabolic Acidosis Bicarbonate deficity Bicarbonate deficity

80 Causes: Gain in acid: ingestion of acids, oliguria, starvation (anorexia), DKA or diabetic ketoacidosis, tissue hypoxia. Gain in acid: ingestion of acids, oliguria, starvation (anorexia), DKA or diabetic ketoacidosis, tissue hypoxia. Loss of bicarbonate: Loss of bicarbonate: diarrhea, intestinal or pancreatic fistula, or renal anomaly.

81 Assessment Kussmaul respirations Kussmaul respirations SOB on exertion SOB on exertion Weakness Weakness Drowsiness to stupor Drowsiness to stupor When pH is < 7.2 cardiac contractility is reduced – BP will decrease When pH is < 7.2 cardiac contractility is reduced – BP will decrease

82 Management Treat and identify underlying cause. Treat and identify underlying cause. IV sodium bicarbonate in severe cases. IV sodium bicarbonate in severe cases. Provide low-protein, high-calorie diet Provide low-protein, high-calorie diet Position to facilitate ventilation Position to facilitate ventilation

83 Metabolic Alkalosis A gain in bicarbonate or a loss of metabolic acid can cause metabolic alkalosis. A gain in bicarbonate or a loss of metabolic acid can cause metabolic alkalosis.

84 Causes: Gain in bicarbonate: Gain in bicarbonate: Ingestion of baking soda or antacids. Loss of acid: Vomiting, nasogastric suctioning, diuretics massive blood transfusion

85 Assessment Signs similar to dehydration Signs similar to dehydration Tachycardia Tachycardia Hypoventilation Hypoventilation Muscle hypertonicity Muscle hypertonicity Confusion, irritability, coma Confusion, irritability, coma

86 Treatment Administer fluid containing sodium and potassium Administer fluid containing sodium and potassium Avoid antacids Avoid antacids Management: Correct the underlying condition Management: Correct the underlying condition


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