1. Fluid & Electrolytes Acid Base Imbalances Chapter 17
Megan McClintock
Winter 2012
Fluid & Electrolytes Acid Base Imbalances Chapter 17

2. Homeostasis
Maintained by the intake and output of water and electrolytes and regulation by the renal and pulmonary systems
Acid-base balance is necessary for many physiologic processes (respiration, metabolism, function of the CNS)
Many disease and treatments affect this balance
Body fluids are in constant motion transporting nutrients, electrolytes, and oxygen to cells while carrying away waste products
Imbalance can be caused by illness, altered fluid intake, prolonged vomiting or diarrhea
Metastatic breast cancer causes hypercalcemia, chemo is given which causes nausea/vomiting which causes decreased sodium so IV fluids are given but they cause fluid overload

3. Water More important to life than any other nutrient
60% of an adult’s body weight, more in a child, less in the elderly
Found in foods (but not in alcohol)
Daily need is about 2000 mL
1 liter of water weighs 1 kg
Can survive only a few days without water
Water carries nutrients and waste products, participates in metabolic reactions and food digestion, solvent for minerals, vitamins, amino acids, glucose, lubricant and cushion around joints, eyes, spinal cord, aids in regulation of normal body temp, maintains blood volume
Fat cells have less water than lean tissue
60% of an adult’s body weight is water, more in a child and less in the elderly – Why is this important? These populations are at higher risk of F&E imbalances
Daily need is mL, found in foods too (not alcohol )
1 Liter of water weights 1 kg – Why is this important? Sudden change in weight is a good indicator of fluid volume
Water loss occurs in 4 organs
Kidneys ( ml in urine)
Skin ( ml, increases with fever, burns, sweating)
Lungs (400 ml, through act of breathing)
GI tract ( ml, in feces or large amounts through vomiting and diarrhea)
(body fluid compartment is covered on another slide)

4. Urine specific gravity
Measures the kidney’s ability to concentrate or dilute urine
1.002 – 1.028
High is dehydrated
Low is overhydrated (or unable to concentrate)
Kidney failure often causes a fixed specific gravity
Serum osmolality is more exact but requires a blood draw
The more concentrated the urine the higher the specific gravity
Some types of kidney damage will cause low SG even though there is very little urine out
Normally SG varies from morning to evening but kidney failure leaves SG at

5. Electrolytes Cations (positively charged) Anions (negatively charged)
K+, Na+, Ca+, Mg+
Transmit nerve impulses to muscles and contract skeletal and smooth muscles
Anions (negatively charged)
Attached to cations
Cl-, HCO3-, PO4-, SO4-
Are always kept in balance
Cations – remember “t” in positive and in cation
Anions – remember “n” in negative and anion
If a positive leaves than another positive must come in or a negative must also leave
Commonly measure in milliequivalents (mEq)

6. Distribution of body fluids & Electrolytes
Intracellular (2/3) – K+, PO4-
Extracellular (1/3) – Na+, Cl-
Interstitial (lymph)
Intravascular (blood plasma)
Transcellular (cerebrospinal, pleural, peritoneal, synovial fluids)
Cells must maintain a balance of 2/3 body fluids inside the cell (intracellular) and 1/3 body fluid outside the cell, if too much water enters then the cell can rupture, if too much water leaves then the cell dehydrates and collapses, movement of major minerals controls the movement of water
If an anion enters the fluid a cation must accompany it or another anion must leave so electrical neutrality is maintained, if Na+ and K+ are moving they go in opposite directions – everywhere sodium goes, water follows
Some live outside cells (sodium, chloride), some live inside cells (K, Mg, PO4, SO4) – cell membranes are selectively permeable (allowing some molecules through but not others), whenever electrolytes move then water follows, proteins attract water and regulate fluid movement, regulation also occurs in the GI tract and kidneys

7. Regulation of Fluid & Electrolyte Movement
Fluids and electrolytes constantly shift from compartment to compartment to facilitate body processes such as tissue oxygenation, acid-base balance, and urine formation. Because cell membranes separating the body fluid compartments are selectively permeable, water can pass through them easily. However, most ions and molecules pass through them more slowly. Fluids and solutes move across these membranes by four processes: osmosis, diffusion, filtration, and active transport.
Diffusion – Like melting a lump of sugar into a cup of water, requires no external energy
Facilitated diffusion – can accelerate the rate of diffusion with a carrier molecule (ie. Glucose transport into the cell), requires no external energy
Osmosis – movement of water between two compartments separated by a semipermeable membrane, requires no external energy, serum osmolality tells us the water balance in the body
Diffusion and osmosis are important in maintaining fluid volume of cells
Active transport – molecules have to move against the concentration gradient requiring external energy, sodium-potassium pump requiring ATP

8. Osmolality Indicates the water balance of the body
Serum osmolality ( )
High is water deficit
Low is water excess
Urine osmolality ( )
High is concentrated
Low is dilute
Serum osmolality tells us the water balance of the body (results are different for urine), if lower is hypo-osmolar (dilute), if higher it is hyper-osmolar (concentrated)
Mostly determined by sodium and glucose levels
Urine osmolality – high is concentrated, low is dilute

9. Fluid Spacing First spacing Second spacing Third spacing Normal Edema
Ascites
Burn edema
When capillary or interstitial pressures change, fluid can shift from one compartment to another
*Plasma to interstitial fluid (edema)
Caused by:
- increased venous hydrostatic pressure so nothing can get into the capillary (ie. Fluid overload, heart failure, liver failure, varicose veins, restrictive clothing, tourniquets)
Decreased plasma oncotic pressure so fluid can’t be drawn back into the capillary (ie. Low protein, renal problems, malnutrition)
Increased interstitial oncotic pressure so capillary walls are damaged and proteins accumulate (ie. Trauma, burns, inflammation)
*Interstitial fluid to plasma
Administration of colloids, dextran, mannitol, hypertonic solutions
Increased tissue hydrostatic pressure (ie. SCDs, TED hose)
Fluid spacing is the distribution of body water
Fluid shifts if capillary or interstitial pressures are altered (ie. Edema, dehydration)
First spacing – normal distribution of fluid in ICF and ECF
Second spacing – abnormal accumulation of interstitial fluid (ie. Edema)
Third spacing – fluid accumulation in part of body where it is not easily exchanged with ECF (trapped – ie. Ascites, sequestration with peritonitis, edema with burns) fluid is trapped and unavailable for use

10. Regulation of Water Balance
Hypothalmic Regulation
Thirst is stimulated
ADH (vasopressin) release is stimulated
Pituitary Regulation
ADH (vasopressin) is released
Adrenal Cortical Regulation
Glucocorticoids & mineralocorticoids are released
Renal Regulation
Adjust urine volume and electrolyte excretion
Normal is 1.5 Liters of urine/day
Hypothalmus - when the blood becomes concentrated (having lost water but not the dissolved substances in it – ie. eating something salty) the mouth gets dry and the hypothalamus initiates drinking behavior, but thirst lags behind the body’s need; can also be stimulated with hypovolemia from excessive vomiting or hemorrhage, thirst is decreased in the elderly Important because people who don’t recognize thirst (ie. Comatose) are at risk
Pituitary – releases ADH which causes the body to retain water; (also called vasopressin) whenever BP or blood volume falls too low or extracellular fluid becomes too concentrated they hypothalamus signals the pituitary gland to release ADH, this is a water conserving hormone that stimulates the kidneys to reabsorb water, so the more water you need the less your kidneys excrete decreasing urine output temporarily which also triggers thirst; stress, nausea, nicotine and morphine can also stimulate ADH release (SIADH causing the kidneys to reabsorb water and not excrete it in the urine, leading to water retention, decreased osmolality, and decreased urine output) (Too little ADH leads to diabetes insipidus with increased urine output that is dilute, increased thirst, and dehydration)
Adrenal Cortex – releases cortisol and aldosterone which causes the body to retain sodium and excrete potassium, when sodium is reabsorbed water is also reabsorbed
Kidney - primary organ for regulating fluid and electrolyte balance by adjusting urine volume and urinary excretion of electrolytes, renin is released causing the body to retain sodium; cells in the kidney release renin in response to low blood pressure causing the kidneys to reabsorb sodium, sodium reabsorption is always accompanied by water retention which restores blood volume and BP, also causes production of angiotensin which constricts blood vessel and raises BP, renal function is decreased in the elderly leading to increased risk of F&E problems (ie. can’t concentrate urine)

11. Regulation of water balance (cont.)
Cardiac Regulation
ANP & BNP will stop the action of the adrenal cortex and the kidney
GI Regulation
Intake and output are reabsorbed here
Diarrhea and vomiting can lead to significant losses
Insensible Water Loss
mL/day from the lungs and skin
Increases with fever, exercise

12. Gerontologic considerations
Structural changes in the kidney and decreased renal blood flow
Decreased GFR
Decreased creatinine clearance
Loss of ability to concentrate urine and thus conserve water
Decrease in renin and aldosterone
Increase in ADH and ANP
Loss of subcutaneous tissue
Decrease in thirst mechanism
Musculoskeletal changes
Mental status changes
Incontinence
Decrease in renin/aldosterone means the body can’t retain sodium or excrete potassium
Increased ADH means more water is reabsorbed
Increased ANP means more sodium and water are excreted which lowers blood volume and blood pressure
Loss of subcu tissue means increased loss of moisture through the skin
Musculoskeletal changes may mean an inability to hold a glass
Mental status changes may mean confusion or disorientation
Incontinence may cause older adults to intentionally decrease their fluid intake

13. What causes it? What can you do? Fluid Volume Deficit
Fluid volume imbalances are typically accompanied by electrolyte imbalances; sudden body weight change is an excellent indicator of overall fluid volume loss or gain (1 liter = 2.2 lbs or 1 kg)
Fluid volume deficit – dehydration, hypovolemia
Infants, clients with neurological or psychological problems, and some older adults who are unable to perceive or respond to the thirst mechanism are at risk for dehydration
Causes – vomiting, diarrhea, hemorrhage, sweating, fever, dehydration, use of diuretics, administration of hypertonic solutions or tube feedings, heat exhaustion/stroke, plasma to interstitial fluid shift
Signs/symptoms – low BP, high pulse, dry mouth, thirst, rapid weight loss, confusion, lethargy, low urine output
Lab values – urine specific gravity > 1.030, increased hematocrit (except in hemorrhage) increased BUN, decreased sodium, decreased osmolality
Treatment – replace fluid loss with isotonic fluids, monitor daily weight and strict Is & Os, give balanced solutions (ie. LR, NS if rapid volume is needed)

14. What causes it? What can you do? Fluid Volume Excess
Fluid volume excess – overhydration, hypervolemia
Causes – congestive heart failure (CHF), renal failure, excessive sodium intake, excess water intake, SIADH (syndrome of inappropriate antidiuretic hormone), interstitita to plasma fluid shift
Signs/symptoms – rapid weight gain, edema, high BP, increased urine output (if kidneys normal), neck vein distention, bounding pulses, crackles in the lungs, shortness of breath, decreased level of consciousness
Lab values – decreased hematocrit, decreased BUN, increased sodium, increased osmolality
Treatment – use of diuretics, fluid restriction, sodium restriction, monitor daily weight and strict Is & Os, no IV fluids

15. Nursing interventions
Strict I/O
Intake – oral, IV, tube feedings, retained irrigants
Output – urine, excess sweating, wound/tube drainage, vomitus, diarrhea
Urine specific gravity
Assessment of CV, Resp, Neuro, Skin status
Daily weight under standardized conditions
Don’t “catch up” IV fluids
No water with NG suction, use isotonic saline
Keep fluids accessible and within reach
Give warm or cold fluids (not room temperature)
CV – BP, pulse force, JVD, HR
Resp – pulmonary edema, shortness of breath, increased respiratory rate
Neuro – cerebral edema or reduced cerebral tissue perfusion
Skin – turgor (less predictive in the elderly due to loss of skin elasticity), temperature, moisture, edema (always evaluate over bone)

16. Serum Electrolytes Sodium (Na) 135 - 145 Potassium (K) 3.5 – 5.0
Primarily responsible for maintaining osmotic pressure (intracellular and extracellular fluids)
Increased with fluid deficit
Decreased with fluid excess
Potassium (K) 3.5 – 5.0
Major component of cardiac function
Increased with poor kidney function
Decreased with excessive urination, diarrhea or vomiting
Chloride (Cl) 96 – 106
Works with Na to maintain osmotic pressure
Decreased with excessive vomiting or diarrhea
Calcium (Ca) 8.6 – 10.2
Transmission of nerve impulses, heart and muscle contractions, blood clotting, formation of teeth and bone
Phosphate (PO4) – 4.4
Function of muscle, RBCs, and the nervous system
Serum electrolytes – substances (acids, bases, salts) that circulate in the blood and control things such as muscle contraction, cardiac function, test measures 4 common electrolytes and 2 indicators of kidney function – Na, K, Cl, HCO3, BUN, CR
An electrolyte abnormality is often the first laboratory sign of an acid-base disorder

17. The Magic fours Electrolyte Range Magic 4 Potassium 3.5 - 5.0 4
Chloride
Sodium pH CO
HCO
Hematocrit normal is 3 times the hemoglobin
To eliminate confusion with your book, Potassium was 3.5 – 5.5 (so that 4 was in the middle), I changed it to what your book reads, same thing happened with Chloride

18. Sodium (135 - 145) Major cation of ECF
Primary determinant of osmolality
GI tract absorbs sodium from food
Regulated by kidneys, ADH, aldosterone
Sodium level reflects the ratio of sodium to water
Imbalances are typically associated with fluid volume problems

19. Hypernatremia (high sodium)
What causes it?
What can you do?
Hypernatremia (high sodium) – water deficit, causes hyperosmolality which causes a shift of water out of the cells leading to cellular dehydration, occurs with water loss or sodium gain
Causes – renal failure, can result from consuming certain drugs (cortisone, cough meds, some antibiotics), excessive salt ingestion, decreased fluid intake, osmotic diuretics (Mannitol), hyperglycemia
Signs/Symptoms – thirst, hyperreflexes, flushed skin, elevated body temp, elevated BP, rough dry tongue, lethargy, seizures, excessive sweating
Treatment – treat the underlying cause (ie. decreased water – water replacement, D5W; increased sodium – salt free IV fluids, diuretics, decreased sodium intake), sodium restriction, avoid high sodium foods (ie. _____________), seizure precautions, have to reduce sodium slowly to avoid swelling in the brain

20. Hyponatremia (low sodium)
What causes it?
What can you do?
Hyponatremia (low sodium) – water excess or loss of sodium, most common electrolyte disorder in the US, occurs frequently in the seriously ill; when there is too little sodium in the tissue fluids water moves into the cells, usually not a problem because tissues will expand but in the brain there is no room for expansion, most symptoms of hyponatremia are related to the brain’s inability to expand in the cranium
Causes - water overload, kidney failure, trauma, CHF (congestive heart failure), fresh water drowning, overadministration of hypotonic fluids, taking water pills (diuretics)
Signs/Symptoms - muscle weakness, confusion, headaches, abdominal cramps, nausea, vomiting, seizures, can progress to coma, first symptoms are in the CNS as brain cells swell
Treatment – usually can not be fixed by adding sodium to the diet, can give NS (3% normal saline) to increase sodium content in the vascular fluid, if caused by fluid excess will need fluid restriction

21. Potassium (3.5 - 5.0) Major cation of ICF
Sodium-potassium pump requires magnesium
Moves into cells during formation of new tissues and leaves the cell during tissue breakdown
Diet is the source of potassium
Kidneys are primary route of loss
Sodium-potassium pump moves potassium into the cell and pumps sodium out
Foods – fruits, vegetables, salt substitutes
If kidney function is impaired then potassium levels will be too high

22. Hyperkalemia (high potassium)
What causes it?
What can you do?
Hyperkalemia (high potassium) - the body is more sensitive to small changes in potassium levels than any other serum electrolyte, very important for cardiac function; can get false high results if lab specimen is not drawn or handled properly
Causes – kidney failure is most common cause, use of salt substitutes or potassium supplements, receiving old or improperly administered blood, cell destruction (ie. crush injuries, burns, hemolysis), acidosis, hypoxia, exercise, catabolic state (ie. severe infection)
Signs/symptoms – diarrhea, apathy, weakness, confusion, numbness to hands/feet, slow pulse, cardiac arrhythmias, cramping leg pain, abdominal cramping
Treatment – cardiac monitor, give kayexalate (either orally or as enema), calcium gluconate, glucose & insulin IV (helps move potassium into cells), teach client to avoid foods high in potassium (cantaloupe, bananas, apricots, broccoli, salt substitutes)

23. Hypokalemia (low potassium)
What causes it?
What can you do?
Hypokalemia (low potassium) – the body is more sensitive to small changes in potassium levels than any other serum electrolyte, very important for cardiac function
Causes – excessive vomiting, suctioning, vomiting, diarrhea, medications (diuretics, laxatives, insulin), alkalosis (causes exchange of H+ for K+), beta adrenergic stimulation, rapid cell building (ie. B12 or erythropoietin to increase RBCs)
Signs/symptoms – weakness, nausea, vomiting, dysrhythmias, constipation, low BP, increased pulse, increased digoxin toxicity, muscle weakness and paralysis, muscle cramping, rhabdomyolosis, hyperglycemia, diuresis
Treatment – for slightly low levels encourage foods high in potassium (fruit juice, citrus fruits, dried fruits, bananas, nuts, veggies), cardiac monitor, watch for digitalis toxicity, must have good urine output (>600 ml/day) before giving any potassium supplements, never give potassium IV push, always must be diluted and given as a drip

24. Calcium (8.6 – 10.2) Primary source is bones
Regulated by parathyroid hormone, calcitonin, and vitamin D
Affects transmission of nerve impulses, heart and muscle contractions, blood clotting, and forming of teeth and bone

25. Hypercalcemia (high calcium)
What causes it?
What are the symptoms?
What can you do?
Causes – hyperparathyroidism, malignancy (esp. breast cancer, lung cancer, multiple myeloma), vitamin D overdose, prolonged immobilization
Signs/symptoms – lethargy, weakness, confusion, fractures, kidney stones, depressed reflexes
Treatment – promotion of excretion of calcium in urine with a loop diuretic (ie. Lasix), hydration with isotonic saline, drink mL daily, synthetic calcitonin, weight-bearing activity, Mithracin (cytotoxic antibioitic) will inhibit bone resorption; with malignancies give pamidronate (Aredia) instead

26. Hyp0calcemia (Low calcium)
Causes – removal of parathyroid gland, acute pancreatitis, multiple blood transfusions, alkalosis
Signs/symptoms – tetany, Trousseau’s sign (carpal spasms caused by inflating a BP cuff above systolic pressure), Chvostek’s sign (contraction of the facial muscle with a tap over the facial nerve in front of the ear), stridor, numbness/tingling around the mouth/extremities, can have cardiac symptoms
Treatment – oral/IV calcium supplements (never given IM), diet high in calcium with vitamin D supplements, very closely observe those who have had thyroid or neck surgery

27. Phosphate Imbalances Hyperphosphatemia Hypophosphatemia
Cause - renal failure
S/S – calcium deposits in joints, skin, kidneys, eyes; hypocalcemia, tetany, neuromuscular irritability
Tx – decrease intake of dairy products, good hydration, fix hypocalcemia
Hypophosphatemia
Cause – malnutrition, malabsorption syndrome, alcohol withdrawal
S/S – CNS depression, confusion, muscle weakness, dysrhythmias
Tx – oral supplements (Neutra-Phos), lots of dairy products, IV phosphate (but this can cause sudden hypocalcemia)
Kidneys are major route of excretion
Reciprocal relationship with calcium – if phosphate is high, calcium is low

28. Magnesium Imbalances Hypermagnesemia Hypomagnesemia
Cause – increased intake (ie. MOM, Maalox) with chronic kidney disease
S/S – lethargy, n/v, loss of DTRs, can have respiratory and cardiac arrest
Tx – avoid magnesium-containing drugs, IV calcium, increased fluid intake, may need dialysis
Hypomagnesemia
Cause – prolonged fasting or starvation, chronic alcoholism, diuretics
S/S – confusion, hyperactive DTRs, tremors, seizures, cardiac dysrhythmias
Tx – oral supplements, increase green veggies, nuts, bananas, oranges, peanut butter, chocolate; IV or IM magnesium (if given too rapidly can cause cardiac or respiratory arrest)
Most magnesium is in the bone
Regulated by GI absorption and renal excretion
These imbalances look very similar to calcium imbalances, oftentimes have potassium imbalance too
Important for normal cardiac function and neuromuscular function

29. Medications Loop diuretics Thiazide diuretics
Potassium sparing diuretics
Electrolytes
Kayexolate
Loop diuretics – Lasix, causes a loss of potassium
Thiazide diuretics – potentiates Digoxin, causes a loss of potassium
Potassium sparing diuretics – spirinolactone, triamterene, potentiate digoxin and lithium, too much potassium could be harmful
Electrolytes – potassium is most common, safety, have to have good urine output, should never exceed 60 mEq/L in IV fluids, should never exceed a rate of mEq/hr, CVC should be used if rapid correction is needed,
Kayexolate – binds with potassium to remove it from the body, liquid or powder, can be given as an enema, antacids can decrease the effectiveness of this med

30. Acid Base Balance
Body metabolism constantly produces acids and they have to be neutralized to maintain balance
Very common to get imbalances with diabetes, COPD, kidney disease, and vomiting/diarrhea

31. Regulation of Acid-Base Balance
Buffer system (immediate)
Primary regulator
Won’t work without good functioning respiratory and renal symptoms
Respiratory system (minutes, max in hours)
Excretes CO2 and water
Renal system (2-3 days to max respond)
Reabsorbs HCO3
For cells to work properly, metabolic processes must maintain a balance between acids and bases, the 2 physiologic buffers in the body are the lungs (work the quickest) and the kidneys, there are also chemical and biologic buffers in the body
Buffer – adjusting the H+ in the body
Lungs – blow off CO2 or return CO2, if increased CO2 or acidosis will stimulate increased rate and depth of breathing (hyperventilate), won’t work if the respiratory system caused the problem
Kidneys – much slower to respond, if the kidneys caused the problem then they can’t fix it
Acidosis < 7.35, Neutral – 7.4, alkalosis > 7.45
CO2 – regulated by the lungs
HCO3 – regulated by the kidneys

32. Arterial Blood Gas pH (7.35 – 7.45) CO2 (35 – 45) HCO3 (22 – 26)
Base excess (+2 to -2)
If high, metabolic alkalosis
If low, metabolic acidosis
Base excess - Calculated figure which provides an estimate of the metabolic component of the acid-base balance; technically is the amount of hydrogen ions it would take to bring the pH back to 7.35 if the CO2 were adjusted to normal
A base excess > +3 = metabolic alkalosis
A base excess < -3 = metabolic acidosis
CO2 is slightly different than your book but easier to remember

33. Determining Acid–Base Balance
Is pH acid, base or normal?
Is CO2 acid, base or normal?
Is HCO3 acid, base or normal?
Which of the components match?
Is there compensation?
Is non-matching reading abnormal? – partial compensation
Is non-matching reading normal? – no compensation
Helps to write the normals at the top of your page so you don’t get confused
After you determine if the pH is acidotic or alkalotic (if normal see below under compensation), you need to determine if the problem is primarily respiratory or primarily metabolic, you decide this by looking at what two components match
if CO2 then the problem is primarily respiratory in nature, if HCO3 then the problem is primarily metabolic in nature
Compensation –
No compensation if non-matching reading is normal with an abnormal pH (acute problem)
Partial compensation if non-matching reading is abnormal with an abnormal pH (body is trying to
return the pH)
Complete compensation if pH is normal but either of the other readings is abnormal (chronic disorder)
Calculating acid-base balance (the other way to do this is by using ROME which we distributed earlier this semester)
Determine acid-base balance (pH) - if low it’s acidosis, if high it’s alkalosis
Determine cause of acid-base balance
CO2 (respiratory) - if high it’s acidosis, if low it’s alkalosis
Are both the pH and CO2 the same (acidosis or alkalosis)? If so, it’s respiratory acidosis or alkalosis (whatever matches with the pH), if not then the respiratory system is only compensating and is not the primary cause of the imbalance
HCO3 (metabolic) - if high it’s alkalosis, if low it’s acidosis
Are both the pH and the HCO3 the same (acidosis or alkalosis)? If so, it’s metabolic acidosis or alkolosis (whatever matches with the pH), if not then the metabolic system is only compensating and not the primary cause of the imbalance

34. Can choose to memorize this table (or I prefer to learn how to do the problem)
Need to fix this table with pH normal being 7.35 – 7.45

35. Can also learn it this way by putting arrows and then matching the arrows (again, I prefer to do it with the words so I don’t have to memorize this)

36. Respiratory Alkalosis

37. Respiratory Alkalosis
Causes
Hyperventilation
Pulmonary disease
High altitudes
Signs/symptoms
Feels “light-headed”
Arrhythmias
Anxiety
Treatment
Breathe into paper bag
Rebreather mask
Anti-anxiety medicine
Relaxation techniques
Reduce stimulation
Treat pain/fever
Assess:
Resp rate/depth
HR & BP
Serum K levels
Hydration status
Check for digitalis toxicity

38. Respiratory acidosis

39. Respiratory Acidosis Causes Signs/symptoms Treatment CNS depression
Loss of lung surface
Neuromuscular disease
Immobility
Mechanical ventilation
Signs/symptoms
Dyspnea
Hypoxia
Drowsiness
Tachycardia
Seizures
Diaphoresis
Treatment
Turn, cough, deep breathe
Semi-Fowler’s position
Suction
Incentive spirometer
Seizure precautions
Decrease use of sedatives
Bronchodilators
May need ventilator
Assess:
Resp rate/depth
HR & BP
Patiency of airway

40. Metabolic alkalosis

41. Metabolic Alkalosis Causes Signs/symptoms Treatment NG suctioning
Prolonged vomiting
Diuretic use
Multiple blood transfusions
CPR (given bicarb)
Signs/symptoms
Dizziness
Dysrhythmias
Convulsions
Confusion
Muscle cramps (late sign)
Treatment
Identify and treat the cause!
IV fluids
Stop giving bicarbonate
Give antiemetics
Give Diamox
Assess:
Resp rate/depth
HR & BP
Serum K levels (usually low)
Hydration status (tend to be dehydrated)
Check for digitalis toxicity
Parasthesias

42. Metabolic acidosis

43. Metabolic acidosis Causes Signs/symptoms Treatment
Diabetic ketoacidosis
Renal or liver failure
Severe diarrhea
Vomiting
Starvation
Signs/symptoms
Kussmaul respirations
Hypotension
Arrythmias
Warm to hot ,flushed skin
Confusion
Treatment
Identify and treat the cause!
Administer insulin (if due to ketoacidosis)
Give antiemetics
IV fluids
IV bicarbonate
Assess:
Renal function (BUN, creatinine)
Serum K levels (tends to go up but down once insulin given)
Hydration status

44. IV Fluids Isotonic Hypertonic Hypotonic Plasma Expanders NS D5W LR
D51/2NS
D10W
Hypotonic
1/2NS
Plasma Expanders
Isotonic – equal to body fluid, keeps fluid in the intravascular volume without causing a fluid shift form one compartment to the other; usually used for dehydration, maintenance fluid
Hypertonic – thicker than body fluid, shifts fluid into the blood plasma by moving fluid from tissue cells; causes cells to shrink; usually used for restoring circulating volume, hyponatremia (watch for wet breath sounds, sodium levels)
Hypotonic – thinner than body fluid, shifts fluid from intravascular to the tissue cells; usually used for hydrating cells (enlarging them)
Plasma Expanders - Albumin exerts colloid osmotic or oncotic pressure, which tends to keep fluid in the intravascular compartment by pulling water from the interstitial space back into the capillaries; Colloids – volume expanders, dextran solutions, amino acids, hetastarch, plasmanate, dextran is not a substitute for whole blood because it doesn’t have any products that can carry oxygen, hetastarch is isotonic and can decrease platelet and hematocrit counts and is contraindicated in bleeding disorders, CHF, renal dysfunction, plasmanate can be used instead of plasma or albumin to replace body protein; Blood and blood products – whole blood, packed RBCs, plasma, albumin; Lipids – fat emulsion solutions, indicated when IV therapy lasts longer than 5 days

45. Central Venous access devices
Centrally inserted catheters (CVCs)
Peripherally inserted central catheters (PICCs)
Implanted infusion ports
Catheters placed in large blood vessels (ie. Subclavian vein or jugular vein)
Used for frequent access, administration of vesicants or parenteral nutrition, hemodynamic monitoring, venous blood sampling
Used if a pt has limited peripheral access or needs long-term access
Biggest risk is infection
CVC – placed by the MD, can also be in the groin, tip is in the superior vena cava, can be multi-lumen, tunneled or non-tunneled, has a cuff that stabilizes the catheter and prevents bacteria migration, must confirm placement with CXR before using, Hickman and Groshong are two types
PICC – placed by specially trained nurses, inserted in the arm, tip is in the superior vena cava, can be multi-lumen insert the catheter through a needle with the use of a guidewire, cx – catheter occlusion, phlebitis; don’t use arm for BP or blood draws
Infusion ports – placed by MD in the OR, can be a single or double, port is a metal sheath with a self-sealing silicone septum, requires access with a Huber-point needle, needs regular flushing

46. Nursing care of CVADs
Inspect site for redness, edema, warmth, drainage, pain
Dressing change/cleaning with sterile technique using chlorhexidine (back and forth scrub to generate friction)
Maintain transparent dressing c/d/I
Change injection caps using sterile technique
Teach pt to turn head away from insertion site during cleaning and cap change
Have patient Valsalva during cap change if unable to clamp
Use push-pause method to flush (creates turbulence)
Removal of non-tunneled CVCs and PICCs may be done by a trained nurse (have pt Valsalva as last of catheter is withdrawn, apply pressure immediately, inspect catheter tip)