Fluid and Electrolytes Continued

  1. Respiratory Acidosis
    First Priority Interventions
    • check breath sounds, VS, SaO2, mucous colors
    • high fowler's q 2hrs to prevent atelectasis
    • incentive spirom q 4hrs when awake
    • maintain airway, ABG values, surgical asepsis with suctioning
    • Iv site needs to be started
    • humidify oxygen, hydrate client, hygiene, oral care q2hrs
    • educate/emotional support
    • supplement oxygen/ oxygen safety
  2. Respiratory Acidosis
    (impaired gas exchange)
    (pH low, PaCO2 high)
    • respirations: shallow and slow, dyspnea
    • Evaluation: LOC is decreased, ABGs (^PaCO2)
    • Signs of early acidosis= Restlessness, Tachycardia, skin dry, pale to cyanotic.
    • Late signs: pulse decreased and cyanosis
    • *We are not breathing off CO2, levels are too high in the body causing an acidic environment.
  3. Metabolic Alkalosis
    (HCO3 high, pH high)
    First Priority Interventions
    • Weigh client for baseline and evaluate
    • evaluate client's and family's knowledge level reguarding care
    • intake and output, daily weight
    • give antiemetics to control vomiting
    • histamine- 2 receptor blocker if on continuous gastric suctioning
    • other causes: self induced vomiting, or diuretic use.
  4. Metabolic Alkalosis
    (HCO3 high, pH high)
    • decreased BP to normal
    • ^HR, ^RR
    • Assess weight
    • Nausea & Vomiting(above waist=lose acid)
    • skeletal muscle weakness, muscle cramping
    • Elevated activity (+chvosteks & +trousseau's sign)
  5. Acid-Base
    Helpful Hints
    • Respiratory is Opposit (pH and PaCO2)
    • Metabolic is equal (pH and HCO3)

    • Below the waist, we lose too much Base: (PaCO2 is too high, then pH is low=acidosis) (respiratory=opposit); (HCO3 is low, then pH is low=acidosis)(metabolic=equal)
    • Above the waist, we lose too much Acid: (PaCO2 is too low, then pH is high=alkalosis) (respiratory=opposit); (HCO3 is high, then pH is high= alkalosis)(metabolic=equal)
    • Respiratory=lungs
    • Metabolic=Kidneys
  6. Calcium Excess
    First priority nursing interventions
    • THE 4 F's
    • Fluids (PO) increase
    • Fluids increase
    • Fluids (IV) that are ordrered
    • Furosemide- Lasix (eliminates calcium)
  7. Calcium Excess
    Calcium >10.5mg/dL
  8. Calcium Excess
    • Constipation
    • Flank Pain (calcium in urine increases)
    • Deep bone pain
    • decreased reflexes
  9. Calcium Excess
    Disturbances involving:
    • immobility
    • hyperparathyroidism
    • Thiazide diuretics
    • Excess calcium or Vit D supplements
    • Malignant tumors
  10. Calcium Deficit
    First priority Interventions
    • S seizure precautions
    • A administer calcium supplements
    • F Food high in calcium (dairy, green)
    • E Emergency equipment on standby
  11. Calcium Deficit
    Ca <9.0mg/dL
  12. Calcium deficit
    • T Trousseau's sign (hand/finger spasms)
    • W watch for ECG changes, decreased pulse, decreased BP
    • I increase bowl sounds, diarrhea
    • T Tetany-muscle spasm
    • C Chostek's sign (facial twitching)
    • H Hperactive Deep tendon reflexes (DTR)
  13. Calcium Deficit <9.0
    Disturbances involving:
    • malabsorption syndromes:Chron's disease
    • End stage renal disease
    • Post thyroidectomy
  14. Hyperkalemia
    Priority Interventions
    • S stop infusion of IV K, avoid salt sub
    • T tall T waves (peaked) (monitor)
    • O orders: kayexalate or administer IV fluids with dextrose and regular insulin
    • P provide potassium restricted foods, admin K-losing diuretics (Lasix), HCTZ
  15. Hyperkalemia
    • Serum K>5.0 mEq/L
    • Arterial blood gases- metabolic acidosis- pH<7.35
    • ECG- spiked/peaked T waves, V-fib
  16. Hyperkalemia
    • D decreased heart rate and BP
    • I irritability, weakness, parathesias
    • E ECG-spiked/peaked T waves & V-fib
    • D Diarrhea, decreased GI motility, increased bowl sounds
  17. Hyperkalemia
    Risk factors
    • may result in extracellular shift and disturbances
    • Risk factors:
    • uncontrolled diabetes
    • decreased excretion of potassium
    • age related risk factors, salt sub, ace inhibitors, potassium sparing diuretics.
  18. Hypokalemia
    priority interventions
    • replacement of K
    • diet-potatoes, avocadoes, broccoli, bananas
    • oral supplements
    • IV supplements (max 5-10 mEq/L/hr diluted*** in an IV fluid) Monitor for phlebitis and urine output
    • Monitor:
    • EKG, LOC, Resp rate, muscle cramping, GI motility
  19. Hypokalemia
    LABS/Diagnostic procedures
    • decreased serum Ka
    • Arterial blood gases:metabolic alkalosis pH>7.45
    • EKG changes: inverted T waves, V-Tach depressed ST segment.
  20. Hypokalemia
    • <3.5
    • decreased hypoactive reflexes
    • muscle cramps
    • weak & irregular pulse
    • EKG changes, inverted T waves
    • decreased bowl sounds (hypoactive), constipation
  21. Hypokalemia
    System disturbances & Risk factors
    • Cardiac dysrhythmias
    • Neuromusculoskeletal
    • GI
    • Risk factors:GI losses:vomiting, nasal gastric suctioning, diarrhea, laxatives
    • Renal losses: diuretics (lasix), use of corticoid steroids
    • Skin Loss: diaphoresis and wounds
    • Insufficient potassium: dietary or prolonged non-elec IV solutions DSW
    • Intracellular shift: tissue repair (burns, starvation, trauma)
    • Older adults: ^risk because of laxative and diuretics
  22. Hypernatremia
    First priority interventions
    • S decrease sodium intake
    • O oral hygiene
    • D Daily weight, diuretic (loop diuretics)
    • I I & O, Increase water intake
    • U use hypotonic and isotonic fluids
    • M monitor for inadequate renal output
  23. Hypernatremia
    • ^serum sodium >145
    • ^serum osmolality >295
  24. Hypernatremia
    • decreased BP
    • ^ Pulse
    • muscle irritability & twitching
    • ^DTR
    • ^Thirst
    • restlessness progressing to confusion
  25. Hypernatremia
    Effected Systems & Fisk Factors
    • NA >145
    • Systems=neurological, Cardiac, Endocrine
    • Risk Factors= NPO status(water deprivation), excessive Na retention, fluid loss, fever, burns, watery diarrhea, Age related (older client not always thirsty)
  26. Metabolic Acidosis
    (HCO3 low, pH low)
    First priority interventions
    • ABGs monitored, assess decreased pulse and respiratory rate
    • Control and manage cause (diarrhea)
    • I & Os weight
    • order fluids
    • SaO2 monitor
    • insulin and fluid hydration for DKA
    • seizure precautions
  27. Metabolic Acidosis
    (HCO3 low, pH low)
    • Below the waist we are losing BASE! =ACIDIC!!!
    • Check ABGs
    • Confusion, stupor, coma
    • ineffective respirations
    • Diarrhea, dry flushed skin
  28. Respiratory Alkalosis
    First priority interventions
    • Slow down & deep breath
    • Watch chest movement
    • Oxygen given if hypocapnia is secondary to hypoxemia
    • With hyperventilation, reassure, calm, decrease client stress, use rebreather mask or paper bag to have them rebreath their own CO2.
  29. Respiratory Alkalosis
    (PaCO2 low, pH high)
    • CNS effect: anxiety, vertigo, clumsy, forgetful
    • Pulse^
    • Evaluate ABGs=PaCO2 low
    • Asprin overdose can occur
    • eventually kidneys compensate after 3 days
    • respirations^ (Hyperventilation)
    • *too much CO2 is being blown off so the lungs become a basic environment
    • *PaCO2 in the body is like an acid. Get rid of too much=basic, Hold on to too much acidic.
Card Set
Fluid and Electrolytes Continued