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Nursing Care of Clients with Altered Fluid, Electrolyte, and Acid–Base Balance

Nursing Care of Clients with Altered Fluid, Electrolyte, and Acid–Base Balance. Fluid and Electrolyte Balance. Necessary for life, homeostasis Nursing role: help prevent, treat fluid, electrolyte disturbances. Fluid. Approximately 60% of typical adult is fluid

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Nursing Care of Clients with Altered Fluid, Electrolyte, and Acid–Base Balance

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  1. Nursing Care of Clients with Altered Fluid, Electrolyte, and Acid–Base Balance

  2. Fluid and Electrolyte Balance • Necessary for life, homeostasis • Nursing role: help prevent, treat fluid, electrolyte disturbances

  3. Fluid • Approximately 60% of typical adult is fluid • Varies with age, body size, gender • Intracellular fluid • Extracellular fluid • Intravascular • Interstitial • Transcellular • “Third spacing”: loss of ECF into space that does not contribute to equilibrium

  4. Electrolytes • Active chemicals that carry positive (cations), negative (anions) electrical charges • Major cations: sodium, potassium, calcium, magnesium, hydrogen ions • Major anions: chloride, bicarbonate, phosphate, sulfate, and proteinate ions • Electrolyte concentrations differ in fluid compartments

  5. Regulation of Fluid • Movement of fluid through capillary walls depends on • Hydrostatic pressure: exerted on walls of blood vessels • Osmotic pressure: exerted by protein in plasma • Direction of fluid movement depends on differences of hydrostatic, osmotic pressure

  6. Regulation of Fluid • Osmosis: area of low solute concentration to area of high solute concentration • Diffusion: solutes move from area of higher concentration to one of lower concentration • Filtration: movement of water, solutes occurs from area of high hydrostatic pressure to area of low hydrostatic pressure • Active transport: physiologic pump that moves fluid from area of lower concentration of one of higher concentration

  7. Active Transport • Physiologic pump that moves fluid from area of lower concentration to one of higher concentration • Movement against concentration gradient • Sodium-potassium pump: maintains higher concentration of extracellular sodium, intracellular potassium • Requires adenosine (ATP) for energy

  8. Fluids Animation

  9. Fluid Volume or Electrolyte Imbalance • Causes of fluid loss • Vomiting, diarrhea • Gastrointestinal suctioning, intestinal fistulas, and intestinal drainage • Diuretic therapy, renal disorders, endocrine disorders • Sweating from excessive exercise, increased environmental temperature • Hemorrhage • Chronic abuse of laxatives

  10. Fluid Volume or Electrolyte Imbalance • Cause of Fluid Loss in the Older Adult • Self limiting fluids (fear of incontinence) • Physical disabilities • Cognitive impairments • Older adults without air conditioning

  11. Fluid Volume Imbalances • Fluid volume deficit (FVD): hypovolemia • Fluid volume excess (FVE): hypervolemia

  12. Fluid Volume Deficit • Loss of extracellular fluid exceeds intake ratio of water • Electrolytes lost in same proportion as they exist in normal body fluids • Dehydration: loss of water along with increased serum sodium level • May occur in combination with other imbalances

  13. Fluid Volume Deficit (cont’d) • Dehydration • Causes: fluid loss from vomiting, diarrhea, GI suctioning, sweating, decreased intake, inability to gain access to fluid • Risk factors: diabetes insipidus, adrenal insufficiency, osmotic diuresis, hemorrhage, coma, third space shifts

  14. Fluid Volume Deficit (cont’d) • Manifestations: rapid weight loss, decreased skin turgor, oliguria, concentrated urine, postural hypotension, rapid weak pulse, increased temperature, cool clammy skin due to vasoconstriction, lassitude, thirst, nausea, muscle weakness, cramps • Laboratory data: elevated BUN in relation to serum creatinine, increased hematocrit • Serum electrolyte changes may occur

  15. Fluid Volume or Electrolyte Imbalance • Treatment for Fluid Volume Deficit (FVD) • Oral, intravenous, or enteral routes • Manage the effects and prevent further complications by monitoring intake, assessing lab values, and observing vital signs and skin integrity

  16. Fluid Volume Deficit - Nursing Management • I&O, VS • Monitor for symptoms: skin and tongue turgor, mucosa, UO, mental status • Measures to minimize fluid loss • Oral care • Administration of oral fluids • Administration of parenteral fluids

  17. Fluid Volume Excess • Due to fluid overload or diminished homeostatic mechanisms • Risk factors: heart failure, renal failure, cirrhosis of liver • Contributing factors: excessive dietary sodium or sodium-containing IV solutions • Manifestations: edema, distended neck veins, abnormal lung sounds (crackles), tachycardia, increased BP, pulse pressure and CVP, increased weight, increased UO, shortness of breath and wheezing • Medical management: directed at cause, restriction of fluids and sodium, administration of diuretics

  18. Fluid Volume Excess - Nursing Management • I&O and daily weights; assess lung sounds, edema, other symptoms; monitor responses to medications- diuretics • Promote adherence to fluid restrictions, patient teaching related to sodium and fluid restrictions • Monitor, avoid sources of excessive sodium, including medications • Promote rest • Semi-Fowler’s position for orthopnea • Skin care, positioning/turning

  19. Manifestations of Imbalances • Hyponatremia • Muscle cramps, weakness, fatigue • Dulled sensorium, irritability, personality changes • Hypernatremia • Most serious effects are seen in the brain • Lethargy, weakness, irritability can progress to seizures, coma, and death

  20. Manifestations of Imbalances • Hypokalemia • EKG changes (flattened or inverted T waves) • Skeletal muscle weakness • Hyperkalemia • Cardiac arrest • Paresthesias • Abdominal cramping

  21. Manifestations of Imbalances • Hypocalcemia • Tetany, paresthesias, muscle spasms • Hypotension • Anxiety, confusion, psychosis • Hypercalcemia • Muscle weakness, fatigue • Personality changes • Anorexia, nausea, vomiting

  22. Manifestations of Imbalances • Hypomagnesemia • Muscle weakness and tremors • Dysphasia • Tachycardia hypertension • Mood and personality changes • Hypermagnesemia • Depressed deep tendon reflexes • Hypotension • Respiratory depression

  23. Manifestations of Imbalances • Hypophosphatemia • Muscle pain and tenderness • Muscle weakness and paresthesias • Confusion • Manifestations of hypophosphatemia • Muscle spasms, tetany • Soft tissue calcifications

  24. Maintaining Acid-Base Balance • Normal plasma pH 7-35-7.45: hydrogen ion concentration • Major extracellular fluid buffer system;bicarbonate-carbonic acid buffer system • Kidneys regulate bicarbonate in ECF • Lungs under control of medulla regulate CO2, carbonic acid in ECF

  25. ACID–BASE DISTURBANCES • Plasma pH is an indicator of hydrogen ion (H+) concentration. • Normal range pH (7.35–7.45). • Buffer systems • Kidneys • Lungs • The H+ concentration is extremely important: • Increased concentration H+ • Increased acidity • Lower the pH. • Deceased H+ concentration • Increased alkalinity • Higher the pH. • pH range compatible with life (6.8–7.8)

  26. Acid-Base Disorders • Acidosis: hydrogen ion concentration above normal (pH below 7.35) • Alkalosis: hydrogen ion concentration below normal (pH above 7.45) • Metabolic Acidosis: bicarbonate is decreased in relation to the amount of acid

  27. Acid-Base Disorders • Metabolic Alkalosis: excess of bicarbonate in relation to the amount of hydrogen ion • Respiratory Acidosis: CO2 is retained, caused by sudden failure of ventilation due to chest trauma, aspiration of foreign body, acute pneumonia, and overdose of narcotics or sedatives • Respiratory Alkalosis: CO2 is blown off, caused by mechanical ventilation and anxiety with hyperventilation

  28. Arterial Blood Gases • pH 7.35 - (7.4) - 7.45 • PaCO2 35 - (40) - 45 mm Hg • HCO3ˉ 22 - (24) - 26 mEq/L • Assumed average values for ABG interpretation • PaO2 80 to 100 mm Hg • Oxygen saturation >94% • Base excess/deficit ±2 mEq/L

  29. ACID–BASE DISTURBANCES AND COMPENSATION • DISORDER INITIAL EVENT COMPENSATION • Respiratory acidosis ↑ PaCO2, ↑ or normal Kidneys eliminate H+ and HCO3 −, ↓ pH retain HCO3− • Respiratory alkalosis ↓ PaCO2, ↓ or normal Kidneys conserve H+ and HCO3−, ↑ pH excrete HCO3− • Metabolic acidosis ↓ or normal PaCO2, Lungs eliminate CO2, ↓ HCO3−, ↓ pH conserve HCO3− • Metabolic alkalosis ↑ or normal PaCO2, Lungs ↓ ventilation to↑ ↑ HCO3−, ↑ pH PCO2, kidneys conserve H+ to excrete HCO3−

  30. IV Site Selection

  31. Complications of IV Therapy • Fluid overload • Air embolism • Septicemia, other infections • Infiltration, extravasation • Phlebitis • Thrombophlebitis • Hematoma • Clotting, obstruction

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