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Loss of water and electrolytes in proportion vomiting diarrhea systemic infection with fever fistulous drainage Decreased intake of water difficulty swallowing.

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Presentation on theme: "Loss of water and electrolytes in proportion vomiting diarrhea systemic infection with fever fistulous drainage Decreased intake of water difficulty swallowing."— Presentation transcript:

1 Loss of water and electrolytes in proportion vomiting diarrhea systemic infection with fever fistulous drainage Decreased intake of water difficulty swallowing coma tube feeding Extra Cellular Fluid Volume Deficit Preceding Events

2 Third spacing: a distributional shift of body fluids into a space which it is not easily exchanged Body cavities abdominal cavity thoracic cavity Bowel obstruction Edema Burns Extracellular Fluid Volume Deficit Preceding Events (continued):

3 Extracellular Fluid Volume Deficit Clinical Observations: Longitudinal furrows in tongue Decreased skin turgor, tearing & salivation Lack of moisture in axilla and groin Urine output under 30 ml/hr Slow filling hand veins when arm is lowered Flat neck veins in supine position Weight loss: 2% = mild deficit, 5% = moderate deficit & 8% = severe deficit (2 lbs. = 1L)

4 Systolic pressure 10mm Hg less standing than supine Decreased central venous pressure Temperature subnormal (unless infection is present) Pulse and respiration increased (compensatory with increased perfusion) Extracellular Fluid Volume Deficit Clinical Observations (continued):

5 Increase in hemoglobin Increase in hematocrit Increase in specific gravity of urine Decrease in urine out put Extracellular Fluid Volume Deficit Laboratory Findings:

6 Kidney tubules deteriorate rapidly Quickly leads to other deficits: 1. bicarbonate deficit 2. potassium deficit Hypovolemic shock Extracellular Fluid Volume Deficit Related Problems:

7 Replacement fluids and IVs Intake and Output Evaluate sweating Monitor urine specific gravity Turn frequently to prevent skin breakdown Oral care Extracellular Fluid Volume Deficit Nursing Care:

8 Any cause of excessive retention of sodium and water: Chronic heart failure, Chronic renal failure, Excessive IV fluids (especially sodium- containing solutions) Extracellular Fluid Volume Excess Preceding Events

9 Puffy Eyelids Peripheral Edema (1+ to 4+) (5 to 10 lbs.) Ascites Effusions into “third spaces” pleural cavity abdominal cavity (compensatory) Moist rales in lungs (can indicate an excess of 1500 ml or more) Extracellular Fluid Volume Excess Clinical Observations:

10 Full, bounding pulse Elevated central venous pressure Slow emptying of hand veins when arm is raised Distended neck veins Increased urinary volume if kidneys functional (BUN and potassium elevated if kidney disease present) Extracellular Fluid Volume Excess Clinical Observations (continued):

11 Decrease in hemoglobin Decrease in hematocrit Extracellular Fluid Volume Excess Laboratory Findings:

12 Client may succumb from pulmonary edema Imbalance may occur with remobilization of edema fluid third post burn day If BUN and potassium are elevated, kidneys may be failing Extracellular Fluid Volume Excess Related Problems:

13 Extracellular Fluid Volume Excess Treatment: Sodium restricted diet Diuretics: Thiazides: Diural and Hydrodiuril Mild Inhibits sodium reabsorption in the Ascending Loop of Henel May need potassium supplement Decreases urinary calcium excretion

14 Diuretics (continued): Loop Diuretics: Lasix Potent Block sodium absorption from the Ascending Loop of Henel Need potassium supplement Increases calcium excretion May use for hypocalemia Extracellular Fluid Volume Excess Treatment:

15 Extracellular Fluid Volume Excess Potassium Conserving Diuretics: Aldactone and Dyrenium Inhibit action of Aldosterone, causing sodium excretion and potassium retention Act on the distal tubules to depress exchanges of sodium May cause potassium excess Treatment:

16 Daily weight Intake and output High Fowler’s position. Bed rest favors diuresis Assess breath sounds Monitor edema with millimeter tape Monitor venous distention Sodium restricted diet Skin care and turn frequently Extracellular Fluid Volume Excess Nursing Care:

17 Sodium Summary of Basic Facts Found in all body cells Gastric mucous, bile, intestinal juices and pancreatic juices all contain substantial sodium Functions of sodium: Regulates fluid volume within compartments Principally regulates ECF Main extracellular cation Maintains osmotic equilibrium between ECF and ICF Maintains blood volume and regulates size of vascular bed

18 Sodium Summary of Basic Facts (continued) Increases cell membrane permeability Aids in conduction of nerve impulses Helps control muscle contractibility, especially the heart Regulation of sodium: Mineral corticoids: Aldosterone which promotes sodium and water retention and potassium excretion Glucocorticoids: sodium absorption increased by acting on the distal tubules

19 Summary of Electrolytes ElectrolyteNeuro Function Sodium DeficitDecreased Sodium ExcessIncreased Potassium DeficitDecreased Potassium ExcessIncreased then Decreased Calcium DeficitIncreased Calcium ExcessDecreased

20 Sodium Deficit Preceding Events May develop from too little sodium or too much water Severe low Na diet Loss of sodium containing secretions without adequate replacement (G.I.) Use of loop diuretics Congestive Heart Failure Excessive administration of sodium free parenteral fluids Water intoxication

21 Sodium Deficit Clinical Observations: Vary greatly but often include: Apprehension, irritability, confusion, seizures, muscle spasms, coma (decrease in neuro) Decreased gastrointestinal mobility (abdominal cramps, diarrhea, nausea) (decrease in neuro) May include symptoms of hypervolemia

22 Sodium Deficit Clinical Observations (continued): Dizziness with position change (decrease in vasomotor) Postural hypo tension (decrease in vasomotor) Cold, clammy skin, thready pulse (vasomotor collapse) Finger printing over sternum (cells swell)

23 Sodium Deficit Laboratory Findings: Plasma sodium below 135 mEq/liter Specific gravity of urine below 1.010

24 Sodium Deficit Related Problems: Heat exhaustion in unacclimatized persons may result in sodium deficit (replacement with H 2 O) Sodium deficit may occur with excessive use of diuretics

25 Sodium Deficit Treatment: Restrict water intake Treat cause Increase oral sodium 3 to 5% NaCl IV (Usually not done)

26 Sodium Deficit Nursing Care: Monitor I & O Encourage high sodium foods Monitor symptoms and labs

27 Sodium Deficit (SIADH) Preceding Events: Trauma CNS disorders Certain malignancies Various pharmacological agents

28 Sodium Deficit (SIADH) Clinical Observations: Lethargy (decrease in neuro) Withdrawal (decrease in neuro) Convulsions (onset of cerebral edema) Coma (cerebral edema) Anorexia (decrease in GI mobility) Nausea (decrease in GI mobility) Vomiting (decrease in GI mobility) Abdominal cramps (decrease in GI)

29 Sodium Deficit (SIADH) Laboratory Findings: Urine osmolality exceeds that of plasma Plasma sodium below 120 mEq/liter Urine specific gravity above 1.012

30 Sodium Deficit (SIADH) Related Problems: Elevated osmolarity of urine differs from other forms of hyponatremia First indication of presence is often depressed plasma sodium Signs and symptoms often appear only after client is beyond help Great danger is cerebral edema, with herniation of brain

31 Sodium Deficit (SIADH) Treatment: Diuretics Hypertonic saline IV Decomycin and lithium carbonate which interferes with ADH at the renal tubules Dilantin which inhibits the release of ADH

32 Sodium Deficit (SIADH) Nursing Care: I and O Weight daily. Should decrease each day.

33 Sodium Excess Preceding Events: Decreased water intake (common in unconscious clients or others unable to perceive thirst) Increased urinary water losses when intake is inadequate High-protein tube feedings without adequate water supplements Osmotic diuresis in clients with hyperglycemia

34 Sodium Excess Preceding Events (continued): Neuro clients with diabetes insipidus (decrease in ADH) Excessive administration of sodium- containing parenteral solutions (e.g., 3% NaCl, or even isotonic saline; has occurred following use of NaHCO in clients with cardiac arrest) Drowning in salt water Tracheobronchitis (water loss)

35 Sodium Excess Clinical Observations: Intense thirst Tongue rough, red and dry Skin flushed Difficulty in speaking without first moistening lips Elevated temperature

36 Sodium Excess Clinical Observations (continued): Firm, rubbery tissue turgor (increase in Na draws H 2 O from ICF) Restlessness and excitement (increase in neuro) Agitation (may progress to mania and convulsions) (increase in neuro) Oliguria and anuria (increase in ADH)

37 Sodium Excess Laboratory Findings: Plasma sodium above 145 mEq/liter Specific gravity of urine above (if water loss is nonrenal)

38 Sodium Excess Related Problems: Often occurs following diarrhea of 5 or 6 days duration

39 Sodium Excess Treatment: High oral intake of water to decrease osmolarity of ECF Hypotonic IVs

40 Summary of Potassium Facts Potassium is the main cation in intracellular fluid Functions: Regulates intracellular osmolarity Necessary for all healing and growth Helps promote conduction of nerve impulses Promotes skeletal muscle impulses Promotes heart muscle function Component of many secretions Kidney excretes 90 to 95% of all potassium it comes in contact with

41 Summary of Potassium Facts (continued) Potassium moves into the cell when glucose is being metabolized Potassium moves out of the cell when: strenuous exercise occurs cell metabolism is impaired, cells die When potassium is lost sodium and hydrogen ions shift into the cell to maintain cellular tonicity and cells become more acid. If a large amount of sodium moves into the cell it will swell and break open

42 Potassium Deficit Preceding Events: Prolonged inadequate intake Use of potassium-losing diuretics without adequate potassium replacement Excessive loss of gastrointestinal fluids Prolonged stress Hyperaldosteronism (increase in K excretion) Increase in utilization

43 Potassium Deficit Clinical Observations: Chronic fatigue (decrease in neuro) Muscle weakness (neuromuscular symptoms not usually seen until serum potassium has decreased to approximately 2.5 mEq/liter) Soft. flabby skeletal muscles Gaseous intestinal distention (ileus) (decrease in neuro) Decreased bowel sounds (decrease in neuro)

44 Potassium Deficit Clinical Observations (continued): Paresthesia (decrease in neuro) Weak, irregular pulse (decrease in neuro) Increased sensitivity to digitalis With severe deficit, paralysis and heart block (decrease in neuro) Cause of death: apnea or heart block (decrease in neuro)

45 Potassium Deficit Laboratory Findings : Repeated plasma potassium below 3.5 mEq/liter Specific EKG findings: low voltage, flattening of T waves, depression ST segment (EKG changes likely when serum potassium is less than 3 mEq/liter) P - R T Normal P - R U Hypokalemia

46 Potassium Deficit Treatment: Potassium IV Increase potassium in diet through fruits and vegetables, but one would have to eat an enormous amount. For 40 mEqs one would have to eat 40 inches of bananas Salt substitutes contain potassium

47 Potassium Deficit Related Problems: Metabolic alkalosis frequently associated

48 Potassium Excess Preceding Events: Kidney failure (K retained) Excessive ingestion of potassium Excessive parenteral administration of potassium Leakage of potassium from cells (burns and crushing injury) Adrenal insufficiency (decrease in aldosterone) Excessive use of potassium-conserving diuretics

49 Potassium Excess Clinical Observations: MODERATE Slight irritability combined with anxiety (increase in neuro) Gastrointestinal hyperactivity (nausea, colic and diarrhea)

50 Potassium Excess Clinical Observations: SEVERE: Paresthesia (can occur at a level of 6 mEq/liter) (decrease in neuro) Weakness (decrease in neuro) Severe cardiac arrhythmias (bradycardia can occur at 7 mEq/liter, heart block at 9 mEq/liter) ( cardiac toxicity) Levels greater than 8.5 mEq/liter are often fatal (due to cardiac standstill or arrythmia)

51 Potassium Excess Laboratory Findings: Specific EKG findings Repeated plasma potassium above 5.6 mEq/liter P - R T T T U S R T Normal >6.5 >8.0

52 Potassium Excess Related Problems: Follows kidney failure Metabolic acidosis frequently associated (K leaves cells goes into ECF)

53 Potassium Excess Treatment: No oral or IV potassium IV calcium acts rapidly to antagonize the effects of potassium, but does not lower the serum potassium level IV sodium bicarbonate causes rapid movement of potassium into the cells Insulin also moves potassium into the cells, and decreases serum potassium

54 Calcium Summary Function: Decrease neuromuscular irritability or increase stability Decrease capillary permeability Promotes normal muscular contractility Promotes transmission of nerve impulses Essential for blood clotting Essential for bones and teeth

55 Calcium Summary Absorption of Calcium: Depends upon the presence of vitamin D Controlled by parathyroid hormone. There is an inverse relationship between calcium and phosphorus -Too much, or hyper secretion, causes an increase in blood calcium and a decrease in phosphorus -Too little, or hypo secretion, causes a decrease in blood calcium and an increase in phosphorus

56 Calcium Deficit Preceding Events: Loss of calcium-rich intestinal secretions Immobilization of calcium Parathyroid hormone deficit Phosphate reciprocity Decrease in intake

57 Calcium Deficit Clinical Observations: Numbness with tingling of fingers and circumoral region (increase in neuro) Hyperactive reflexes (increase in neuro) Muscle cramps (increase in neuro) Tetany (increase in neuro) Laryngeal stridor (increase in neuro) Convulsions (increase in neuro) Fractures due to bone porosity (seen in chronic hypocalcemia)

58 Calcium Deficit Clinical Observations (continued): Positive Trousseau’s sign (carpo spasm of hand when blood supply decreased or nerve stimulated by pressure) (increase in neuro)

59 Calcium Deficit Clinical Observations (continued): Chvostek’s sign positive (tapping facial nerve causes spasm of lip and cheek) (increase in neuro)

60 Calcium Deficit Laboratory Findings: Plasma calcium below 9 mg/dl or 2.25mmol/L

61 Calcium Deficit Related Problems Elevated phosphate Vitamin D deficiency Inadequate ultraviolet exposure

62 Calcium Deficit Treatment: IV Calcium (Calcium Gluconate) Synthetic parathormone Oral Calcium (Calcium Carbonate)

63 Calcium Deficit Nursing Care: Monitor airway for laryngeal spasm Calcium supplement. Best in divided doses Seizure precautions

64 Calcium Excess Preceding Events: Hyperparathyroidism Widespread bony metastasis Prolonged immobilization Excessive Vitamin D Multiple myeloma (bone destruction liberates Ca) Paget’s disease

65 Calcium Excess Clinical Observations: Anorexia (decrease in GI mobility) Nausea and vomiting (decrease in GI mobility) Hypotonic skeletal muscles (recall that calcium acts as a sedative at the myoneural junction) Lethargy (decrease in neuro)

66 Calcium Excess Clinical Observations (continued): Stupor (decrease in neuro) Coma (decrease in neuro) Cardiac arrest (decrease in neuro) Polydipsia and polyuria (flush kidney) Deep bony pain (decrease in calcification) Pain in flanks (related to kidney stones)

67 Calcium Excess Laboratory Findings: Plasma calcium above 2.75mmol/L or 11 mg/dl Radiographic examination shows generalized osteoporosis, widespread bone cavitations, radiopaque urinary stones Elevated BUN (due to fluid volume deficit or renal damage)

68 Calcium Excess Related Problems: Kidney damage caused by stones

69 Calcium Excess Treatment: Increase urinary excretion of calcium –Lasix –Hydration (3000 to 4000cc/day) –Ethacrynic acid (Edecrin) Synthetic Calcitonin Plicamycin (Mithracin) to inhibit bone reabsorption Low Calcium Diet Mobilization Pamidronate (Aredia ) to inhibit osteoclasts for malignancy


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