Fluid & Electrolytes And Acid Base Balance

Fluids and Electrolytes Acid Base Balance Prepared by : Dr. Malyn Basbas-Uy

Fluid volume deficit (dehydration): 

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mechanism that influences fluid balance and sodium levels; decreased quantities of fluid and electrolytes may be caused by deficient intake (poor dietary habits, anorexia, and nausea), excessive output (vomiting, nasogastric suction, and prolonged diarrhea), or failure of regulatory mechanism that influences fluid balance and sodium levels.

Fluid volume deficit (dehydration): A.

Pathophysiology: Water moves out of the cells to replace a significant water loss; cells eventually become unable to compensate for the lost fluid, and cellular dehydration begins, leading to circulatory collapse.

Fluid volume deficit (dehydration):

B. Risk factors: 1. No fluids available. 2. Available fluids not drinkable. 3. Inability to take fluids independently. 4. No response to thirst; does not recognize the need for fluids. 5. Inability to communicate need; does not speak same language. 6. Aphasia.

Fluid volume deficit (dehydration): cont.

7. Weakness, comatose. 8. Inability to swallow. 9. Psychological alterations. 10. Overuse of diuretics. 11. Increased vomiting. 12. Fever. 13. Wounds, burns. 14. Blood loss. 15. Endocrine abnormalities

Fluid volume deficit (dehydration):

C. Assessment: 1. Subjective data a. Thirst. b. Behavioral changes: apprehension, apathy, lethargy, confusion, restlessness. c. Dizziness. d. Numbness and tingling of hands and feet. e. Anorexia and nausea. f. Abdominal cramps.

Fluid volume deficit (dehydration):

2. Objective data a. Sudden weight loss of 5%. b. Vital signs: 1. Decreased BP; postural changes. 2. Increased temperature. 3. Irregular, weak, rapid pulse. 4. Increased rate and depth of respirations.

Fluid volume deficit (dehydration):

c. Skin: cool and pale in absence of infection; decreased turgor. d. Urine: oliguria to anuria, high specific gravity. e. Eyes: soft, sunken. f. Tongue: furrows. g. Lab data: 1. Blood—increased hematocrit and BUN. 2. Urine—decreased 17-

D. Nursing care plan/implementation: 1. Goal: restore fluid and electrolyte balance —increase fluid intake to hydrate client. a. IVs and blood products as ordered; small, frequent drinks by mouth. b. Daily weights (same time of day) to monitor progress of fluid replacement. c. I&O, hourly outputs (when in acute state). d. Avoid hypertonic solutions (may cause fluid shift when compensatory mechanisms begin to function).

D. Nursing care plan/implementation:

2. Goal: promote comfort. a. Frequent skin care (lack of hydration causes dry skin, which may increase risk for skin breakdown). b. Position: change every hour to relieve pressure. c. Medications as ordered: antiemetics, antidiarrheal.

D. Nursing care plan/implementation:

3. Goal: prevent physical injury. a. Frequent mouth care (mucous membrane dries due to dehydration; therefore, client is at risk for breaks in mucous membrane, halitosis). b. Monitor IV flow rate—observe for circulatory overload, pulmonary edema related to potential fluid shift when compensatory mechanisms begin or client is unable to tolerate rate of fluid replacement.

E. Analysis/nursing diagnosis: 1. Fluid volume deficit related to inadequate fluid intake F. Evaluation/outcome criteria: 1. Mentally alert. 2. Moist, intact mucous membranes. 3. Urinary output approximately equal to intake. 4. No further weight loss. 5. Gradual weight gain.

Fluid volume excess (fluid overload):

most common cause is an increase in sodium;  excessive quantities of fluid and electrolytes may be due to increased ingestion, tube feedings, intravenous infusions, multiple tapwater enemas, or  a failure of regulatory systems, resulting in inability to excrete excesses. 

Fluid volume excess (fluid overload):

A. Pathophysiology:  hypo-osmolar water excess in extracellular compartment leads to intracellular water excess because the concentration of solutes in the intracellular fluid is greater than that in the extracellular fluid. Water moves to equalize concentration, causing swelling of the cells. The most common cause is an increase in

Fluid volume excess (fluid overload):

B. Risk factors: 1. Excessive intake of electrolyte-free fluids. 2. Increased secretion of ADH in response to stress, drugs, anesthetics. 3. Decreased or inadequate output of urine. 4. Psychogenic polydipsia. 5. Certain medical conditions: tuberculosis; encephalitis; meningitis; endocrine disturbances; tumors of lung, pancreas, duodenum, heart failure. 6. Inadequate kidney function or kidney failure.

Fluid volume excess (fluid overload):

C. Assessment: 1. Subjective data Behavioral changes: irritability, apathy, confusion, disorientation. b. Headache. c. Anorexia, nausea, cramping. d. Fatigue. e. Dyspnea. b.

Fluid volume excess (fluid overload):

2. Objective data a. Vital signs: elevated blood pressure. b. Skin: warm, moist; edema— eyelids, facial, dependent, pitting. c. Sudden weight gain of 5 lb. d. Pink, frothy sputum; productive. e. Constant, irritating cough.

Objective data (cont.)

f. Crackles in lungs. g. Pulse, bounding. h. Engorgement of neck veins in sitting position. i. Urine: polyuria, nocturia. j. Lab data: 1. Blood—decreasing hematocrit, BUN. 2. Urine—decreasing specific gravity.

Fluid volume excess (fluid overload):

D. Analysis/nursing diagnosis: 1. Fluid volume excess related to excessive fluid intake or decreased fluid output.

E. Nursing care plan/implementation: 1. Goal: maintain oxygen to all cells. a. Position: semi-Fowler's or Fowler's to facilitate improved gas exchange. b. Vital signs: PRN, minimum q4hr. c. Fluid restriction.

2. Goal: promote excretion of excess fluid. a. Medications as ordered: diuretics. b. Monitor electrolytes, especially Mg++, K+ c. If in kidney failure: may need dialysis; explain procedure. d. Assist client during paracentesis, thoracentesis, phlebotomy.

Nursing care plan/implementation:

3. Goal: obtain/maintain fluid balance. a. Daily weights; 1 kg = 1000 mL fluid. b. Measure: all edematous parts, abdominal girth, I&O. c. Limit: fluids by mouth, IVs, sodium. d. Strict monitoring of IV fluids.

Fluid volume excess (fluid overload): Nursing care plan/implementation:

4. Goal: prevent tissue injury. a. Skin and mouth care as needed. b. Evaluate feet for edema and discoloration when client is out of bed. c. Observe suture line on surgical clients d. IV route preferred for parenteral medications; Z track if medications

5. Goal: health teaching. a. Improve nutritional status with low sodium diet. b. Identify cause that put client at risk for imbalance. c. Desired and side effects of diuretics and other prescribed medications. d. Monitor urinary output, ankle edema; e. Limit fluid intake when kidney/cardiac function Impaired.

Fluid volume excess (fluid overload): Nursing care plan/implementation Evaluation/outcome criteria

F. Evaluation/outcome criteria: 1. Fluid balance obtained. 2. No respiratory, cardiac complications. 3. Vital signs within normal limits. 4. Urinary output improved, no evidence of edema.

Common electrolyte imbalances 

electrolytes are taken into the body in foods and fluids;

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normally lost through sweat and urine. May also be lost through hemorrhage, vomiting, and diarrhea.

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Electrolytes have major influences on: body water regulation and osmolality, acid-base regulation, enzyme reactions, and neuromuscular activity.

Clinically important electrolytes:

A.

Sodium (Na+): Normal 135–145 mEq/L. – Most prevalent cation in extracellular fluid. – Controls osmotic pressure; essential for neuromuscular functioning and intracellular chemical reactions. – Aids in maintenance of acid-base balance. – Necessary for glucose to be

1. Hyponatremia —sodium deficit, resulting from either a sodium loss or water excess. Serum-sodium level below 135 mEq/L; symptoms usually do not occur until below 120 mEq/L unless rapid drop. 2. Hypernatremia —excess sodium in the blood, resulting from either high sodium intake, water loss, or low water intake. Serum-sodium level above 145 mEq/L.

Clinically important electrolytes:

B. Potassium (K+): normal 3.5–5.0 mEq/L. • Direct effect on excitability of nerves and muscles. • Contributes to intracellular osmotic pressure and influences acid-base balance. • Major intracellular cation. • Required for storage of nitrogen as muscle protein.

Clinically important electrolytes:

1. Hypokalemia —potassium deficit related to dehydration, starvation, vomiting, diarrhea, diuretics. Serum-potassium level below 3.5 mEq/L; symptoms may not occur until below 2.5 mEq/L. 2. Hyperkalemia —potassium excess related to severe tissue damage, renal disease, excess administration of oral or IV potassium. Serum-potassium level above 5 mEq/L; symptoms usually occur when above 6.5

Clinically important electrolytes

C. Calcium (Ca++): Normal 4.5–5.5 mEq/L. • Essential to muscle metabolism, cardiac function, and bone health. • Controlled by parathyroid hormone; reciprocal relationship between calcium and phosphorus.

Calcium (Ca++):

1. Hypocalcemia —loss of calcium related to inadequate intake, vitamin D deficiency, hypoparathyroidism, damage to the parathyroid gland, decreased absorption in the GI tract, excess loss through kidneys. Serum-calcium level below 4.5 mEq/L. 2. Hypercalcemia —calcium excess related to hyperparathyroidism, immobility, bone tumors, renal failure, excess intake of Ca++ or vitamin D. Serum-calcium level

Clinically important electrolytes

D. Magnesium (Mg++): Normal 1.5–2.5 mEq/L. • Essential to cellular metabolism of carbohydrates and proteins. 1. Hypomagnesemia —magnesium deficit related to impaired absorption from GI tract, excessive loss through kidneys, and prolonged periods of poor nutritional intake. Hypomagnesemia leads to neuromuscular irritability. Serummagnesium level below 1.5mEq/L.

Magnesium (Mg++):

2. Hypermagnesemia —magnesium excess related to renal insufficiency, overdose during replacement therapy, severe dehydration, repeated enemas with Mg++ sulfate. Serum-magnesium level above 2.5 mEq/L.

Electrolyte Imbalances Hyponatremia

Disorder and Related Condition: • Addison's disease • Starvation • GI suction • Thiazide diuretics • Excess water intake, enemas • Fever • Fluid shifts • Ascites • Burns • Small-bowel obstruction • Profuse perspiration

Electrolyte Imbalances Hyponatremia Assessment

Subjective Data: • Apathy, apprehension, mental confusion, delirium • Fatigue • Vertigo, headache • Anorexia, nausea • Abdominal and muscle cramps

Electrolyte Imbalances Hyponatremia Assessment

Objective Data: • Pulse: rapid and weak • BP: postural hypotension • Shock, coma • GI: weight loss, diarrhea, loss through NG tubes • Muscle weakness

Electrolyte Imbalances Hyponatremia

» Analysis/Nursing Diagnosis: – Diarrhea – Fluid volume excess – Altered nutrition, less than body requirements – Sensory-perceptual alteration (kinesthetic)

Hyponatremia

» Nursing Care Plan/Implementation: – Obtain normal sodium level: identify cause of deficit, increase sodium intake PO (salty foods), IVs–hypertonic solutions – Prevent further sodium loss: irrigate NG tubes with saline; hourly I&O to monitor kidney output – Prevent injury related to shock, dizziness, decreased sensorium; dangle before ambulation – Skin care

Electrolyte Imbalances Hyponatremia

» Evaluation/Outcome Criteria: – Na+ 135–145 mEq/L – No complications of shock present – Return of muscle strength – Alert, oriented – Limits intake of plain water

Electrolyte Imbalances Hypernatremia Disorder and Related Condition:  High sodium intake  Low water intake  Diarrhea  High fever with rapid respirations  Impaired renal functions  Acute tracheobronchitis

Electrolyte Imbalances Hypernatremia Assessment

Subjective Data: • Lethargy • Restlessness, agitation • Confusion Objective Data: • BP and temperature: elevated • Neuromuscular: diminished reflexes • Skin: flushed; firm turgor • GI: mucous membrane dry, sticky • GU: decreased output

Electrolyte Imbalances Hypernatremia

» Analysis/Nursing Diagnosis: – Fluid volume deficit – Fluid volume excess – Altered nutrition, less than body requirements – Sensory-perceptual alteration (kinesthetic)

Electrolyte Imbalances Hypernatremia

» Nursing Care Plan/Implementation: – Obtain normal sodium level: decrease sodium in take – I&O to recognize signs and symptoms of complications (e.g., heart failure, pulmonary edema)

Electrolyte Imbalances Hypernatremia

» Evaluation/Outcome Criteria: – Na+ 135–145 mEq/L – No complaint of thirst – Alert, oriented – Relaxed in appearance – Identifies high sodium foods to avoid – K+ 3.5–5.0 mEq/L

Hypokalemia Disorder and Related Condition: Decreased intake: » Poor potassium food intake » Excessive dieting » Nausea » Alcoholism » IV fluids without added potassium Increased loss: » GI suctioning, vomiting, diarrhea » Ulcerative colitis » Drainage: ostomy, fistulas » Medications: potassiumlosing diuretics, digoxin, cathartics » Increased aldosterone production; Renal disorders

Hypokalemia » Assessment

Subjective Data: • Apathy, lethargy, fatigue, weakness • Irritability, mental confusion • Anorexia, nausea • Leg cramps

Hypokalemia » Assessment Objective Data:

• Muscles: weakness, paralysis, paresthesia, hyporeflexia • Respirations: shallow to respiratory arrest • Cardiac: decreased BP; elevated, weak, irregular pulse; arrhythmias • ECG: low, flat T waves; prolonged ST segment; elevated U wave; potential arrest • GI: vomiting, flatulence, constipation; decreased motility distention paralytic ileus • GU: urine not concentrated; polyuria, nocturia; kidney damage • Speech: slow

Hypokalemia

» Analysis/Nursing Diagnosis: – Decreased cardiac output – Fatigue – Altered cardiopulmonary tissue perfusion – Ineffective breathing patterns – Constipation – Bathing/hygiene self-care deficit – Impaired home maintenance management – Sensory-perceptual alteration

Hypokalemia

» Nursing Care Plan/Implementation: • Replace lost potassium: increase potassium in diet; liquid PO potassium medications—dilute in juice to aid taste; give potassium only if kidneys functioning • Prevent injury to tissues: prevent infiltration, pain, tissue damage • Prevent potassium loss: Irrigate NG tubes with saline, not water

Hypokalemia

» Evaluation/Outcome Criteria: – Identifies cause of imbalance – Lists foods to include in diet – Lists signs and symptoms of imbalance – Return of muscle strength – No cardiac arrhythmias

Hyperkalemia Disorder and Related Condition:    

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Burns Crushing injuries Kidney disease Excessive infusion or ingestion of K+ Adrenal insufficiency Mercurial poisoning

Hyperkalemia » Assessment – Subjective Data: • Irritability • Weakness, muscle cramps • Nausea, intestinal cramps

Hyperkalemia » Assessment Objective Data:

• Muscles: paresthesia, flaccid muscle paralysis (later) • Cardiac; irregular pulse; arrhythmias; bradycardia asystole • ECG: high T waves; depressed ST segment; widened QRS complex; diminished or absent P waves; ventricular fibrillation • GI: explosive diarrhea; hyperactive bowel sounds • Kidney: scanty to no urine

Hyperkalemia

» Analysis/Nursing Diagnosis: • Decreased cardiac output • Altered urinary elimination • Activity intolerance • Ineffective breathing patterns • Diarrhea • Impaired home maintenance management

Hyperkalemia

» Nursing Care Plan/Implementation: • Decrease amount of potassium in body; identify and treat cause of imbalance; give foods low in K+; avoid drugs or IV fluids containing K+ • If kidney failure present, may need to prepare for dialysis » Evaluation/Outcome Criteria:  K+ 3.5–5.0 mEq/L  No complications (e.g., arrhythmias, acidosis, respiratory failure)

Hypocalcemia Disorder and Related Condition: • • • • • • • • • • •

Acute pancreatitis Diarrhea Peritonitis Damage to parathyroid during thyroidectomy Hypothyroidism Burns Pregnancy and lactation Low vitamin D intake Multiple blood transfusions Renal disorders Massive infection

Hypocalcemia

» Assessment Subjective Data: • Fatigue • Tingling/numbness; fingers and circumoral • Abdominal cramps • Palpitations • Dyspnea

Hypocalcemia » Assessment

Objective Data: • Muscle spasms: tonic muscles, carpopedal, laryngeal • Neuromuscular: grimacing, hyperirritable facial nerves • Tetany convulsions • Orthopedic: osteoporosis fractures • Cardiac: arrhythmias arrest • GI: diarrhea

Hypocalcemia

» Analysis/Nursing Diagnosis: • Pain • Diarrhea • Altered nutrition, less than body requirements • Risk for injury • Sensory-perceptual alteration (gustatory)

Hypocalcemia

» Nursing Care Plan/Implementation: • Prevent tetany (medical emergency): calcium gluconate IV, 2.5–5.0 mL 10% solution; repeated q10min to maximum dose of 30 mL • Prevent tissue injury due to hypoxia and sloughing; administer slowly; avoid infiltration

Nursing Care Plan/Implementation: (cont.)

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Prevent injury related to medication administration. Caution: drug interaction with carbonate, phosphate, digitalis; avoid hypercalcemia In less acute condition: increase calcium intake—calcium gluconate or lactate

Hypocalcemia

» Evaluation/Outcome Criteria:   

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Ca++ 4.5–5.5 mEq/L No signs of tetany Absent Trousseau's and Chvostek's signs Lists foods high in vitamin D and calcium

Hypercalcemia Disorder and Related Condition: •

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Parathyroid glands: overactive, tumor Increased immobility Decreased renal function Bone cancer Increased vitamin D and calcium intake Milk-alkali syndrome—selfadministration of antacids;

Hypercalcemia

» Assessment Subjective Data: • Pain: flank, deep bone, shin splints • Muscle weakness, fatigue • Anorexia, nausea • Headache • Thirst polyuria

Hypercalcemia » Assessment

Objective Data: • Muscles: relaxed • GU: kidney stones • GI: increased milk intake, constipation, dehydration • Neurological: stupor coma

Hypercalcemia

» Analysis/Nursing Diagnosis: – Decreased cardiac output – Constipation – Activity intolerance – Altered urinary elimination – Pain

Hypercalcemia Nursing Care Plan/Implementation: 

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Reduce calcium intake: decrease foods high in calcium; identify cause of imbalance; give steroids, diuretics as ordered; isotonic saline IV Prevent injury: prevent pathological fractures (e.g., advanced cancer); prevent renal calculi by increasing fluid intake

Hypercalcemia

» Evaluation/Outcome Criteria:  Ca++ 4.5–5.5 mEq/L  No pain reported  No fractures/calculi seen on x-ray exam

Hypomagnesemia Disorder and Related Condition: • •

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Impaired GI absorption Prolonged malnutrition or starvation Alcoholism Excess loss of magnesium through kidneys, related to increased aldosterone production Prolonged diarrhea Draining GI fistulas

Hypomagnesemia » Assessment Subjective Data: • Agitation • Depression • Confusion • Paresthesia Objective Data: • Muscles: irritable, tremors, spasticity, tetany convulsions • Cardiac: arrhythmias, tachycardia

Hypomagnesemia

» Analysis/Nursing Diagnosis: – Risk for injury related to seizure activity – Decreased cardiac output

Hypomagnesemia » Nursing Care Plan/Implementation: – Provide safety: prevent injury to client who is disoriented; administer magnesium salts PO or IV – Health teaching: prevention; diet—high magnesium foods: fruits, green vegetables, whole grain cereals, milk, meats, nuts » Evaluation/Outcome Criteria:  Mg++ 1.5–2.5 mEq/L

Hypermagnesemia Disorder and Related Condition • • • •

Renal failure Diabetic ketoacidosis Severe dehydration Antacid therapy

Hypermagnesemia » Assessment

Subjective Data: • Drowsiness, lethargy Objective Data: • Neuromuscular: loss of deep tendon reflexes • Respiratory: depression • Cardiac: arrest, hypotension

Hypermagnesemia » Analysis/Nursing Diagnosis: • • • • •

Ineffective breathing pattern Decreased cardiac output Fluid volume deficit Fluid volume excess Altered cardiopulmonary tissue perfusion

Hypermagnesemia » Nursing Care Plan/Implementation: – Obtain normal magnesium level: IV calcium, fluids; possible dialysis » Evaluation/Outcome Criteria:  Mg++ 1.5–2.5 mEq/L  No complications (e.g., respiratory depression, arrhythmias)  Identifies magnesium-based antacids  (e.g., Gelusil)  Deep-tendon reflexes 2+

Acid-Base Balance 

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concentration of hydrogen ions in extracellular fluid is determined by the ratio of bicarbonate to carbonic acid. The normal ratio is 20: 1. Even when arterial blood gases are abnormal, if the ratio remains at 20: 1, no imbalance will occur.

A. Causes of blood gas abnormalities:

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Acid-base balance

B. Types of acid-base imbalance: 1. Acidosis: hydrogen ion concentration increases and pH decreases. 2. Alkalosis: hydrogen ion concentration decreases and pH increases. 3. Metabolic imbalances: bicarbonate is the problem. In primary conditions, the level of bicarbonate is directly proportional to pH.

Metabolic imbalances a. Metabolic acidosis: excessive acid is produced or added to the body, bicarbonate is lost, or acid is retained due to poorly functioning kidneys. Deficit of bicarbonate. b. Metabolic alkalosis: excessive acid is lost or bicarbonate or alkali is retained. Excess of bicarbonate. c. As compensatory mechanism, Pco2 will be low in metabolic acidosis, as the body attempts to eliminate excess carbonic acid and elevate pH. Pco2 will become elevated

Acid-base balance

4. Respiratory imbalances: carbonic acid is the problem. In primary conditions, Pco2 is inversely proportional to the pH. a. Respiratory acidosis: pulmonary ventilation decreases, causing an elevation in the level of carbon dioxide or carbonic acid. Excess of Pco2.

Respiratory imbalances

b. Respiratory alkalosis: pulmonary ventilation increases, causing a decrease in the level of carbon dioxide or carbonic acid. Deficit of Pco2. c. As a compensatory mechanism, the level of bicarbonate will increase in respiratory acidosis and decrease in respiratory alkalosis.

Acid-base balance

C. Assessment: * D. Analysis/nursing diagnosis: 1. Impaired gas exchange related to hyperventilation. 2. Ineffective breathing pattern related to decreased thoracic movements. 3. Ineffective airway clearance related to retained secretions. 4. Risk for injury related to poorly functioning kidneys. 5. Altered renal tissue perfusion related to

6. Altered urinary elimination related to renal failure. 7. Fluid volume excess related to altered kidney function. 8. Fluid volume deficit related to diarrhea or dehydration. 9. Knowledge deficit (learning need) related to self-administration of antacid medications. E. Nursing care plan/implementation * F. Evaluation/outcome criteria *

Acid-Base Imbalances Respiratory Acidosis

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Disorder and Related Conditions: Acute bronchitis Emphysema Respiratory obstruction Atelectasis Damage to respiratory center Pneumonia Asthmatic attack Drug overdose

Acid-Base Imbalances Respiratory Acidosis » Assessment

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Subjective Data:

• Headache • Irritability • Disorientation • Weakness • Dyspnea on exertion • Nausea

Acid-Base Imbalances Respiratory Acidosis » Assessment

Objective Data: • Hypoventilation: rate or rapid and shallow • Cyanosis; Tachycardia • Diaphoresis • Dehydration • Coma (CO2 narcosis) • Hyperventilation to compensate if no pulmonary pathology present • HCO3, normal • Paco2, elevated; pH <7.35

Acid-Base Imbalances Respiratory Acidosis

Nursing Care Plan/Implementation:  Assist with normal breathing: encourage coughing; suction airway; postural drainage; pursedlip breathing;  Protect from injury: oxygen as needed; encourage fluids; avoid sedation; medications as ordered— antibiotics, bronchial dilators 

Health teaching: identify cause, prevent future episodes; increase awareness regarding risk factors and early signs of impending imbalance; encourage

Acid-Base Imbalances Respiratory Acidosis

» Evaluation/Outcome Criteria:  Normal acid-base balance obtained  Respiratory rate: 16–20  No signs of pulmonary infection (e.g., sputum colorless, breath sounds clear)  Demonstrates breathing exercises (e.g., diaphragmatic breathing)

Metabolic Acidosis Disorder and Related Conditions:         

Diabetic ketoacidosis Hyperthyroidism Severe infections Lactic acidosis in shock Renal failure uremia Prolonged starvation diet; low protein diet Diarrhea, dehydration Hepatitis Burns

Metabolic Acidosis » Assessment 

Subjective Data:

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Headache Restlessness Apathy, weakness Disorientation Thirst Nausea, abdominal pain

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Metabolic Acidosis » Assessment

Objective Data:         

Kussmaul's respirations: deep, rapid air hunger; Temperature Vomiting, diarrhea Dehydration Stupor convulsions coma HCO3, below normal Paco2 normal K+ >5 pH <7.35

Metabolic Acidosis

Nursing Care Plan/Implementation:  Restore normal metabolism: – correct underlying problem; sodium bicarbonate PO/IV; sodium lactate; fluid replacement, Ringer's solution; diet: high calorie  Prevent complications: – regular insulin for ketoacidosis; hourly outputs; prepare for dialysis if in kidney failure  Health teaching: – identify signs and symptoms of primary illness, prevent complications, cardiac arrest; diet instructions

Metabolic Acidosis

Evaluation/Outcome Criteria:  Normal acid-base balance obtained  No rebound respiratory alkalosis following therapy  No tetany following return of normal pH  Alert, oriented  No signs of K+ excess

Respiratory Alkalosis Disorder and Related Conditions:       

Hyperventilation—CO2 loss Hypoxia, high altitudes Fever Metabolic acidosis Increased ICP, encephalitis Salicylate poisoning After intensive exercise

Respiratory Alkalosis » Assessment

Subjective Data: Circumoral paresthesia  Weakness  Apprehension 

Respiratory Alkalosis » Assessment Objective Data:  Increased respirations  Increased neuromuscular irritability; hypereflexia, muscle twitching, tetany, positive Chvostek's sign  Convulsions  Unconsciousness  Hypokalemia  HCO3, normal  Paco2 decreased 

Respiratory Alkalosis

Nursing Care Plan/Implementation: > Increase carbon dioxide level: rebreathing into a paper bag; adjusting respirator for CO2 retention and oxygen inspired; correct hypoxia > Prevent injury: safety measures for those who are unconscious; hypothermia for elevated temperature > Health teaching: recognize stressful events; counseling if problem is hysteria

Respiratory Alkalosis

Evaluation/Outcome Criteria:  Normal acid-base balance obtained  Recognizes psychological and environmental factors causing condition  Respiratory rate returns to normal limits  No cardiac arrhythmias  Alert, oriented

Metabolic Alkalosis Disorder and Related Conditions:  Potassium deficiencies  Vomiting  GI suctioning  Intestinal fistulas  Inadequate electrolyte replacement  Increased use of antacids  Diuretic therapy, steroids  Increased ingestion/injection of bicarbonates

Metabolic Alkalosis » Assessment

Subjective Data:    

Lethargy Irritability Disorientation Nausea

Metabolic Alkalosis » Assessment

Objective Data:        

Respirations: shallow; apnea, decreased thoracic movement; cyanosis Pulse: irregular cardiac arrest Muscles: twitching tetany, convulsions G. I.: vomiting, diarrhea, paralytic ileus HCO3, elevated above 26 Paco2 normal, K+ <3.5, pH >7.45

Metabolic Alkalosis

Nursing Care Plan/Implementation:  Obtain, maintain acid-base balance: irrigate NG tubes with saline; monitor I&O; IV saline, potassium added; isotonic solutions PO; monitor vital signs 

Prevent physical injury: monitor for potassium loss, side effects of medications

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Health teaching: increase sodium when loss expected; instructions regarding selfadministration of medications (e.g., baking soda)

Metabolic Alkalosis

Evaluation/Outcome Criteria:     

Normal acid-base balance obtained No signs of potassium deficit Respiratory rate: 16–20 No arrhythmias—pulse regular Lists food sources high in potassium

Blood Gas Abnormalities: Causes Decreased Po2 

Collapsed alveoli (atelectasis) – 1. Airway obstruction  a. By the tongue  b. By a foreign body – 2. Failure to take deep breaths  a. Pain (rib fracture, pleurisy)  b. Paralysis of respiratory muscles (spinal cord injury, polio)  c. Depression of the respiratory center (head injury, drug overdose) – 3. Collapse of the whole lung (pneumothorax)

Blood Gas Abnormalities: Causes (cont.)

Decreased Po2 

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Fluid in the alveoli – 1. Pulmonary edema – 2. Pneumonia – 3. Near-drowning – 4. Chest trauma Other gases in the alveoli – 1. Smoke inhalation – 2. Inhalation of toxic chemicals – 3. Carbon monoxide poisoning Respiratory arrest

Blood Gas Abnormalities: Causes • Elevated Pco2  Decreased CO2 elimination (hypoventilation) 1. Decreased tidal volume

a. Pain (rib fractures, pleurisy) b. Weakness (myasthenia gravis) c. Paralysis (spinal cord injury, polio)

2. Decreased respiratory rate a. Head injury b. Depressant drugs c. Stroke

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Increased CO2 production 1. Fever 2. Muscular exertion 3. Anaerobic metabolism

“Always treat your patients as you would treat your family.” - Dra. Uy