Chamberlain College of NursingFundamentals of Nursing

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Homeostasis: To maintain a stable, relatively constant condition

Body fluids and components in constant motion in an effort to maintain homeostasis

Transporting water, electrolytes, oxygen, nutrients in and cell metabolism waste or unnecessary components out.

Many conditions or diseases can disruptSweatingAltered Fluid IntakeVomitingDiarrheaDiabetesOrgan Failure

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Intake and output (et al) to be equal

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WaterWhat it does

Transportation of nutrients, electrolytes and oxygen to the cells

Excretion of waste products

Regulation of body temperature

Lubricator, insulator, and shock absorber of joints and membranes

Medium for food digestion

Water composition in60% in AdultIncreased in ChildDecreased in Older Adult

Found in Foods (not ETOH)

2000 mL-3000 mL/day1 liter H2O=1 kg body

weight

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1 liter Weighs 1 kilogramPatient weighs 78

kilogramsHas vomiting and

diarrheaDaily weights are

initiatedPatient dropped to

75 kilogramsHow much fluid is

he deprived?

78 kilograms- 75 kilograms_______ 3 kilograms loss

3 kilogram loss:3 kg 1

liter

1 kg

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Intake and LossIntake:Fluids: 1500 mL/daySolid Foods 800 mL/dayMetabolism 300 mL/day

Loss: Kidneys 1200mL-1500 mLSkin 500-600 mL/dayLungs 400 mL/dayGI tract 100-200 mL/dayDrainage: ???

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Intake and outputMeasurable

IntakeOral and tube

feedingsParental fluidsEnemasRetained irrigant

Not Measurable:Solid foodsMetabolism

MeasurableUrine EmesisFecesDrainage from body

cavity

Not Measurable:SweatingVaporization

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ElectrolytesChemicals dissolved in body fluidDistribution of electrolytes affects fluid balanceHelps regulates intake, output, acid/base

balance, hormonesSodium

Major Extra cellular electrolyte Controls and regulates WATER balance

Potassium Major Intra cellular electrolyte Helps maintain intracellular water balance Transmits nerve impulses, muscle contraction

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Fluid and Electrolyte LabsElectrolyte Normal Action

Sodium 135-145 mEq/dl Water

Potassium 3.5-4.5 mEq/dl Nerves, muscles, heart

Chloride 98-106 mmol/dl Osmotic pressure, acid base balance

Calcium 9.0-10.5 mg/dl Nerve, heart, blood clotting

Phosphate 3.0-4.5 mEq/dl Calcium (inverse relationship)

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Fluid and Electrolyte : LabsBUN- nitrogen in the blood from ureaCreatinine- byproduct of muscle metabolismHematocrit- volume percentage of erythrocytesHemoglobin- the iron containing pigment of the

red blood cellsUrine Specific Gravity- Urine Concentration

BMP (“Chem 7) (Basic Metabolic Panel)- Na+, K+, Cl-, BUN, Creatinine, CO2,

Glucos

CMP (Chem 14) (Comprehensive Metabolic Panel) Na+, K+, Cl-, Ca+, BUN,

Creatinine, CO2, Glucose, Liver Enzymes, (ALT, AST, Bilirubin) Alkaline Phosphatase, Total Protein, Albumin

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Osmolality & OsmolarityBoth terms refer to concentration of a

solutionConcentration creates osmotic pressure

(pulling power)Higher concentration = greater pulling powerNormal value 275 – 295 mOsm/L

Osmolality Concentration of particles per kilogram of water

Osmolarity Concentration of particles per liter of solution (not

necessarily water)

Terms often used interchangeablyfe66; IV 96 13

Two Compartments of Fluid in the BodyIntracellular fluid (ICF)—fluid within cells (70%)Extracellular fluid (ECF)—fluid outside cells

(30%)Includes intravascular and interstitial fluidstranscellular

Think of it as 3 compartments:Inside the cellsBlood & Blood vesselsTissue

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Distribution of FluidsIntracellular fluid (ICF) – fluid within cells (70%)

Vital for normal cell functionContains oxygen, electrolytes, & glucose

Extracellular fluid (ECF) – fluid outside cells (30%)Interstitial fluids – surround cellIntravascular fluids – plasma within vascular systemTranscellular fluids – cerebrospinal, pericardial,

pancreatic, pleural, intraocular, biliary, peritoneal, & synovial fluid

*** To maintain proper fluid balance, the distribution of fluid between the two compartments must remain relatively constant.

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Diffusion Osmosis Active Transport

Filtration

Definition: The process where by solutes move from an area of higher concentration to an area of lower concentration.

Molecules are randomly vibrating

The fluid with more particles more concentrated has more pulling power.

Fluid will get pulled across a membrane from a more dilute area to a more concentrated area.

Osmolarity: The pulling power or concentration of a solution.

Particles “swimming upstream” *pushing*

The molecules need a ”push” to get across the membrane.

Energy is required. (ATP)

Example: Sodium-potassium pump

Solutes can only pass through the capillary walls.Membranes act as barriers. We need pressure to get across.

Capillary Osmotic Pressure

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Hypotonic Isotonic Hypertonic

# of particles fewer than plasma.

A hypotonic fluid will shift and flow

into a more concentrated

solution.

# of particles just like plasma.

Two isotonic fluids on different sides of a barrier stay put!

# of particles greater than plasma

A hypertonic fluid will pull a less concentrated

solution into itself.

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Kidneys:Juxtaglomerular Apparatus

Kidneys:Adrenal Cortex

Hypothalamus Heart

Sense low sodium volumeRelease reninConverts angiotension I to Angiotension IIStimulates release of aldosterone (RAAS)

Senses low serum osmolarity or low sodiumReleases aldosteroneReabsorbs sodium Increases K+excretion in to the urineIncreases serum osmolarityExcretes sodium in the urine

Senses high serum osmolarity or high Na+

Stimulates thirstTriggers release of ADH: vasopressin Retains water in blood Concentrates urineMild constriction of blood vesselsDecreases serum osmolarity

Senses increased volume : stretch receptors in the right atriumSecretes ANP, BNPInhibits ADHStops RAASIncreased Na+excretion through urine stops reabsorption of Na+

Dilates blood vesselsDecreases serum osmolarity

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Fluid SpacingFirst spacing

Normal distribution of fluid in ICF and ECFSecond spacing

Abnormal accumulation of interstitial fluid (edema)

Third spacingFluid accumulation in part of body where it is

not easily exchanged with ECF

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Gerontologic ConsiderationsDecreased body weight 45-50% instead of 60%

Places them at higher risk for f/e imbalancesDecreased muscle massStructural changes-

Kidneys decreased GFR, decreased renin/aldosterone Decreased creatinine clearance, decreased ability to

concentrate. Decreased ability to conserve water

Loss of Subcutaneous tissue, decreased thirst, musculoskeletal changes, mental status changes, incontinence- leading to withholding the water to not be incontinent, then becoming dehydrated.

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Fluid and Electrolyte DisordersFluid Volume DeficitFluid Volume ExcessHypernatremia/ HyponatremiaHyperkalemia/ HypokalemiaHypercalcemia/ HypocalcemiaHyperphosphatemia/

HypophosphatemiaHypermagnesemia/Hypomagnesemia

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Extracellular Fluid Volume Imbalances

ECF volume deficit (Hypovolemia)Abnormal loss of normal body fluids

diarrhea, fistula drainage, hemorrhageInadequate intake

Access, desire, medication influencePlasma-to-Interstitial fluid shift

Edema, 3rd Spacing Treatment: replace water and electrolytes with

balanced IV solutions

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Fluid Volume Deficit: Hypovolemia or Dehydration

Fluid Intake is less than Fluid Output:

Hypovolemia—water and electrolyte losses about equal

Clinical Dehydration—more water lost than electrolytesFluid volume deficit + hypernatremia

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Causes of Fluid Volume Deficit• Prolonged fever• GI Losses: Watery diarrhea, Vomiting, drainage from tubes• Loss of plasma or whole blood: Burns, Hemorrhage, Traumas, Surgery• Excessive sweating• Renal failure• Hyperglycemia• Inability to drink or express thirst (confused)• Concentrated tube feedings• Third-space shifts• Use of diuretics

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Fluid Deficit: Signs & SymptomsModerate Severe

ThirstDizziness weakness confusion anxietyPostural hypotensionFlushed, dry skin Possible feverDry mucous membranesDecreased urine output; dark yellow to amberChange in skin turgor (?)Weight loss

HR RR BPLethargy progressing to comaDry, cracked tongueCold, clammy skindelayed capillary refillTentingDark or no urine (less than 30 ml/hour)No tears or sweatSunken eyeballs

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Lab ValuesHypovolemia: Loss of fluids and electrolytes.

(Excessive fluid loss like hemorrhage)Increased Hematocrit/HemoglobinIncreased BUNElevated specific gravity

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Lab ValuesDehydration

Elevated HematocritElevated SodiumIncreased serum osmolality Urine specific gravity greater than 1.030

We’ve lost water, but not electrolytes. More particles, less fluid.

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Fluid Volume Deficit:The Nursing ProcessDiagnoses:

Deficient fluid volumeRisk for imbalanced fluid volumeReadiness for enhanced fluid balance

Currently in balance but have many risk factorsGoals/Outcomes:

Restore fluid lossIdentify patients at riskMaintain balance between fluid intake and

outputPrevent fluid imbalance

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Treatment for Fluid Volume DeficitReplace missing fluidsDehydration: Oral fluids or IV

Low sodium, hypotonic like 0.45 NSWhy: Blood is concentrated; Na level is high

Hypotonic solutions will draw fluid into cells and swell them if given too quickly

Administer gradually

Hypovolemia: Isotonic fluids 0.9NS or Lactated Ringer’s/blood transfusion PRN

Why: Restore blood volume and normalize BP

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Nursing management: FVDVSLOC changesSafe environmentI and ODaily weightsLab valuesSkin turgor and integrityIV accessUrinary catheter

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Extracellular Fluid Volume Imbalances

Fluid volume excess (Hypervolemia)Excessive intake of fluids, Abnormal retention of fluids

Congestive Heart Failure, Renal Disease, Medication influences

Interstitial-to-plasma fluid shift

Treatment: remove fluid without changing electrolyte composition or osmolality of ECF

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Fluid Volume Excess: Over hydration

Excessive retention of either just water or water and sodium.

s/s and treatment will be similarCauses:

kidney, heart, or liver failureToo rapid infusion of IV fluidsCorticosteroids

Labs: Hemodilution: More water than particlesLow H and HLow or normal NaDecreased serum osmolalityDecreased BUN

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Fluid Volume Excess: Signs & Symptoms

EdemaDependent areas firstFace and whole body later (anasarca)Skin: taut, shiny

Bounding pulse/elevated BPJVD: Jugular vein distentionSOB; crackles; coughWeight gainLOC: confusion/lethargyMuscle cramps/weaknessNausea

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Fluid Volume Excess: TreatmentRestrict sodium and water intake

May give hypertonic fluids VSRespiratory statusI and OLab valuesDaily weightsRaise HOBSafety and ComfortMeds as needed to help organ functionTeaching and prevention

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Electrolytes: What are they? Substances that split when put in water

Separate into IONS: CHARGED PARTICLES: +positive or CATIONS -negative or ANIONS

Found in ALL fluid compartments

Cations are supposed to equal Anions:+Sodium, Potassium, Calcium, Magnesium-Bicarbonate, Chloride, Phosphorous

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Electrolytes• Measurement:• International standard is mill moles per liter (mmol/L)• U.S. uses milliequivalent (mEq)

• Electrolyte Composition:• ICF•Prevalent cation is K+

•Prevalent anion is PO43

• ECF•Prevalent cation is Na+

•Prevalent anion is Clfe66; IV 96 39

Major Electrolytes in Brief Sodium:135-145mEq/L (fluids; acid-base; nerve and muscle cells) Potassium:3.5-5mEq/L (fluids; cell excitability) Calcium: Ionized Calcium 4.5-5.5mg/dl (teeth; bones; clotting;

nerve/muscle cells) Magnesium: 1.5-2.5 mEq/L (nerve/muscle cells; cellular reactions) Chloride: 95-105mEq/L (fluids; pH and acid-base balance) Bicarbonate:22-26(arterial)mEq/L,24-30(venous) (acid-base

balance)

Phosphate:2.8-4.5mg/dl acid-base balance; metabolism)

Cations (+) Anions (-)Na+ SodiumK+ PotassiumCa+ CalciumMg+ Magnesium

Cl- ChlorideHCO3

- BicarbonateHPO4

2- PhosphateSO4

2- Sulfate

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Sodium: HypernatremiaNA+= >145 mEq (Norm: 135-145 mEq)

Water loss or excess Na+

Decreased Na+ excretion- renal failure, corticosteroids

Increased NA+ intake- eating too much salt/ hypertonic IV fluids

Increased water loss, fever, infection, hyperventilation, sweating, diarrhea

You are “FRIED”F-FeverR-RestlessI-Increased fluid retention E-EdemaD-Decreased urine outputExtreme: Mental status change, fever, seizuresTreat the etiology- diuretics, Na+ restriction, avoid Na+ foods, seizure precautions

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Sodium: HyponatremiaNa+=<135 mEq (Norm: 135-145 mEq)

Water excess or loss of Sodium

Dilution- polydipsia, diabetes, SIADH, CHF

Increase excretion of Na+- sweating, diuretics, GI wound drainage, renal disease

Decreased intake of Na+ NPO, low NA+ diet, severe vomiting, diarrhea

SymptomsConfusion, headache,

CNS, neurological (BRAIN)

Abdominal Cramps, Nausea, vomiting

Replace Na+ (usually IV )

Hypertonic solution (3% Na+ Solution)

Fluid Restriction if caused by fluid excess

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Potassium: Hyperkalemia>5.0 mEq (Norm 3.5-5 mEq)Major Intracellular cationNa+/K+ Pump- No

hormonal controlSource: primarily diet

Avocado, fish, bananas, OJ, raisins, dried fruit, meat, milk, fruits, vegetables

Oral supplements, IV supplements

Route of loss: Kidneys/urine

Disrupts Cardiac Function-increased cell excitabilityHyperkalemia- cause is primarily from kidney dysfunctionFalse high results:lab inaccuraciesPoor lab collection practices/improper specimen handlingProlonged tourniquetOld blood, cell destruction, acidosis, hypoxia, exercise, catabolic state, K+ sparing diuretics (spironolactone)

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HyperkalemiaSymptoms

MURDERM- muscle weaknessU-Urine-oliguria,

anuriaR-Respiratory distressD-Decreased cardiac

contractilityE-ECG changesR-Reflexes:

hyperreflexia or anreflexia

Treatment:Cardiac MonitoringKayexelate (oral or

rectal)Calcium gluconate,

LasixStop K+ in IV fluidsAvoid foods high in

potassiumDialysis if severe

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Potassium: Hypokalemia>3.5 mEq (Norm 3.5-5.0 mEq)Cardiac Function

(decreased excitability of cells)

Causes: vomiting, NG suction, diarrhea, diuretics, laxatives, insulin, metabolic alkalosis, rapid cell building, B12 or erythropoietin to increase RBC

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HypokalemiaSigns/SymptomsDysrhythmia,

weakness, nausea/vomiting, paralytic ileus, constipation, decreased blood pressure, weak pulse, increase digoxin, muscle weakness, paralysis, diuresis

TreatmentCardiac MonitorFoods high in

potassiumWatch for digoxin

toxicityPotassium IV only if

good outputSpironolactoneTreat constipation

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Potassium Intravenous Supplements

Must have adequate urine output (at least 600 mL/Day)

Never IV push- cardiac arrest potential

Cardiac MonitorAssess IV site often-

Very irritating- prefer CVC

Always dilute- no more than 20 mEq/hr; no more than 40 mEq in IV bag

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Hypercalcemia>10.5 mg (Norm 9.0-10.5 mg)Bones- primary sourceAffects transmission of

nerve impulses, heart and muscle contractions, blood clotting, formation of teeth and bones

Must have Vitamin D to absorb

Dietary intake GI absorption

Parathyroid hormone-causes Ca+ to

increase Ca+ to release from bones and increase Vitamin D

Decrease kidney excretion of Ca+

Calcitonin decreases calcium absorption, inhibits bone reabsorption

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HypercalcemiaHypercalcemiaNausea, constipationCardiac ArrestDecreased

excitability, tetany, increased heart, interrupts muscle cell

Prolonged immobilization, renal failure

Lethargy, confusion, sever muscle weakness, fractures, kidney stones, increased clotting time

Treatment:Get rid of calcium,

Lasix, Hydration

3-4000mL/day, weight bearing activity NO antacids

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Hypocalcemia<9.0 mg (Norm 9.0-10.5 mg)Removal of parathyroid,

immobility, malabsorption, renal failure post menopausal

Treatment:Calcium supplements,

diet increase Calcium with Vitamin D supplement

Biggest risk: Thyroid surgery

Signs/Symptoms: CATS

C- ConvulsionA-ArrhythmiasT- TetanyS- Spasms/Stridor

Trousseaus- Carpal/pedal spasms

Chvostec’s sign- facial nerve

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Phosphate 3.0-4.5 mEqHyperphosphatemia

Cause: renal failure, tumors, lysis syndrome,

s/s- Calcium deposits in joints, skin, kidneys, eyes, hypocalcemia, tetany, neuromuscular irritability

Treatment: Correct Hypocalcemia (inverse relationship)

Hypophosphatemia

Cause: malnutrition, malabsorption, alcohol abuse, too many antacids

s/s- CNS depression, confusion, muscle weakness, dysrhythmias, fractures

Treatment: oral supplements, decrease calcium intake, IV replacement

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Magnesium 1.3-2.1 mEq HypermagnesemiaCause: increased

intake, MOM, Maalox, Chronic kidney disease

s/s lethargy, nausea/vomiting, loss of deep tendon reflexes, respiratory/cardiac arrest

Treatment: avoid magnesium containing foods/drugs, dialysis if severe

HypomagnesemiaCause: prolonged

fasting, starvation, alcohol abuse,

s/s increased deep tendon reflexes, confusion, tremors, seizures, cardiac changes

Treatment oral supplements, increased green vegetables, nuts, bananas oranges, peanut butter, chocolate

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1115115

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Electrolytes: Food sourcesSodium

Table salt/processed and canned foods/deliPotassium

Bananas/citrus/melon/apricots/broccoli/potatoes

MagnesiumGrains/beans/green leafy

veg/seafood/meat/chocolateCalcium

dairyfe66; IV 96 57

Administering MedicationsMineral-electrolyte preparations

often powders dissolved in water or juicediluted so they don’t taste so bad and don’t

irritate the stomachSudden hyperkalemia can cause cardiac arrestPOTASSIUM GIVEN IV PUSH IS LETHAL

(Never, never, never do this !!!)Diuretics

Rid body of excess fluid (and electrolytes!) Must be monitored closely to prevent further

imbalances.Intravenous therapy

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Acid-Base BalanceChemical balance in the body is regulated by acidity

or alkalinity, which is measured by the pH valueArterial Blood Gas (ABG) analysis is the best way to

evaluate acid-base balance and oxygenationOur body must maintain a delicate balance between

acidity and alkalinity in order for life to be maintained

Common Health problems which lead to imbalanceDiabetes mellitusVomiting and diarrhea Respiratory conditions

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Acid–Base Balance: Where’s the hydrogen?

Our acidity defines us. It’s a delicate balance, without which life cannot be supported. All our internal chemical reactions can only take place within the right acid-base environment.

Acidsubstance that releases H+ ion when dissolved in

waterBase

substance that will bind with H+ ion when dissolved in water

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pHNormal values 7.35-7.45Compatible with life 6.8 - 8.0Body fluids maintained normal values by:

Buffers, Respiratory system, Renal system

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ABG’s: Measuring acid-basepH 7.35-7.45

Hydrogen ion concentration

PaCO2: 35-45mmHG Arterial carbon dioxide- Carbonic Acid

HCO3: 22-26mEq/L Bicarbonate

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Causes of Acid-Base BalanceMetabolic Acidosis

Diabetic ketoacidosisDiarrheaRenal failureShockAspirin overdoseSepsis

Metabolic AlkalosisLoss of gastric secretionsOveruse of antacidsK+ wasting diuretics

Respiratory AcidosisHypoventilationCOPDAirway obstructionDrug overdoseChest traumaPulmonary edemaNeuromuscular disease

Respiratory AlkalosisHyperventilationHypoxiaAnxietyHigh altitudePregnancyFever

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Acid/Base CompensationLungseliminates or retains

carbonic acid Very fast/efficient to

respond to changeAlters rate/depth of

respirationsFaster rate/more

depth - eliminates CO2 and pH rises

Slower rate/less depth retains CO2 and pH lowers

KidneysRegulate by

selectively excreting or conserving bicarbonate and hydrogen ions

Slower to respond to changeTakes hours to days

to restore H+ ion concentration.

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Let’s Practice …Mr. Lowery, 54, suffered an acute anterior wall MI and is now in cardiogenic shock. ABGs show:

pH: 7.27 PaCO2: 38

HCO3- : 14

What is his acid/base status ???

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Rationales and objectives of parenteral therapy

Maintenance therapy for daily body requirements

Replacement therapy for present lossesRestoration therapy for concurrent or

continuing losses: HemorrhageLow Platelets Vomiting Diarrhea

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Intravenous TherapyDelivery method considerations

Purpose of therapyLength of time the infusion is to runDiagnosis, age, and health historyType of solution used or what drugs are being

administeredCondition of veins

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General Guidelines/Short Peripheral CathetersShort Peripheral Catheter: Use the smallest size catheter to

accommodate therapySize of Catheter Use

14-16 gauge Trauma, large volume at a rapid rate

18 gauge Surgical patient, rapid administration of fluids and blood products

20-24 gauge Most medical/surgical patients, daily use

22-24 gauge Older adults, small vein access

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General Guidelines:Peripherally inserted central catheterMajor factors:

Therapy will continue for 1 month or moreTherapy includes administration of a vesicant

infusion or long-term antibiotic therapy

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Placement of Peripherally Inserted Central Catheter (PICC)

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Central LinesLarge Lumen Catheter surgically placed into

a central vein (subclavian or internal jugular)Used for:

Long Term TherapyAll IV TherapiesBlood DrawsBad peripheral veinsLarge fluid volumesTotal parenteral nutrition

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Central Line ConsiderationsSurgically placed (not PICC) Placement verified by x-ray (Superior Vena

Cava)Sterile dressings and techniqueFlushing and Locking per facility policyComplications include: Central Line Infection,

pneumothorax, hemothorax, cardiac perforation, Watch for: SOB, chest pain, cough, hypotension,

tachycardia, anxiety after or during insertion

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Implanted PortsFluid reservoir is surgically inserted in a

subcutaneous pocket(usually upper chest) with catheter via the internal jugular or subclavian vein with the tip resting in the superior vena cava

All IV Therapies can be administered through the port

Have a low infection rateHas cosmetic advantagesMust use non-coring needle to access

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Isotonic Hypotonic Hypertonic

Isotonic fluid stays inside the bloodstream or intravascular compartment.

Ex: 0.9% NSLR (contains Na+, Cl+, K+, & Ca+ )

A hypotonic fluid will shift and flow into a more concentrated solution.

Draw fluid from vessels and move fluid into the cells.

Ex: D5W0.45% NS

A hypertonic fluid will pull a less concentrated solution into itself.

Draw fluid out of the cells and into the blood

Used for panic low Na levels (115)

Ex: 3% NS5% NSfe66; IV 96 79

Skills:Administering Parenteral Fluids

The nurse should observe for the following guidelines:Monitor the solution infusion rate Infuse the amount of prescribed solution.Maintain the patency of the IV catheter.Monitor site every 1 to 2 hours or as per policyDuring parenteral therapy, the patient’s I&O

should be recorded.

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Skills:Administering Parenteral Fluids

Intravenous Therapy/VenipunctureBefore the procedure, assemble and make ready

the equipment.Assess the patient’s veins (start distally)Select and clean a puncture site. Follow strict

aseptic principlesPerform venipuncture.Begin infusion.Teach the patient about the signs and symptoms

of problems and ways to perform activities while on IV therapy.

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Skills:Administering Parenteral Fluids

Intravenous Therapy/Venipuncture Intravenous Monitoring

Patency A condition of being opened and unblocked

Flow rate is ordered by the physician. Assess tubing for kinks or obstructions. Inspect and palpate the site for complications Assess for signs and symptoms of fluid overload.

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Skills:Administering Parenteral Fluids-

complicationsIntravenous Therapy/Venipuncture

Phlebitis This results from mechanical irritation (the needle

moving in the vein), the low pH of some IV solutions, and highly concentrated additives.

Classic Signs Erythema, warmth, edema, and discomfort

Applying warm compresses to the inflamed area lessens discomfort.

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2011 Recommendations of the Infusion Nurses SocietyPhlebitis Scale

Grade Clinical Criteria

0

1

2

3

4

No symptoms

Erythema at access site with or without edema

Pain at access site with erythema or edema

Pain at access site with erythema or edema plus streak formation and palpable cord

Pain at access site with erythema and edema, streak, palpable cord>1 inch in length & purulent drainage

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Infiltration ScaleSymptoms 0 1 2 3 4

Blanching

Edema < 1 inch 1-6 inches > 6 inches >6 inches, pitting

Cool to touch

Pain +/- +/- Mild to moderate; numbness

Moderate to severe;Circulatory impairment

Blood or vesicant therapy

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ExtravasationDefinition: seepage of IV medication into

tissueCause: vein has ruptured allowing vesicant

to seep into surrounding tissuesSymptoms: swelling, redness, pain, blistersExtravasation kit may be used to neutralize

the damage

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Severed CatheterCatheter “broke” off an tip entered the

circulatory systemRare but deadly.Pain at site, decreased BP, weak rapid pulse,

cyanosisApply tourniquet above site of painNotify MD statMonitor and support patientAvoid causing by:

Never reinserting a needle through a catheter after withdrawing it.

Remove catheter slow & parallel to skinInspect catheter after removal

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Complications of IV therapyInfection: redness, warmth, pain, hardness,

fever, purulent drainage

If infection is suspected, determine whether culture of catheter is needed PRIOR to

discontinuing

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Skills for Administering Parenteral FluidsIntravenous Therapy/Venipuncture

Septicemia A systemic infection occurs from pathogens

introduced into the circulating bloodstream. Signs and Symptoms

Fever, chills, prostration, pain, headache, nausea, and vomiting

Antibiotic therapy is vigorously initiated if blood cultures verify a septicemia condition.

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Nursing care of the IV patientCheck IV order for completeness, accuracyI and O and WeightsMonitor rate of infusion (IV fluids can kill!)Remember the size and age of your patient (don’t

overload them!)Change site, dressing, tubing and solution per

agency policy (usually every 24 hours)Documentation:

Date, time, site, type of catheter insertedType and amount of fluid infusedPatient’s response to therapy and teaching

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Blood Transfusions : ProcessVerify physician order; Obtain ConsentPatient must have a type and cross-match blood sample

performedLarge bore catheter: 18 gaugeAdminister with 0.9% Normal SalineBaseline vital signs, hold and notify if abnormalPre-medication may be ordered: Diphenhydramine,

Acetaminophen

Double check with two RNs at patient’s bedside: Everything must match!

Begin transfusion slowly- watch for reactionsObserve closely for first 15 min- Stop immediately if any sign of

reactionBlood may not hang longer than 4 hours

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Blood Transfusion ReactionsCaused by: Blood incompatibilityAllergic sensitivity

Signs and Symptoms: Change in Vital Signs, fever, chills, rash, hypotension, shock

STOP TRANSFUSION Treatment: give Normal Saline, prepare for emergency drugs; save tubingAnaphylactic Reaction is promptly treated with antihistamines, steroids, and epinephrine

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Skills: Blood Transfusion Reactions

Blood Transfusion Reactions If the infused blood is not compatible with the

patient’s blood type, an acute hemolytic reaction will occur.

A transfusion reaction is an emergency. Transfusion is stopped immediately and the reaction must be treated intensively to reduce complications and death of patient.

Signs and symptoms Statement of “not feeling right” Chills, fever, low back pain, pruritus, Hives/Rash,

hypotension, nausea and vomiting, decreased urine output, hematuria, chest pain, dyspnea, shock

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