-
Water Body Comp
- Infants 70-80%
- Adult 50-60%
- Older Adult 45-55%
-
Body weight percentages
- Extracellular 20%
- Plasma 5%
- Interstitial 15%
- Intracellular 40%
-
•Oncotic Pressure
- Colloidal osmotic
- pressure is osmotic pressure exerted by colloids (proteins) in solution
- Protein molecules
- attract water, pulling fluid from the tissue space
-
•Hydrostatic pressure
- ▫The force within a
- fluid compartment
- ▫Hydrostatic pressure
- is the major force that pushes water out of the vascular system
-
▫Shifts of plasma to
interstitial fluid
- Elevation of venous
- hydrostatic pressure
Think “edema”
- Decrease in plasma
- oncotic pressure
- Albumin losses,
- malnutrition
- Elevation of
- interstitial oncotic pressure
-
Shifts
of interstitial fluid to plasma
- Adm. of hypertonic
- solutions
-
•Hypernatremia Na>145mEq/L
▫Clinical manifestations
Intense thirst
Restlessness
Agitation, sz, coma
Weight gain
Edema
Elevated BP & CVP
-
hypernatremia nursing dx
•Nursing diagnoses
▫DI
▫Osmotic diuresis
-
•Hyponatremia Na <135
Clinicalmanifestations
Confusion
Postural hpn
N&V
Dry mucous membranes
-
Hyponatremia
•Nursing diagnoses
▫Diarrhea, vomiting
▫Diuretics
▫Adrenal insufficiency
▫Burns, weeping wounds
▫
-
•Hyperkalemia
K>5.5
Clinical
manifestations
Irritability
Anxiety
Abdominal cramping
Irregular pulse
Tall peaked T wave
Widening QRS
Cardiac irritability
-
Affect of K+ on cardiac cycle
-
Hyperkalemia Nursing diagnosis
▫Acidosis
▫Tissue catabolism
▫Crush injury
▫Lysis of cells
▫Renal disease
▫ACE inhibitors
-
Hypokalemia K+<3.5
clinical manifestations
Fatigue
Muscle cramps
Paresthesia
Decreased DTR
bradycardia
-
Hypokalemia Nursing Diagnosis
▫GI losses
▫Renal losses
▫Alkalosis
▫Tissue repair
▫starvation
-
•Hypercalcemia Ca+ >11
▫Clinical
manifestations
Lethargy weakness
Confusion, ataxia
Nephrolithiasis
Bone fractures
-
Hypercalcemia Nursing Diagnosis
▫Multiple myeloma
▫Hyperparathyroidism
▫Vit. D overdose
-
•Hypocalcemia
Ca+
<9
▫Hyperreflexia
▫Chvosteks sign
▫Trousseaus sign
▫Laryngeal spasm
- ▫Tetany & seizures (far
- more acute)
-
Hypocalcemia Nursing Diagnoses
▫CRF
▫Elevated phosphorous
▫1° hypoparathyroidism
▫Acute pancreatitis
▫Chronic alcoholism
-
•Hypermagnesemia
▫Renal failure
▫Adrenal insufficiency
-
Hypomagnesemia
▫Chronic alcoholism
▫NG suction
-
Hypotonic
(.45% NS)
- Provides more water
- then electrolytes , diluting the ECF. Expands both compartments.
- Will not replace the vascular space, do not use for fluid resuscitation
-
▫Isotonic (.9%NS)
- Expands only the ECF,
- ideal fluid replacement for a patient with a volume deficit (burns, GSW,
- dehydration).
- These solutions have tonicity similar to plasma, will distribute in ECF
-
▫Hypertonic (D10%)
- Raises the osmolality of the ECF and expands it by drawing water out of the cells, unchecked can
- cause volume overload.
- Used occasionally for osmotic therapy or intravascular volume expansion
-
Blood Gas Values
check in the following order
▫PO2 (90-110)
▫Ph (7.35-7.45)
- ▫ Base Excess (BE) (-2
- +/-2)*** we will not focus on
-
Resp. Acidosis: decreased pH increased PCO2
•Increase in CO2 increases hydrogen ion concentrations, and the pH drops
-
Compensation
- •Role of lungs
- ▫In resp. acidosis,there is a high CO2 and low pH, there will be an automatic increase RR
- •Role of kidneys
- ▫As the blood acidityincreases, renal mechanisms act slowly in maintaining pH…retained CO2combines with H2O to form carbonic acid. Carbonic acid dissociates torelease H+ and HCO3- and stimulates the kidneys to retain HCO3-and Na ions
-
Metabolic
Acidosis
Both pH & HCO3 decreased
- •XS acid or reduced HCO3-
- in the body, over production or XS H+ will lead to
- decreased pH of less than 7.40. This is followed by a reduction in bicarb.
-
Compensatory Mechanisms
- •When H+ accumulate in the
- body chemical buffers in cells and ECF bind with the XS H+.
- As H+
- reaches XS proportions, buffers cannot bind with them and blood pH drops.
- •The compensation for an accumulation of resp. or
- metabolic acids occurs in the lungs and kidneys.
-
Metabolic
Alkalosis
Both pH & HCO3 increased
•Results from XS bicarb or decreased hydrogen ions
-
Compensation
for resp. & metabolic alkalosis
•Lungs
- ▫The CO2 (while it may
- have been normal drops)
- ▫Hydrogen ion
- concentration drops in order to bind with bicarb to form carbonic acid (which
- will be excreted via the kidneys
- ▫Once the compensatory
- mechanisms are in effect there
- will be a drop in bicarb ions and pH
•Kidneys
- ▫After approx. 6 hours
- the kidneys to increase excretion
- of bicarb reduce the excretion of hydrogen ions
-
Alkalosis
in severe vomiting
- •Alkalosis can ensue if there is severe vomiting; loss of
- electrolytes are no longer available to the body from the alimentary canal to
- replace those lost in the vomit and in the urine (Na+, Cl-,
- HCO3-)
•The greatest losses are chloride ions
-
•pH 7.36
•PaCO2 67 mm Hg
•PaO2 47 mm Hg
•HCO3 37 mEq/L
What is this?
▫Respiratory acidosis
-
•pH 7.18
•PaCO2 38 mm Hg
•PaO2 70 mm Hg
•HCO3- 15 mEq/L
What is
this?
◦Metabolic acidosis
-
•pH 7.60
•PaCO2 30 mm Hg
•PaO2 60 mm Hg
•HCO3- 22 mEq/L
•What is this?
-
•pH 7.58
•PaCO2 35 mm Hg
•PaO2 75 mm Hg
•HCO3- 50 mEq/L
•What is this?
-
•pH 7.28
•PaCO2 28 mm Hg
•PaO2 70 mm Hg
•HCO3- 18 mEq/L
•What is this ?
- ▫Metabolic
- acidosis partial
- bc lungs
- are compensating but PH is not normal
-
•Jeri’s been on a 3-day party binge
•Friends are unable to awaken her
•Assessment reveals level of consciousness difficult to
arouse
•Respiratory rate 8
•Shallow breathing pattern
•Diminished breath sounds
- Respiratory
- acidosis reflected by pH <7.35 and PCO2 >45 mm Hg. The
- HCO3
- will be normal (20-30 mEq/L) if her
- respiratory depression has lasted less than 24 hours; if more than 24 hours,
- the HCO3
- may be elevated due to compensation. The PaO2 may be <80 mm Hg
- because of respiratory depression leading to hypoxemia.
- 2.What
- is your treatment?
- Determine
- the cause of the respiratory depression. If induced by opioids or benzodiazepines,
- treat with appropriate antagonists. If induced by alcohol or other CNS
- depressants, breathing must be stimulated until the effects of drugs have worn
- off. Mechanical ventilation may be necessary to increase respiratory rate and
- depth, increasing oxygenation and promoting excretion of carbon dioxide.
-
•Presented to the ER after a sexual assault
•Physical examination reveals hysterical emotional
distress
•Respiratory rate 38
•Lungs clear
O2
sat 96%
1.WhatABGs doyou expect?
2.What is your treatment?
- Respiratory
- alkalosis indicated by pH >7.45 and PCO2 <35 mm Hg. The
- HCO3
- will be normal (20-30 mEq/L) because
- compensation will not occur in this acute event.
- Relieve
- her anxiety and coax her to take slow breaths. Carbon dioxide may be
- administered by mask, or she may be asked to breathe into a paper bag placed
- over her nose and mouth.
-
•History of fever, aches, and chills
•Generally feeling ill
•Cough productive of yellow, thick sputum for the past 4
days
•Examination reveals temp 38.4° C
•Respiratory rate 20
•Lungs with crackles in left lower lobes
1.What
ABGs do you expect?
2.What
is your treatment?
- The
- possible pneumonia in this case may cause hypoxemia with the PaO2
- <80 mm Hg. If untreated, the patient could trend to respiratory acidosis
- with decreasing pH and increasing PCO2.
- Promote
- coughing to clear the lungs, administer oxygen, and treat the underlying
- infection.
-
DKA ABG's?
- The diabetic ketoacidosis is a metabolic
- acidosis indicated by a pH <7.35 and an HCO3 <20 mEq/L. The PCO2
- will be within normal range if the acidosis is uncompensated but will be <35
- mm Hg if compensation has occurred. The PaO2 will not be
- affected.
- Administer
- insulin to promote normal glucose metabolism, and administer fluids and
- electrolytes to replace those lost because of the hyperglycemia.
-
•History of nausea and vomiting for the past week
•Has been self-medicating himself with baking soda to
control his abdominal discomfort
What are the ABG's and what is the trmt?
- The
- metabolic alkalosis in this case would be reflected by a pH >7.45 and an HCO3
- >30 mEq/L. Because of the
- duration of this condition, compensation may be indicated by a PCO2
- >45 mm Hg.
- Determine
- the underlying cause of the vomiting if possible, and stop the use of baking
- soda (sodium bicarbonate). Antiemetic drugs and nasogastric intubation may help relieve the vomiting, and IV
- replacement of fluids and electrolytes may be necessary.
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