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Lesson 3.1
Chapter 3
Lesson 3.1
Chapter 3
Fluids, Electrolytes, Acid-Base Balance, and Intravenous Therapy
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Learning ObjectivesLearning Objectives
Theory
1. Recall the various functions fluid performs in the body.
2. Identify the body’s mechanisms for fluid regulation.
3. Review three ways in which body fluids are continually being distributed among the fluid compartments.
4. Distinguish the signs and symptoms of various electrolyte imbalances.
5. Discuss why the elderly have more problems with fluid and electrolyte imbalances.
6. Recognize the disorders that cause specific fluid and electrolyte imbalances.
7. Compare the major causes of acid-base imbalances.
8. State correct interventions to correct an acid-base imbalance.
9. Discuss the steps in managing an intravenous infusion.
10. Describe the measures used to prevent the complications of intravenous therapy.
11. Identify intravenous fluids that are isotonic.12. Discuss the principles of intravenous
therapy.
Clinical Practice
1. Assess patients for signs of dehydration.
2. Correctly assess for and identify edema and signs of overhydration.
3. Apply knowledge of normal laboratory values in order to recognize electrolyte imbalances.
4. Carry out interventions to correct an electrolyte imbalance.
5. Determine if a patient has an acid-base imbalance.
6. Carry out measures to prevent the complications of Intravenous therapy.
7. Compare interventions for the care of a patient receiving total parenteral nutrition with one undergoing intravenous therapy.
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Functions of WaterFunctions of Water
• Transportation
• Heat regulation
• Maintenance of hydrogen (H+) balance
• Medium for the enzymatic action of digestion
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Control of Fluid BalanceControl of Fluid Balance
• Thirst mechanism and osmoreceptors• Antidiuretic hormone (ADH)• Aldosterone and atrial natriuretic peptide
(ANP) • Baroreceptors in the carotid sinus and
aortic arch and the sympathetic/parasympathetic nervous system
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Movement of Fluid and Electrolytes
Movement of Fluid and Electrolytes
• Passive transport:– Diffusion – Osmosis– Isotonic, hypertonic, and hypotonic – Osmotic pressure – Filtration and hydrostatic pressure
• Active transport:– Sodium pump and ATP
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Fluid Imbalances: Deficient Fluid Volume
Fluid Imbalances: Deficient Fluid Volume
Risk factors• Inability to take in sufficient quantities of fluid
because of impaired swallowing, extreme weakness, disorientation or coma, or the unavailability of water
• Loss of excessive amounts of fluid through prolonged vomiting, diarrhea, hemorrhage, diaphoresis (sweating), excessive wound drainage, or diuretic therapy
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Assessment (Data Collection)Assessment (Data Collection)
• Turgor
• Furrowed, dry tongue
• Blood pressure
• Pulse
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Nausea and VomitingNausea and Vomiting
• “Sick to my stomach"
• Pallor, mild diaphoresis, cold clammy skin, excessive salivation, and attempts to remain quiet and motionless
• Vomitus odor, color, contents (e.g., undigested food), and amount
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Medical TreatmentMedical Treatment
• Antihistamines, sedative-hypnotics, anticholinergics, and phenothiazines
• Complementary and alternative therapy
• NPO, then progressing slowly to a regular diet
• Carbonated drinks
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DiarrheaDiarrhea
• Frequent watery bowel movements, abdominal cramping, and general weakness
• Watery stools often contain mucus and are blood‑streaked; frequency could be as high as 15 to 20 liquid stools.
• Acute diarrhea and local irritation• Chronic and prolonged diarrhea in ulcerative
colitis, irritable bowel syndrome, allergies, lactose intolerance, and nontropical sprue
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DiarrheaDiarrhea
• Dehydration, malnutrition, and anemia
• Bowel sounds likely to be loud gurgling and tinkling sounds that come in waves and are hyperactive
• Note and record the number of stools during the shift and the characteristics of each stool and associated pain
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Acute DiarrheaAcute Diarrhea
• Limit the intake of food• Progress to clear, bland liquids and to solids
with increased calories and high‑protein, high‑carbohydrate content
• Give rehydrating solutions containing glucose and electrolytes
• Avoid iced fluids, carbonated drinks, whole milk, roughage, raw fruits, and highly seasoned foods
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Medications for DiarrheaMedications for Diarrhea
• Cause of the disorder and the length of time the conditionMild cases:– Kaolin and bismuth preparations, (e.g., Kaopectate)
• Antispasmodic drugs such as belladonna or paregoric • Bismuth and "traveler's diarrhea" • Codeine, diphenoxylate (Lomotil), or loperamide
(Imodium)• Drugs and causative organisms• Metabolic acidosis and buffer solutions
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Nursing ManagementNursing Management
• Provide physical and mental rest, prevent unnecessary loss of water and nutrients, protect the rectal mucosa, and replace fluids
• Maintain a calm and dignified manner, accept and understand the patient's behavior, and provide privacy and a restful environment
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Excess Fluid VolumeExcess Fluid Volume
• Hematocrit: – 35% to 54%, depending on age and sex
• Urine concentration: – Specific gravity: 1.003 to 1.030 (average
range is 1.010 to 1.025)
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EdemaEdema
• Localized edema and generalized edema
• General causes of edema:– An increase in capillary hydrostatic pressure– A loss of plasma proteins– An obstruction of lymphatic circulation– An increase in capillary permeability
• Dependent edema
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TreatmentTreatment
• Correct the underlying cause • Assist the body to rebalance fluid content• Restrict fluids• Give diuretic drugs• Allow bed rest• Provide low-sodium diet• Use elastic stockings or sequential
compression devices
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Home Care: Fluid Volume Deficit
Home Care: Fluid Volume Deficit
• Log of intake and output
• Small amounts of liquid every hour while awake
• Emergency department and intravenous fluids
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Home Care: Fluid ExcessHome Care: Fluid Excess
• Weigh daily
• Assess edema
• Know when to notify physician
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ElectrolytesElectrolytes
• Ions:– Negatively charged anions– Positively charged cations
• Creation of an electrical impulse:– Transmission of nerve impulses– Contraction of muscles– Excretion of hormones and other
substances from glandular cells
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Osmolality Osmolality
• Concentration of the solution determined by the number of solutes
• Osmolality controls water movement and the body fluid distribution in the intracellular and extracellular compartments
• Intracellular fluid and potassium• Extracellular fluid and sodium• Normal osmolality: 280 to 294 milliosmoles
per kilogram
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Sodium ImbalancesSodium Imbalances
Hyponatremia (below 135 mEq/L)
Signs and symptoms:– Fatigue, lethargy, muscle weakness– Muscle cramps– Abdominal cramps and nausea and vomiting– Headache, confusion, seizures– Decreased blood pressure
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Sodium ImbalancesSodium Imbalances
Hypernatremia (above 145 mEq/L)Signs and symptoms:
– Decreased urine output if compensatory ADH is being secreted
– Increased thirst with dry mucous membranes
– Weakness and agitation– Good tissue turgor and firm subcutaneous
tissues
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Potassium ImbalancesPotassium Imbalances
Hypokalemia (below 3.5 mEq/L)
Signs and symptoms: – Cardiac dysrhythmias and ECG changes– Muscle weakness and decreased reflexes– Urinary retention and increased urine pH– Abdominal pain, gaseous distention, and
paralytic ileus– Lethargy and confusion
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Potassium ImbalancesPotassium Imbalances
Hyperkalemia (above 5.0 mEq/L)
Signs and symptoms: – ECG changes and cardiac dysrhythmias
that may progress to cardiac arrest– Paresthesias and muscle weakness
progressing to paralysis– Fatigue and nausea
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Calcium ImbalancesCalcium Imbalances
Hypocalcemia (below 8.4 mg/dL)Signs and symptoms:
– Paresthesia and abdominal cramps– Muscle twitching, carpopedal spasm,
Trousseau sign, and hyperactive reflexes– Chvostek sign – Tetany – Weak heart contractions – Laryngospasm
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Calcium ImbalancesCalcium Imbalances
Hypercalcemia (above 10.6 mg/dL)
Signs and symptoms: – Muscle weakness, lethargy, stupor, and
personality change– Anorexia and nausea– Polyuria – Dysrhythmias and cardiac arrest – Decreased bone density
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Magnesium ImbalancesMagnesium Imbalances
Hypomagnesemia (below 1.3 mEq/L)
Causes:– Diuretic use– Diabetic ketoacidosis– Hyperparathyroidism– Hyperaldosteronism
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Magnesium ImbalancesMagnesium Imbalances
Hypermagnesemia (above 2.1 mEq/L)
Causes:– Renal failure– Overuse of magnesium-containing antacids
and cathartics
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Anion ImbalancesAnion Imbalances
Imbalances of chloride, phosphate, and bicarbonate accompany cation imbalances:
• Hypochloremia (below 95 mEq/L) and hyponatremia
• Hyperchloremia (above 103 mEq/L) with hypernatremia and metabolic acidosis
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Anion ImbalancesAnion Imbalances
Imbalances of chloride, phosphate, and bicarbonate accompany cation imbalances
• Hypophosphatemia (below 3.0 mg/dL): – Aluminum-containing antacids that bind
phosphate– Vitamin D deficiency– Hyperparathyroidism
• Hyperphosphatemia (above 4.5 mg/dL) and renal failure
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Control Mechanisms and pHControl Mechanisms and pH
Buffer pairs – Bicarbonate–carbonic
acid buffer system – Phosphate system– Hemoglobin system– Protein system
Respiratory system – Carbon dioxide– Carbonic acid
Kidneys – Bicarbonate ion
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Acid–Base ImbalancesAcid–Base Imbalances
• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis
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Arterial Blood Gas AnalysisArterial Blood Gas Analysis
• Partial pressure exerted by oxygen (PaO2) 80 to 100 mm Hg
• Partial pressure of carbon dioxide (PaCO2) 35 to 45 mm Hg
• pH 7.35 to 7.45• SaO2 (also abbreviated O2 Sat) 94% to 100%• HCO3 22 to 26 mEq/L• Base excess or deficit measured in "+" or "−"
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Respiratory AcidosisRespiratory Acidosis
An increase in carbon dioxide levels occurs in a variety of disorders
Signs and symptoms:– Complaints of increasing difficulty in breathing– History of respiratory obstruction (acute or chronic)– Dyspnea, weakness, dizziness, restlessness,
sleepiness, and change in mental alertness
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Respiratory Acidosis Treatment
Respiratory Acidosis Treatment
Airway:• Tracheostomy and endotracheal tube • Oxygen administration • Mechanical ventilation• Postural drainage, deep‑breathing exercises,
bronchodilators, and antibiotics • Narcotics, hypnotics, and tranquilizers as
respiratory depressants
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Metabolic AcidosisMetabolic Acidosis
An excessive loss of bicarbonate ions or an increased production or retention of hydrogen ions
Causes: – Excessive loss of bicarbonate ions from
diarrhea– Renal failure– Diabetic ketoacidosis– Hyperkalemia
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Symptoms of Metabolic Acidosis
Symptoms of Metabolic Acidosis
• Weakness, lethargy, headache, and confusion
• Stupor, unconsciousness, coma, and death
• Fruity odor and ketone bodies (ketoacidosis)
• Vomiting and diarrhea
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Metabolic Acidosis Treatment Metabolic Acidosis Treatment
• Insulin and diabetic ketoacidosis
• Dialysis and kidney failure
• Severe metabolic acidosis and administration of IV bicarbonate or lactate
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Respiratory AlkalosisRespiratory Alkalosis
Causes of
hyperventilation – Anxiety– High fever – Aspirin overdose
Symptoms – Deep, rapid breathing– Tingling of the fingers– Pallor around the
mouth– Dizziness– Spasms of the
muscles of the hands
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Treatment for HyperventilationTreatment for Hyperventilation
• Treat the underlying disorder
• Have patient use re-breather mask
• Calm patient’s hysteria and prevent further hyperventilation
• Administer sedatives to calm the patient
• Have patient breathe into a paper sack
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Causes of Metabolic AlkalosisCauses of Metabolic Alkalosis
• Vomiting • Extensive gastrointestinal suction • Hypokalemia• Excessive consumption of antacids with
bicarbonate • Other causes
– Drainage from intestinal fistula– Diuresis – Steroid therapy
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Signs and Symptoms of Metabolic Alkalosis
Signs and Symptoms of Metabolic Alkalosis
• Irritability, disorientation, lethargy, muscle twitching, tingling and numbness of the fingers, and convulsions
• Slow shallow respirations, decreased chest movements, and cyanosis
• Symptoms of potassium and calcium depletion
• Tetany, seizures, and coma
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Treatment of Metabolic Alkalosis
Treatment of Metabolic Alkalosis
• Correcting underlying cause
• Fluid and electrolyte replacement
• Administration of an acidifying solution such as ammonium chloride
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Home CareHome Care
• Fluid intake or restriction
• Sodium restriction
• Controlling underlying disorder
• Arterial blood gases
• Oxygen and electrolytes
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Intravenous TherapyIntravenous Therapy
• Total parenteral nutrition
• Isotonic, hypotonic, and hypertonic
• Blood‑related fluids
• Plasma expanders
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Nursing Responsibilities: Administering IV Fluids
Nursing Responsibilities: Administering IV Fluids
• Venipuncture
• National Patient Safety Goal
• Central intravenous lines
• Subcutaneous infusion and hypodermoclysis
• Intraosseous infusion
• Epidural infusion