CARING FOR CLIENTS WITH FLUID, ELECTROLYTE, AND ACIDBASE IMBALANCES

1
CHAPTER 18

• CARING FOR CLIENTS WITH FLUID, ELECTROLYTE, AND
  ACID-BASE IMBALANCES

2
FACTS

• 60 OF ADULT BODY IS WATER
• INTRACELLULAR FLUID within the cells makes up
  majority of water content
• EXTRACELLULAR FLUID outside the cells-
  interstitial fluid between the cells
  intravascular fluid or fluid in the plasma or
  liquid part of the blood
• The body uses physiologic processes to keep a
  balance of water at all times in the body
• Fig 18-1, fig 18-2

3
REGULATION

• OSMORECEPTORS the release or inhibition of ADH
  (antidiuretic hormone)
• RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM mechanism
  in the kidneys that increases both BP and blood
  volume FIG 18-4
• ATRIAL NATRIURETIC PEPTIDE hormone-like
  substance produced in the hearts atrial muscle
  that works to decrease the blood volume to lower
  the BP

4
DISTRIBUTION

• OSMOSIS the movement of water through a
  semipermeable membrane in order to keep the same
  concentration on each side
• FILTRATION promotes movement of fluid and some
  dissolved particles through a semipermeable
  membrane to keep the same concentration on each
  side
• PASSIVE AND FACILITATED DIFFUSION- when dissolved
  substances are moved through the semipermeable
  membrane
• ACTIVE TRANSPORT uses an energy source to move
  dissolved particles against the grain from an
  area of low concentration to high concentration.

5
FLUID IMBALANCES

• HYPOVOLEMIA low volume of extracellular fluid
  fluid volume deficit
• DEHYDRATION when there is a deficit of both
  intra and extracellular fluid.
• Causes inadequate fluid intake, fluid loss,
  wound loss, perfuse urination or perspiration

6
HYPOVOLEMIA fluid volume deficit

• Table 18-2
• S/S one of the earliest signs is thirst
• Findings elevated hct and blood cell counts
• Medical management- find the cause treat with
  increased fluids via oral or IV route
• Nursing management see nursing guidelines 18-1
• See nursing care plan pg 18-1

7
HYPERVOLEMIA-fluid volume excess

• A high volume of water in the intravascular fluid
  compartment.
• Can be caused by excessive intake of fluids or
  too rapid IV infusion, heart failure, poor fluid
  elimination as in kidney failure.
• S/S pitting edema, dependent edema, moist
  breath sounds usually last s/s.
• Medical mgmt treat the cause, diuretics, limit
  salt and sodium intake

8
NURSING MANAGEMENT

• ASSESSMENT
• weight
• accurate I O note imbalances
• auscultate lungs
• regular measurements of v/s
• note edema
• note any activity intolerances

9
THIRD SPACING

• Fluid trapped within the tissue compartments
  that should be in the blood or cells. May also
  have generalized edema brawny edema or anasarca
• Medical mgmt- restore circulatory volume in
  hypotensive pts and eliminate the trapped fluid
• Nursing management assess for both hypo and
  hypervolemia

10
ELECTROLYTE IMBALANCES

• Measured via a blood test call ELECTROLYTES OR
  LYTES
• Reasons for deficits
• inadequate dietary intake
• administration of IV fluids without
  electrolytes added
• vomiting and diarrhea
• diuretics

• Reasons for excess
• excess oral or IV use
• kidney failure
• endocrine disorders

11
SODIUM- Na

• HYPONATREMIA
• causes profuse sweating, diuresis, n/v, GI
  suction or draining fistulas
• S/S Mental confusion, muscular
  weakness,anorexia, n/v, tachycardia
• Correct underlying cause

• HYPERNATREMIA
• Causes Profuse, watery diarrhea, excessive
  intake of salt, high fever
• S/S Thirst, dry, sticky mucus membranes,
  decreased urine output, lethargy
• Adm water or IV solution

12
POTASSIUM-K

• HYPOKALEMIA
• Causes diuretics, v/d, lge doses of meds like
  IV insulin
• S/S fatigue, weakness, cardiac arrhythmias
  fig 18-9 u wave on ECG
• eliminate the cause

• HYPERKALEMIA
• Causes renal failure, burns, adm of K
  sparing diuretics
• S/S Diarrhea, nausea, muscle weakness, cardiac
  arrythymias
• Depends on the cause- severe cases treated with
  Kayexalate

13
CALCIUM-Ca

• HYPOCALCEMIA
• Causes Vitamin D deficiency, severe burns,
  acute pancreatitis
• S/S Tingling in the extremities, muscle and abd
  cramping
• Administer oral calcium and Vit D or IV if severe
• Trousseau sign fig 18-11
• Chvosteks sign fig 18-12

• HYPERCALCEMIA
• Causes Parathyroid gland tumors, multiple
  fractures, Pagets disease
• S/S Deep bone pain, constipation, anorexia,
  polyuria
• Mild-increase oral fluids and limit calcium
  consumption

14
MAGNESIUM-Mg

• HYOPMAGNESEMIA
• Causes Chronic alcoholism, diabetic
  ketoacidosis, toxemia of pregnancy
• S/S Tachycardia, cardiac arrhythmias, leg
  foot cramps
• Po mag or if severe, IV mag

• HYPERMAGNESEMIA
• Causes Renal failure, excessive use of antacids
  or laxatives that contain mag
• S/S Flushing and a feeling of warmth,
  hypotension, lethargy
• Decrease mag intake, severe hemodialysis
• Watch cardiac monitor, check BP frequently

15
ACID-BASE BALANCE

• pH refers to the amount of hydrogen ions in a
  solution.
• pH of 7 is neutral
• pH range normal for human body 7.35 7.45 or
  slightly alkaline
• Acid-pH of less than 7
• Base-alkaline pH of more than 7

16
BUFFER SYSTEM

• BICARBONATE-CARBONIC ACID BUFFER SYSTEM major
  buffer system in human body
• Works mostly in the lungs and kidneys
• Acidosis excessive build up of acids or loss of
  bicarbonate
• Alkalosis excessive accumulation of base or a
  loss of acid in body fluids

17
ACID-BASE IMBALANCES table 18-3

• METABOLIC ACIDOSIS
• Diabetic ketoacidosis, renal failure, asa OD
• Deep and rapid breathing, anorexia, n/v, h/a
• Abnormal ABG
• Elimination of cause, replacement of fluids
  electrolytes

• METABOLIC ALKALOSIS
• Excessive use of po or IV bicarbonate containing
  drugs, diuretic use, vomiting, suction
• N/V, confusion, tetany
• Abnormal ABG
• Treat the cause, replace K or NaCl

18
ACID-BASE IMBALANCES

• RESPIRATORY ACIDOSIS
• Pneumothorax, pneumonia, asthma
• Extreme respiratory insufficiency
• Abnormal ABG
• May need mechanical ventilation

• RESPIRATORY ALKALOSIS
• Tachypnea, rapid breathing due to acute anxiety,
  high fever
• Increased respiratory rate
• Abnormal ABG
• Correct the cause, breathe into a paper bag,
  sedation

19
General Nutritional Considerations

• The large majority, 75 of the Na intake of the
  average American comes from processed foods
• Physical stress or high intake of calcium,
  protein, vitamin D or ETOH may increase the need
  for Mg which can be found in cocoa, chocolate,
  nuts, seafood, green leafy vegetables.
• !!!!!!!!!!another good reason to eat
  chocolate!!!!!!!!!

20
General Pharmacologic Considerations

• Calcium replacement is given with caution to
  clients with kidney stones because high calcium
  levels in the kidney tubules may contribute to
  more kidney stones being formed.
• Clients receiving IV K replacement may
  experience burning along the vein. The
  discomfort is related to the concentration. May
  need to dilute it in more fluid if not
  contraindicated to lessen the discomfort.

21
General Gerontologic Considerations

• Use the skin of the forehead in older adults to
  assess for skin turgor.
• The most common electrolyte imbalance in the
  older adult is dehydration
• Overuse of sodium bicarbonate (baking soda) an
  inexpensive substitute for commercial antacids,
  may lead to metabolic alkalosis in the elderly.