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Fluid, Electrolyte and Acid-Base Balance By Linda A. Martin, EdD, MSN APRN, BC, CNE.

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Presentation on theme: "Fluid, Electrolyte and Acid-Base Balance By Linda A. Martin, EdD, MSN APRN, BC, CNE."— Presentation transcript:

1 Fluid, Electrolyte and Acid-Base Balance By Linda A. Martin, EdD, MSN APRN, BC, CNE

2

3 Fluid Balance

4 General Concepts Intake = Output = Fluid Balance Intake = Output = Fluid Balance Sensible losses Sensible losses Urination Urination Defecation Defecation Wound drainage Wound drainage Insensible losses Insensible losses Evaporation from skin Evaporation from skin Respiratory loss from lungs Respiratory loss from lungs

5 Fluid Compartments Intracellular Intracellular 40% of body weight 40% of body weight Extracellular Extracellular 20% of body weight 20% of body weight Two types Two types INTERSTITIAL (between) INTERSTITIAL (between) INTRAVASCULAR (inside) INTRAVASCULAR (inside)

6 Age-Related Fluid Changes Full-term baby - 80% Full-term baby - 80% Lean Adult Male - 60% Lean Adult Male - 60% Aged client - 40% Aged client - 40%

7 Fluid and Electrolyte Transport PASSIVE TRANSPORT SYSTEMS PASSIVE TRANSPORT SYSTEMS Diffusion Diffusion Filtration Filtration Osmosis Osmosis ACTIVE TRANSPORT SYSTEM ACTIVE TRANSPORT SYSTEM Pumping Pumping Requires energy expenditure Requires energy expenditure

8 Diffusion Molecules move across a biological membrane from an area of higher to an area of lower concentration Molecules move across a biological membrane from an area of higher to an area of lower concentration Membrane types Membrane types Permeable Permeable Semi-permeable Semi-permeable Impermeable Impermeable

9 Filtration Movement of solute and solvent across a membrane caused by hydrostatic (water pushing) pressure Movement of solute and solvent across a membrane caused by hydrostatic (water pushing) pressure Occurs at the capillary level Occurs at the capillary level If normal pressure gradient changes (as occurs with right-sided heart failure) edema results from “third spacing” If normal pressure gradient changes (as occurs with right-sided heart failure) edema results from “third spacing”

10 Osmosis Movement of solvent from an area of lower solute concentration to one of higher concentration Movement of solvent from an area of lower solute concentration to one of higher concentration Occurs through a semipermeable membrane using osmotic (water pulling) pressure Occurs through a semipermeable membrane using osmotic (water pulling) pressure

11 Active Transport System Solutes can be moved against a concentration gradient Solutes can be moved against a concentration gradient Also called “pumping” Also called “pumping” Dependent on the presence of ATP Dependent on the presence of ATP

12 Fluid Types Isotonic Isotonic Hypotonic Hypotonic Hypertonic Hypertonic

13 Isotonic Solution No fluid shift because solutions are equally concentrated No fluid shift because solutions are equally concentrated Normal saline solution (0.9% NaCl) Normal saline solution (0.9% NaCl)

14 Hypotonic Solution Lower solute concentration Lower solute concentration Fluid shifts from hypotonic solution into the more concentrated solution to create a balance (cells swell) Fluid shifts from hypotonic solution into the more concentrated solution to create a balance (cells swell) Half-normal saline solution (0.45% NaCl) Half-normal saline solution (0.45% NaCl)

15 Hypertonic Solution Higher solute concentration Higher solute concentration Fluid is drawn into the hypertonic solution to create a balance (cells shrink) Fluid is drawn into the hypertonic solution to create a balance (cells shrink) 5% dextrose in normal saline (D5/0.9% NaCl) 5% dextrose in normal saline (D5/0.9% NaCl)

16 Regulatory Mechanisms Baroreceptor reflex Baroreceptor reflex Volume receptors Volume receptors Renin-angiotensin-aldosterone mechanism Renin-angiotensin-aldosterone mechanism Antidiuretic hormone Antidiuretic hormone

17 Baroreceptor Reflex Respond to a fall in arterial blood pressure Respond to a fall in arterial blood pressure Located in the atrial walls, vena cava, aortic arch and carotid sinus Located in the atrial walls, vena cava, aortic arch and carotid sinus Constricts afferent arterioles of the kidney resulting in retention of fluid Constricts afferent arterioles of the kidney resulting in retention of fluid

18 Volume Receptors Respond to fluid excess in the atria and great vessels Respond to fluid excess in the atria and great vessels Stimulation of these receptors creates a strong renal response that increases urine output Stimulation of these receptors creates a strong renal response that increases urine output

19 Renin-Angiotensin-Aldosterone Renin Renin Enzyme secreted by kidneys when arterial pressure or volume drops Enzyme secreted by kidneys when arterial pressure or volume drops Interacts with angiotensinogen to form angiotensin I (vasoconstrictor) Interacts with angiotensinogen to form angiotensin I (vasoconstrictor)

20 Renin-Angiotensin-Aldosterone Angiotensin Angiotensin Angiotensin I is converted in lungs to angiotensin II using ACE (angiotensin converting enzyme) Angiotensin I is converted in lungs to angiotensin II using ACE (angiotensin converting enzyme) Produces vasoconstriction to elevate blood pressure Produces vasoconstriction to elevate blood pressure Stimulates adrenal cortex to secrete aldosterone Stimulates adrenal cortex to secrete aldosterone

21 Renin-Angiotensin-Aldosterone Aldosterone Aldosterone Mineralocorticoid that controls Na+ and K+ blood levels Mineralocorticoid that controls Na+ and K+ blood levels Increases Cl- and HCO3- concentrations and fluid volume Increases Cl- and HCO3- concentrations and fluid volume

22 Aldosterone Negative Feedback Mechanism ECF & Na+ levels drop  secretion of ACTH by the anterior pituitary  release of aldosterone by the adrenal cortex  fluid and Na+ retention ECF & Na+ levels drop  secretion of ACTH by the anterior pituitary  release of aldosterone by the adrenal cortex  fluid and Na+ retention

23 Antidiuretic Hormone Also called vasopressin Also called vasopressin Released by posterior pituitary when there is a need to restore intravascular fluid volume Released by posterior pituitary when there is a need to restore intravascular fluid volume Release is triggered by osmoreceptors in the thirst center of the hypothalamus Release is triggered by osmoreceptors in the thirst center of the hypothalamus Fluid volume excess  decreased ADH Fluid volume excess  decreased ADH Fluid volume deficit  increased ADH Fluid volume deficit  increased ADH

24 Fluid Imbalances Dehydration Dehydration Hypovolemia Hypovolemia Hypervolemia Hypervolemia Water intoxication Water intoxication

25 Dehydration Loss of body fluids  increased concentration of solutes in the blood and a rise in serum Na+ levels Loss of body fluids  increased concentration of solutes in the blood and a rise in serum Na+ levels Fluid shifts out of cells into the blood to restore balance Fluid shifts out of cells into the blood to restore balance Cells shrink from fluid loss and can no longer function properly Cells shrink from fluid loss and can no longer function properly

26 Clients at Risk Confused Confused Comatose Comatose Bedridden Bedridden Infants Infants Elderly Elderly Enterally fed Enterally fed

27 What Do You See? Irritability Irritability Confusion Confusion Dizziness Dizziness Weakness Weakness Extreme thirst Extreme thirst  urine output  urine output Fever Fever Dry skin/mucous membranes Dry skin/mucous membranes Sunken eyes Sunken eyes Poor skin turgor Poor skin turgor Tachycardia Tachycardia

28 What Do We Do? Fluid Replacement - oral or IV over 48 hrs. Fluid Replacement - oral or IV over 48 hrs. Monitor symptoms and vital signs Monitor symptoms and vital signs Maintain I&O Maintain I&O Maintain IV access Maintain IV access Daily weights Daily weights Skin and mouth care Skin and mouth care

29 Hypovolemia Isotonic fluid loss from the extracellular space Isotonic fluid loss from the extracellular space Can progress to hypovolemic shock Can progress to hypovolemic shock Caused by: Caused by: Excessive fluid loss (hemorrhage) Excessive fluid loss (hemorrhage) Decreased fluid intake Decreased fluid intake Third space fluid shifting Third space fluid shifting

30 What Do You See? Mental status deterioration Mental status deterioration Thirst Thirst Tachycardia Tachycardia Delayed capillary refill Delayed capillary refill Orthostatic hypotension Orthostatic hypotension Urine output < 30 ml/hr Urine output < 30 ml/hr Cool, pale extremities Cool, pale extremities Weight loss Weight loss

31 What Do We Do? Fluid replacement Fluid replacement Albumin replacement Albumin replacement Blood transfusions for hemorrhage Blood transfusions for hemorrhage Dopamine to maintain BP Dopamine to maintain BP MAST trousers for severe shock MAST trousers for severe shock Assess for fluid overload with treatment Assess for fluid overload with treatment

32 Hypervolemia Excess fluid in the extracellular compartment as a result of fluid or sodium retention, excessive intake, or renal failure Excess fluid in the extracellular compartment as a result of fluid or sodium retention, excessive intake, or renal failure Occurs when compensatory mechanisms fail to restore fluid balance Occurs when compensatory mechanisms fail to restore fluid balance Leads to CHF and pulmonary edema Leads to CHF and pulmonary edema

33 What Do You See? Tachypnea Tachypnea Dyspnea Dyspnea Crackles Crackles Rapid, bounding pulse Rapid, bounding pulse Hypertension Hypertension S3 gallop S3 gallop Increased CVP, pulmonary artery pressure and pulmonary artery wedge pressure (Swan-Ganz) Increased CVP, pulmonary artery pressure and pulmonary artery wedge pressure (Swan-Ganz) JVD JVD Acute weight gain Acute weight gain Edema Edema

34 Edema Fluid is forced into tissues by the hydrostatic pressure Fluid is forced into tissues by the hydrostatic pressure First seen in dependent areas First seen in dependent areas Anasarca - severe generalized edema Anasarca - severe generalized edema Pitting edema Pitting edema Pulmonary edema Pulmonary edema

35 What Do We Do? Fluid and Na+ restriction Fluid and Na+ restriction Diuretics Diuretics Monitor vital signs Monitor vital signs Hourly I&O Hourly I&O Breath sounds Breath sounds Monitor ABGs and labs Monitor ABGs and labs Elevate HOB and give O2 as ordered Elevate HOB and give O2 as ordered Maintain IV access Maintain IV access Skin & mouth care Skin & mouth care Daily weights Daily weights

36 Water Intoxication Hypotonic extracellular fluid shifts into cells to attempt to restore balance Hypotonic extracellular fluid shifts into cells to attempt to restore balance Cells swell Cells swell Causes: Causes: SIADH SIADH Rapid infusion of hypotonic solution Rapid infusion of hypotonic solution Excessive tap water NG irrigation or enemas Excessive tap water NG irrigation or enemas Psychogenic polydipsia Psychogenic polydipsia

37 What Do You See? Signs and symptoms of increased intracranial pressure Signs and symptoms of increased intracranial pressure Early: change in LOC, N/V, muscle weakness, twitching, cramping Early: change in LOC, N/V, muscle weakness, twitching, cramping Late: bradycardia, widened pulse pressure, seizures, coma Late: bradycardia, widened pulse pressure, seizures, coma

38 What Do We Do? Prevention is the best treatment Prevention is the best treatment Assess neuro status Assess neuro status Monitor I&O and vital signs Monitor I&O and vital signs Fluid restrictions Fluid restrictions IV access IV access Daily weights Daily weights Monitor serum Na+ Monitor serum Na+ Seizure precautions Seizure precautions

39 Electrolytes

40 Electrolytes Charged particles in solution Charged particles in solution Cations (+) Cations (+) Anions (-) Anions (-) Integral part of metabolic and cellular processes Integral part of metabolic and cellular processes

41 Positive or Negative? Cations (+) Cations (+) Sodium Sodium Potassium Potassium Calcium Calcium Magnesium Magnesium Anions (-) Anions (-) Chloride Chloride Bicarbonate Bicarbonate Phosphate Phosphate Sulfate Sulfate

42 Major Cations EXTRACELLULAR EXTRACELLULAR SODIUM (Na+) SODIUM (Na+) INTRACELLULAR INTRACELLULAR POTASSIUM (K+) POTASSIUM (K+)

43 Electrolyte Imbalances Hyponatremia/ hypernatremia Hyponatremia/ hypernatremia Hypokalemia/ Hyperkalemia Hypokalemia/ Hyperkalemia Hypomagnesemia/ Hypermagnesemia Hypomagnesemia/ Hypermagnesemia Hypocalcemia/ Hypercalcemia Hypocalcemia/ Hypercalcemia Hypophosphatemia/ Hyperphosphatemia Hypophosphatemia/ Hyperphosphatemia Hypochloremia/ Hyperchloremia Hypochloremia/ Hyperchloremia

44 Sodium Major extracellular cation Major extracellular cation Attracts fluid and helps preserve fluid volume Attracts fluid and helps preserve fluid volume Combines with chloride and bicarbonate to help regulate acid-base balance Combines with chloride and bicarbonate to help regulate acid-base balance Normal range of serum sodium mEq/L Normal range of serum sodium mEq/L

45 Sodium and Water If sodium intake suddenly increases, extracellular fluid concentration also rises If sodium intake suddenly increases, extracellular fluid concentration also rises Increased serum Na+ increases thirst and the release of ADH, which triggers kidneys to retain water Increased serum Na+ increases thirst and the release of ADH, which triggers kidneys to retain water Aldosterone also has a function in water and sodium conservation when serum Na+ levels are low Aldosterone also has a function in water and sodium conservation when serum Na+ levels are low

46 Sodium-Potassium Pump Sodium (abundant outside cells) tries to get into cells Sodium (abundant outside cells) tries to get into cells Potassium (abundant inside cells) tries to get out of cells Potassium (abundant inside cells) tries to get out of cells Sodium-potassium pump maintains normal concentrations Sodium-potassium pump maintains normal concentrations Pump uses ATP, magnesium and an enzyme to maintain sodium-potassium concentrations Pump uses ATP, magnesium and an enzyme to maintain sodium-potassium concentrations Pump prevents cell swelling and creates an electrical charge allowing neuromuscular impulse transmission Pump prevents cell swelling and creates an electrical charge allowing neuromuscular impulse transmission

47 Hyponatremia Serum Na+ level < 135 mEq/L Serum Na+ level < 135 mEq/L Deficiency in Na+ related to amount of body fluid Deficiency in Na+ related to amount of body fluid Several types Several types Dilutional Dilutional Depletional Depletional Hypovolemic Hypovolemic Hypervolemic Hypervolemic Isovolemic Isovolemic

48 Types of Hyponatremia Dilutional - results from Na+ loss, water gain Dilutional - results from Na+ loss, water gain Depletional - insufficient Na+ intake Depletional - insufficient Na+ intake Hypovolemic - Na+ loss is greater than water loss; can be renal (diuretic use) or non-renal (vomiting) Hypovolemic - Na+ loss is greater than water loss; can be renal (diuretic use) or non-renal (vomiting) Hypervolemic - water gain is greater than Na+ gain; edema occurs Hypervolemic - water gain is greater than Na+ gain; edema occurs Isovolumic - normal Na+ level, too much fluid Isovolumic - normal Na+ level, too much fluid

49 What Do You See? Primarily neurologic symptoms Primarily neurologic symptoms Headache, N/V, muscle twitching, altered mental status, stupor, seizures, coma Headache, N/V, muscle twitching, altered mental status, stupor, seizures, coma Hypovolemia - poor skin turgor, tachycardia, decreased BP, orthostatic hypotension Hypovolemia - poor skin turgor, tachycardia, decreased BP, orthostatic hypotension Hypervolemia - edema, hypertension, weight gain, bounding tachycardia Hypervolemia - edema, hypertension, weight gain, bounding tachycardia

50 What Do We Do? MILD CASE MILD CASE Restrict fluid intake for hyper/isovolemic hyponatremia Restrict fluid intake for hyper/isovolemic hyponatremia IV fluids and/or increased po Na+ intake for hypovolemic hyponatremia IV fluids and/or increased po Na+ intake for hypovolemic hyponatremia SEVERE CASE SEVERE CASE Infuse hypertonic NaCl solution (3% or 5% NaCl) Infuse hypertonic NaCl solution (3% or 5% NaCl) Furosemide to remove excess fluid Furosemide to remove excess fluid Monitor client in ICU Monitor client in ICU

51 Hypernatremia Excess Na+ relative to body water Excess Na+ relative to body water Occurs less often than hyponatremia Occurs less often than hyponatremia Thirst is the body’s main defense Thirst is the body’s main defense When hypernatremia occurs, fluid shifts outside the cells When hypernatremia occurs, fluid shifts outside the cells May be caused by water deficit or over- ingestion of Na+ May be caused by water deficit or over- ingestion of Na+ Also may result from diabetes insipidus Also may result from diabetes insipidus

52 What Do You See? Think S-A-L-T Think S-A-L-T Skin flushed Skin flushed Agitation Agitation Low grade fever Low grade fever Thirst Thirst Neurological symptoms Neurological symptoms Signs of hypovolemia Signs of hypovolemia

53 What Do We Do? Correct underlying disorder Correct underlying disorder Gradual fluid replacement Gradual fluid replacement Monitor for s/s of cerebral edema Monitor for s/s of cerebral edema Monitor serum Na+ level Monitor serum Na+ level Seizure precautions Seizure precautions

54 Potassium Major intracellular cation Major intracellular cation Untreated changes in K+ levels can lead to serious neuromuscular and cardiac problems Untreated changes in K+ levels can lead to serious neuromuscular and cardiac problems Normal K+ levels = mEq/L Normal K+ levels = mEq/L

55 Balancing Potassium Most K+ ingested is excreted by the kidneys Most K+ ingested is excreted by the kidneys Three other influential factors in K+ balance : Three other influential factors in K+ balance : Na+/K+ pump Na+/K+ pump Renal regulation Renal regulation pH level pH level

56 Sodium/Potassium Pump Uses ATP to pump potassium into cells Uses ATP to pump potassium into cells Pumps sodium out of cells Pumps sodium out of cells Creates a balance Creates a balance

57 Renal Regulation Increased K+ levels  increased K+ loss in urine Increased K+ levels  increased K+ loss in urine Aldosterone secretion causes Na+ reabsorption and K+ excretion Aldosterone secretion causes Na+ reabsorption and K+ excretion

58 pH Potassium ions and hydrogen ions exchange freely across cell membranes Potassium ions and hydrogen ions exchange freely across cell membranes Acidosis  hyperkalemia (K+ moves out of cells) Acidosis  hyperkalemia (K+ moves out of cells) Alkalosis  hypokalemia (K+ moves into cells) Alkalosis  hypokalemia (K+ moves into cells)

59 Hypokalemia Serum K+ < 3.5 mEq/L Serum K+ < 3.5 mEq/L Can be caused by GI losses, diarrhea, insufficient intake, non-K+ sparing diuretics (thiazide, furosemide) Can be caused by GI losses, diarrhea, insufficient intake, non-K+ sparing diuretics (thiazide, furosemide)

60 What Do You See? Think S-U-C-T-I-O-N Think S-U-C-T-I-O-N Skeletal muscle weakness Skeletal muscle weakness U wave (EKG changes) U wave (EKG changes) Constipation, ileus Constipation, ileus Toxicity of digitalis glycosides Toxicity of digitalis glycosides Irregular, weak pulse Irregular, weak pulse Orthostatic hypotension Orthostatic hypotension Numbness (paresthesias) Numbness (paresthesias)

61 What Do We Do? Increase dietary K+ Increase dietary K+ Oral KCl supplements Oral KCl supplements IV K+ replacement IV K+ replacement Change to K+-sparing diuretic Change to K+-sparing diuretic Monitor EKG changes Monitor EKG changes

62 IV K+ Replacement Mix well when adding to an IV solution bag Mix well when adding to an IV solution bag Concentrations should not exceed mEq/L Concentrations should not exceed mEq/L Rates usually mEq/hr Rates usually mEq/hr NEVER GIVE IV PUSH POTASSIUM

63 Hyperkalemia Serum K+ > 5 mEq/L Serum K+ > 5 mEq/L Less common than hypokalemia Less common than hypokalemia Caused by altered kidney function, increased intake (salt substitutes), blood transfusions, meds (K+-sparing diuretics), cell death (trauma) Caused by altered kidney function, increased intake (salt substitutes), blood transfusions, meds (K+-sparing diuretics), cell death (trauma)

64 What Do You See? Irritability Irritability Paresthesia Paresthesia Muscle weakness (especially legs) Muscle weakness (especially legs) EKG changes (tented T wave) EKG changes (tented T wave) Irregular pulse Irregular pulse Hypotension Hypotension Nausea, abdominal cramps, diarrhea Nausea, abdominal cramps, diarrhea

65 What Do We Do? Mild Mild Loop diuretics (Lasix) Loop diuretics (Lasix) Dietary restriction Dietary restriction Moderate Moderate Kayexalate Kayexalate Emergency Emergency 10% calcium gluconate for cardiac effects 10% calcium gluconate for cardiac effects Sodium bicarbonate for acidosis Sodium bicarbonate for acidosis

66 Magnesium Helps produce ATP Helps produce ATP Role in protein synthesis & carbohydrate metabolism Role in protein synthesis & carbohydrate metabolism Helps cardiovascular system function (vasodilation) Helps cardiovascular system function (vasodilation) Regulates muscle contractions Regulates muscle contractions

67 Hypomagnesemia Serum Mg++ level < 1.5 mEq/L Serum Mg++ level < 1.5 mEq/L Caused by poor dietary intake, poor GI absorption, excessive GI/urinary losses Caused by poor dietary intake, poor GI absorption, excessive GI/urinary losses High risk clients High risk clients Chronic alcoholism Chronic alcoholism Malabsorption Malabsorption GI/urinary system disorders GI/urinary system disorders Sepsis Sepsis Burns Burns Wounds needing debridement Wounds needing debridement

68 What Do You See? CNS CNS Altered LOC Altered LOC Confusion Confusion Hallucinations Hallucinations

69 What Do You See? Neuromuscular Neuromuscular Muscle weakness Muscle weakness Leg/foot cramps Leg/foot cramps Hyper DTRs Hyper DTRs Tetany Tetany Chvostek’s & Trousseau’s signs Chvostek’s & Trousseau’s signs

70 What Do You See? Cardiovascular Cardiovascular Tachycardia Tachycardia Hypertension Hypertension EKG changes EKG changes

71 What Do You See? Gastrointestinal Gastrointestinal Dysphagia Dysphagia Anorexia Anorexia Nausea/vomiting Nausea/vomiting

72 What Do We Do? Mild Mild Dietary replacement Dietary replacement Severe Severe IV or IM magnesium sulfate IV or IM magnesium sulfate Monitor Monitor Neuro status Neuro status Cardiac status Cardiac status Safety Safety

73 Mag Sulfate Infusion Use infusion pump - no faster than 150 mg/min Use infusion pump - no faster than 150 mg/min Monitor vital signs for hypotension and respiratory distress Monitor vital signs for hypotension and respiratory distress Monitor serum Mg++ level q6h Monitor serum Mg++ level q6h Cardiac monitoring Cardiac monitoring Calcium gluconate as an antidote for overdosage Calcium gluconate as an antidote for overdosage

74 Hypermagnesemia Serum Mg++ level > 2.5 mEq/L Serum Mg++ level > 2.5 mEq/L Not common Not common Renal dysfunction is most common cause Renal dysfunction is most common cause Renal failure Renal failure Addison’s disease Addison’s disease Adrenocortical insufficiency Adrenocortical insufficiency Untreated DKA Untreated DKA

75 What Do You See? Decreased neuromuscular activity Decreased neuromuscular activity Hypoactive DTRs Hypoactive DTRs Generalized weakness Generalized weakness Occasionally nausea/vomiting Occasionally nausea/vomiting

76 What Do We Do? Increased fluids if renal function normal Increased fluids if renal function normal Loop diuretic if no response to fluids Loop diuretic if no response to fluids Calcium gluconate for toxicity Calcium gluconate for toxicity Mechanical ventilation for respiratory depression Mechanical ventilation for respiratory depression Hemodialysis (Mg++-free dialysate) Hemodialysis (Mg++-free dialysate)

77 Calcium 99% in bones, 1% in serum and soft tissue (measured by serum Ca++) 99% in bones, 1% in serum and soft tissue (measured by serum Ca++) Works with phosphorus to form bones and teeth Works with phosphorus to form bones and teeth Role in cell membrane permeability Role in cell membrane permeability Affects cardiac muscle contraction Affects cardiac muscle contraction Participates in blood clotting Participates in blood clotting

78 Calcium Regulation Affected by body stores of Ca++ and by dietary intake & Vitamin D intake Affected by body stores of Ca++ and by dietary intake & Vitamin D intake Parathyroid hormone draws Ca++ from bones increasing low serum levels (Parathyroid pulls) Parathyroid hormone draws Ca++ from bones increasing low serum levels (Parathyroid pulls) With high Ca++ levels, calcitonin is released by the thyroid to inhibit calcium loss from bone (Calcitonin keeps) With high Ca++ levels, calcitonin is released by the thyroid to inhibit calcium loss from bone (Calcitonin keeps)

79 Hypocalcemia Serum calcium < 8.9 mg/dl Serum calcium < 8.9 mg/dl Ionized calcium level < 4.5 mg/Dl Ionized calcium level < 4.5 mg/Dl Caused by inadequate intake, malabsorption, pancreatitis, thyroid or parathyroid surgery, loop diuretics, low magnesium levels Caused by inadequate intake, malabsorption, pancreatitis, thyroid or parathyroid surgery, loop diuretics, low magnesium levels

80 What Do You See? Neuromuscular Neuromuscular Anxiety, confusion, irritability, muscle twitching, paresthesias (mouth, fingers, toes), tetany Anxiety, confusion, irritability, muscle twitching, paresthesias (mouth, fingers, toes), tetany Fractures Fractures Diarrhea Diarrhea Diminished response to digoxin Diminished response to digoxin EKG changes EKG changes

81 What Do We Do? Calcium gluconate for postop thyroid or parathyroid client Calcium gluconate for postop thyroid or parathyroid client Cardiac monitoring Cardiac monitoring Oral or IV calcium replacement Oral or IV calcium replacement

82 Hypercalcemia Serum calcium > 10.1 mg/dl Serum calcium > 10.1 mg/dl Ionized calcium > 5.1 mg/dl Ionized calcium > 5.1 mg/dl Two major causes Two major causes Cancer Cancer Hyperparathyroidism Hyperparathyroidism

83 What Do You See? Fatigue, confusion, lethargy, coma Fatigue, confusion, lethargy, coma Muscle weakness, hyporeflexia Muscle weakness, hyporeflexia Bradycardia  cardiac arrest Bradycardia  cardiac arrest Anorexia, nausea/vomiting, decreased bowel sounds, constipation Anorexia, nausea/vomiting, decreased bowel sounds, constipation Polyuria, renal calculi, renal failure Polyuria, renal calculi, renal failure

84 What Do We Do? If asymptomatic, treat underlying cause If asymptomatic, treat underlying cause Hydrate the patient to encourage diuresis Hydrate the patient to encourage diuresis Loop diuretics Loop diuretics Corticosteroids Corticosteroids

85 Phosphorus The primary anion in the intracellular fluid The primary anion in the intracellular fluid Crucial to cell membrane integrity, muscle function, neurologic function and metabolism of carbs, fats and protein Crucial to cell membrane integrity, muscle function, neurologic function and metabolism of carbs, fats and protein Functions in ATP formation, phagocytosis, platelet function and formation of bones and teeth Functions in ATP formation, phagocytosis, platelet function and formation of bones and teeth

86 Hypophosphatemia Serum phosphorus < 2.5 mg/dl Serum phosphorus < 2.5 mg/dl Can lead to organ system failure Can lead to organ system failure Caused by respiratory alkalosis (hyperventilation), insulin release, malabsorption, diuretics, DKA, elevated parathyroid hormone levels, extensive burns Caused by respiratory alkalosis (hyperventilation), insulin release, malabsorption, diuretics, DKA, elevated parathyroid hormone levels, extensive burns

87 What Do You See? Musculoskeletal Musculoskeletal muscle weakness muscle weakness respiratory muscle failure respiratory muscle failure osteomalacia osteomalacia pathological fractures pathological fractures CNS CNS confusion, anxiety, seizures, coma confusion, anxiety, seizures, coma Cardiac Cardiac hypotension hypotension decreased cardiac output decreased cardiac output Hematologic Hematologic hemolytic anemia hemolytic anemia easy bruising easy bruising infection risk infection risk

88 What Do We Do? MILD/MODERATE MILD/MODERATE Dietary interventions Dietary interventions Oral supplements Oral supplements SEVERE SEVERE IV replacement using potassium phosphate or sodium phosphate IV replacement using potassium phosphate or sodium phosphate

89 Hyperphosphatemia Serum phosphorus > 4.5 mg/dl Serum phosphorus > 4.5 mg/dl Caused by impaired kidney function, cell damage, hypoparathyroidism, respiratory acidosis, DKA, increased dietary intake Caused by impaired kidney function, cell damage, hypoparathyroidism, respiratory acidosis, DKA, increased dietary intake

90 What Do You See? Think C-H-E-M-O Think C-H-E-M-O Cardiac irregularities Cardiac irregularities Hyperreflexia Hyperreflexia Eating poorly Eating poorly Muscle weakness Muscle weakness Oliguria Oliguria

91 What Do We Do? Low-phosphorus diet Low-phosphorus diet Decrease absorption with antacids that bind phosphorus Decrease absorption with antacids that bind phosphorus Treat underlying cause of respiratory acidosis or DKA Treat underlying cause of respiratory acidosis or DKA IV saline for severe hyperphosphatemia in patients with good kidney function IV saline for severe hyperphosphatemia in patients with good kidney function

92 Chloride Major extracellular anion Major extracellular anion Sodium and chloride maintain water balance Sodium and chloride maintain water balance Secreted in the stomach as hydrochloric acid Secreted in the stomach as hydrochloric acid Aids carbon dioxide transport in blood Aids carbon dioxide transport in blood

93 Hypochloremia Serum chloride < 96 mEq/L Serum chloride < 96 mEq/L Caused by decreased intake or decreased absorption, metabolic alkalosis, and loop, osmotic or thiazide diuretics Caused by decreased intake or decreased absorption, metabolic alkalosis, and loop, osmotic or thiazide diuretics

94 What Do You See? Agitation, irritability Agitation, irritability Hyperactive DTRs, tetany Hyperactive DTRs, tetany Muscle cramps, hypertonicity Muscle cramps, hypertonicity Shallow, slow respirations Shallow, slow respirations Seizures, coma Seizures, coma Arrhythmias Arrhythmias

95 What Do We Do? Treat underlying cause Treat underlying cause Oral or IV replacement in a sodium chloride or potassium chloride solution Oral or IV replacement in a sodium chloride or potassium chloride solution

96 Hyperchloremia Serum chloride > 106 mEq/L Serum chloride > 106 mEq/L Rarely occurs alone Rarely occurs alone Caused by dehydration, renal failure, respiratory alkalosis, salicylate toxicity, hyperpara-thyroidism, hyperaldosteronism, hypernatremia Caused by dehydration, renal failure, respiratory alkalosis, salicylate toxicity, hyperpara-thyroidism, hyperaldosteronism, hypernatremia

97 What Do You See? Metabolic Acidosis Metabolic Acidosis Decreased LOC Decreased LOC Kussmaul’s respirations Kussmaul’s respirations Weakness Weakness Hypernatremia Hypernatremia Agitation Agitation Tachycardia, dyspnea, tachypnea, HTN Tachycardia, dyspnea, tachypnea, HTN Edema Edema

98 What Do We Do? Correct underlying cause Correct underlying cause Restore fluid, electrolyte and acid-base balance Restore fluid, electrolyte and acid-base balance IV Lactated Ringer’s solution to correct acidosis IV Lactated Ringer’s solution to correct acidosis

99 Acid-Base Balance

100 Acid-Base Basics Balance depends on regulation of free hydrogen ions Balance depends on regulation of free hydrogen ions Concentration of hydrogen ions is measured in pH Concentration of hydrogen ions is measured in pH Arterial blood gases are the major diagnostic tool for evaluating acid- base balance Arterial blood gases are the major diagnostic tool for evaluating acid- base balance

101 Arterial Blood Gases pH pH PaCO mmHg PaCO mmHg HCO mEq/L HCO mEq/L

102 Acidosis pH < 7.35 pH < 7.35 Caused by accumulation of acids or by a loss of bases Caused by accumulation of acids or by a loss of bases

103 Alkalosis pH > 7.45 pH > 7.45 Occurs when bases accumulate or acids are lost Occurs when bases accumulate or acids are lost

104 Regulatory Systems Three systems come into play when pH rises or falls Three systems come into play when pH rises or falls Chemical buffers Chemical buffers Respiratory system Respiratory system Kidneys Kidneys

105 Chemical Buffers Immediate acting Immediate acting Combine with offending acid or base to neutralize harmful effects until another system takes over Combine with offending acid or base to neutralize harmful effects until another system takes over Bicarb buffer - mainly responsible for buffering blood and interstitial fluid Bicarb buffer - mainly responsible for buffering blood and interstitial fluid Phosphate buffer - effective in renal tubules Phosphate buffer - effective in renal tubules Protein buffers - most plentiful - hemoglobin Protein buffers - most plentiful - hemoglobin

106 Respiratory System Lungs regulate blood levels of CO2 Lungs regulate blood levels of CO2 CO2 + H2O = Carbonic acid CO2 + H2O = Carbonic acid High CO2 = slower breathing (hold on to carbonic acid and lower pH) High CO2 = slower breathing (hold on to carbonic acid and lower pH) Low CO2 = faster breathing (blow off carbonic acid and raise pH) Low CO2 = faster breathing (blow off carbonic acid and raise pH) Twice as effective as chemical buffers, but effects are temporary Twice as effective as chemical buffers, but effects are temporary

107 Kidneys Reabsorb or excrete excess acids or bases into urine Reabsorb or excrete excess acids or bases into urine Produce bicarbonate Produce bicarbonate Adjustments by the kidneys take hours to days to accomplish Adjustments by the kidneys take hours to days to accomplish Bicarbonate levels and pH levels increase or decrease together Bicarbonate levels and pH levels increase or decrease together

108 Arterial Blood Gases (ABG) Uses blood from an arterial puncture Uses blood from an arterial puncture Three test results relate to acid-base balance Three test results relate to acid-base balance pH pH PaCO2 PaCO2 HCO3 HCO3

109 Interpreting ABGs Step 1 - check the pH Step 1 - check the pH Step 2 - What is the CO2? Step 2 - What is the CO2? Step 3 - Watch the bicarb Step 3 - Watch the bicarb Step 4 - Look for compensation Step 4 - Look for compensation Step 5 - What is the PaO2 and SaO2? Step 5 - What is the PaO2 and SaO2?

110 Step 1 - Check the pH pH < 7.35 = acidosis pH < 7.35 = acidosis pH > 7.45 = alkalosis pH > 7.45 = alkalosis Move on to Step 2 Move on to Step 2

111 Step 2 - What is the CO2? PaCO2 gives info about the respiratory component of acid-base balance PaCO2 gives info about the respiratory component of acid-base balance If abnormal, does the change correspond with change in pH? If abnormal, does the change correspond with change in pH? High pH expects low PaCO2 (hypocapnia) High pH expects low PaCO2 (hypocapnia) Low pH expects high PaCO2 (hypercapnia) Low pH expects high PaCO2 (hypercapnia)

112 Step 3 – Watch the Bicarb Provides info regarding metabolic aspect of acid-base balance Provides info regarding metabolic aspect of acid-base balance If pH is high, bicarb expected to be high (metabolic alkalosis) If pH is high, bicarb expected to be high (metabolic alkalosis) If pH is low, bicarb expected to be low (metabolic acidosis) If pH is low, bicarb expected to be low (metabolic acidosis)

113 Step 4 – Look for Compensation If a change is seen in BOTH PaCO2 and bicarbonate, the body is trying to compensate If a change is seen in BOTH PaCO2 and bicarbonate, the body is trying to compensate Compensation occurs as opposites, (Example: for metabolic acidosis, compensation shows respiratory alkalosis) Compensation occurs as opposites, (Example: for metabolic acidosis, compensation shows respiratory alkalosis)

114 Step 5 – What is the PaO2 and SaO2 PaO2 reflects ability to pickup O2 from lungs PaO2 reflects ability to pickup O2 from lungs SaO2 less than 95% is inadequate oxygenation SaO2 less than 95% is inadequate oxygenation Low PaO2 indicates hypoxemia Low PaO2 indicates hypoxemia

115 Acid-Base Imbalances Respiratory Acidosis Respiratory Acidosis Respiratory Alkalosis Respiratory Alkalosis Metabolic Acidosis Metabolic Acidosis Metabolic Alkalosis Metabolic Alkalosis

116 Respiratory Acidosis Any compromise in breathing can result in respiratory acidosis Any compromise in breathing can result in respiratory acidosis Hypoventilation  carbon dioxide buildup and drop in pH Hypoventilation  carbon dioxide buildup and drop in pH Can result from neuromuscular trouble, depression of the brain’s respiratory center, lung disease or airway obstruction Can result from neuromuscular trouble, depression of the brain’s respiratory center, lung disease or airway obstruction

117 Clients At Risk Post op abdominal surgery Post op abdominal surgery Mechanical ventilation Mechanical ventilation Analgesics or sedation Analgesics or sedation

118 What Do You See? Apprehension, restlessness Apprehension, restlessness Confusion, tremors Confusion, tremors Decreased DTRs Decreased DTRs Diaphoresis Diaphoresis Dyspnea, tachycardia Dyspnea, tachycardia N/V, warm flushed skin N/V, warm flushed skin

119 ABG Results Uncompensated Uncompensated pH < 7.35 pH < 7.35 PaCO2 >45 PaCO2 >45 HCO3 Normal HCO3 Normal Compensated Compensated pH Normal pH Normal PaCO2 >45 PaCO2 >45 HCO3 > 26 HCO3 > 26

120 What Do We Do? Correct underlying cause Correct underlying cause Bronchodilators Bronchodilators Supplemental oxygen Supplemental oxygen Treat hyperkalemia Treat hyperkalemia Antibiotics for infection Antibiotics for infection Chest PT to remove secretions Chest PT to remove secretions Remove foreign body obstruction Remove foreign body obstruction

121 Respiratory Alkalosis Most commonly results from hyperventilation caused by pain, salicylate poisoning, use of nicotine or aminophylline, hypermetabolic states or acute hypoxia (overstimulates the respiratory center) Most commonly results from hyperventilation caused by pain, salicylate poisoning, use of nicotine or aminophylline, hypermetabolic states or acute hypoxia (overstimulates the respiratory center)

122 What Do You See? Anxiety, restlessness Anxiety, restlessness Diaphoresis Diaphoresis Dyspnea (  rate and depth) Dyspnea (  rate and depth) EKG changes EKG changes Hyperreflexia, paresthesias Hyperreflexia, paresthesias Tachycardia Tachycardia Tetany Tetany

123 ABG Results Uncompensated Uncompensated pH > 7.45 pH > 7.45 PaCO2 < 35 PaCO2 < 35 HCO3 Normal HCO3 Normal Compensated Compensated pH Normal pH Normal PaCO2 < 35 PaCO2 < 35 HCO3 < 22 HCO3 < 22

124 What Do We Do? Correct underlying disorder Correct underlying disorder Oxygen therapy for hypoxemia Oxygen therapy for hypoxemia Sedatives or antianxiety agents Sedatives or antianxiety agents Paper bag breathing for hyperventilation Paper bag breathing for hyperventilation

125 Metabolic Acidosis Characterized by gain of acid or loss of bicarb Characterized by gain of acid or loss of bicarb Associated with ketone bodies Associated with ketone bodies Diabetes mellitus, alcoholism, starvation, hyperthyroidism Diabetes mellitus, alcoholism, starvation, hyperthyroidism Other causes Other causes Lactic acidosis secondary to shock, heart failure, pulmonary disease, hepatic disease, seizures, strenuous exercise Lactic acidosis secondary to shock, heart failure, pulmonary disease, hepatic disease, seizures, strenuous exercise

126 What Do You See? Confusion, dull headache Confusion, dull headache Decreased DTRs Decreased DTRs S/S hyperkalemia (abdominal cramps, diarrhea, muscle weakness, EKG changes) S/S hyperkalemia (abdominal cramps, diarrhea, muscle weakness, EKG changes) Hypotension, Kussmaul’s respirations Hypotension, Kussmaul’s respirations Lethargy, warm & dry skin Lethargy, warm & dry skin

127 ABG Results Uncompensated Uncompensated pH < 7.35 pH < 7.35 PaCO2 Normal PaCO2 Normal HCO3 < 22 HCO3 < 22 Compensated Compensated pH Normal pH Normal PaCO2 < 35 PaCO2 < 35 HCO3 < 22 HCO3 < 22

128 What Do We Do? Regular insulin to reverse DKA Regular insulin to reverse DKA IV bicarb to correct acidosis IV bicarb to correct acidosis Fluid replacement Fluid replacement Dialysis for drug toxicity Dialysis for drug toxicity Antidiarrheals Antidiarrheals

129 Metabolic Alkalosis Commonly associated with hypokalemia from diuretic use, hypochloremia and hypocalcemia Commonly associated with hypokalemia from diuretic use, hypochloremia and hypocalcemia Also caused by excessive vomiting, NG suction, Cushing’s disease, kidney disease or drugs containing baking soda Also caused by excessive vomiting, NG suction, Cushing’s disease, kidney disease or drugs containing baking soda

130 What Do You See? Anorexia Anorexia Apathy Apathy Confusion Confusion Cyanosis Cyanosis Hypotension Hypotension Loss of reflexes Loss of reflexes Muscle twitching Muscle twitching Nausea Nausea Paresthesia Paresthesia Polyuria Polyuria Vomiting Vomiting Weakness Weakness

131 ABG Results Uncompensated Uncompensated pH > 7.45 pH > 7.45 PaCO2 Normal PaCO2 Normal HCO3 >26 HCO3 >26 Compensated Compensated pH Normal pH Normal PaCO2 > 45 PaCO2 > 45 HCO3 > 26 HCO3 > 26

132 What Do We Do? IV ammonium chloride IV ammonium chloride D/C thiazide diuretics and NG suctioning D/C thiazide diuretics and NG suctioning Antiemetics Antiemetics

133 IV Therapy Crystalloids – volume expander Crystalloids – volume expander Isotonic (D5W, 0.9% NaCl or Lactated Ringers) Isotonic (D5W, 0.9% NaCl or Lactated Ringers) Hypotonic (0.45% NaCl) Hypotonic (0.45% NaCl) Hypertonic (D5/0.9% NaCl, D5/0.45% NaCl) Hypertonic (D5/0.9% NaCl, D5/0.45% NaCl) Colloids – plasma expander (draw fluid into the bloodstream) Colloids – plasma expander (draw fluid into the bloodstream) Albumin Albumin Plasma protein Plasma protein Dextran Dextran

134 Total Parenteral Nutrition Highly concentrated Highly concentrated Hypertonic solution Hypertonic solution Used for clients with high caloric and nutritional needs Used for clients with high caloric and nutritional needs Solution contains electrolytes, vitamins, acetate, micronutrients and amino acids Solution contains electrolytes, vitamins, acetate, micronutrients and amino acids Lipid emulsions given in addition Lipid emulsions given in addition

135 The End (Whew!!!!!!)


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