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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
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Respiratory Acidosis
(impaired gas exchange)
(pH low, PaCO2 high)
Signs/Assessment
- 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.
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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.
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Metabolic Alkalosis
(HCO3 high, pH high)
Sigs/Assessment
- 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)
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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
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Calcium Excess
First priority nursing interventions
- THE 4 F's
- Fluids (PO) increase
- Fluids increase
- Fluids (IV) that are ordrered
- Furosemide- Lasix (eliminates calcium)
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Calcium Excess
Lab
Calcium >10.5mg/dL
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Calcium Excess
SIGNS
- Constipation
- Flank Pain (calcium in urine increases)
- Deep bone pain
- decreased reflexes
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Calcium Excess
Disturbances involving:
- immobility
- hyperparathyroidism
- Thiazide diuretics
- Excess calcium or Vit D supplements
- Malignant tumors
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Calcium Deficit
First priority Interventions
- S seizure precautions
- A administer calcium supplements
- F Food high in calcium (dairy, green)
- E Emergency equipment on standby
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Calcium Deficit
Labs/diagnostic
Ca <9.0mg/dL
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Calcium deficit
SIGNS
- 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)
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Calcium Deficit <9.0
Disturbances involving:
- malabsorption syndromes:Chron's disease
- End stage renal disease
- Post thyroidectomy
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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
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Hyperkalemia
Labs/diagnostic
- Serum K>5.0 mEq/L
- Arterial blood gases- metabolic acidosis- pH<7.35
- ECG- spiked/peaked T waves, V-fib
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Hyperkalemia
SIGNS
- 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
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Hyperkalemia
K>5.0mEq/L
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.
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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
- NEVER GIVE IV PUSH K!!!!
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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.
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Hypokalemia
SIGNS
- <3.5
- decreased hypoactive reflexes
- muscle cramps
- weak & irregular pulse
- EKG changes, inverted T waves
- decreased bowl sounds (hypoactive), constipation
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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
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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
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Hypernatremia
LABS
- ^serum sodium >145
- ^serum osmolality >295
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Hypernatremia
SIGNS
- decreased BP
- ^ Pulse
- muscle irritability & twitching
- ^DTR
- ^Thirst
- restlessness progressing to confusion
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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)
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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
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Metabolic Acidosis
(HCO3 low, pH low)
SIGNS/Asssessment
- Below the waist we are losing BASE! =ACIDIC!!!
- Check ABGs
- Confusion, stupor, coma
- ineffective respirations
- Diarrhea, dry flushed skin
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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.
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Respiratory Alkalosis
(PaCO2 low, pH high)
SIGNS
- 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.
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