Fluids & Electrolytes

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Information about Fluids & Electrolytes
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Published on March 13, 2009

Author: nionoveno

Source: slideshare.net

Description

Discussion of fluids and electrolytes disorders with patient management.

Nio Cruzada Noveno, RN, MAN, MSN Fluids & Electrolytes

BODY FLUIDS Functions of Fluids Body fluids: Facilitate in the transport [nutrients, hormones proteins, & others…] Aid in removal of cellular metabolic wastes Provide medium for cellular metabolism Regulate body temperature Provide lubrication of musculoskeletal joints Component in all body cavities [parietal, pleural fluids] Water is the principal body fluid & essential for life. Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Functions of Fluids

Body fluids:

Facilitate in the transport

[nutrients, hormones proteins, & others…]

Aid in removal of cellular metabolic wastes

Provide medium for cellular metabolism

Regulate body temperature

Provide lubrication of musculoskeletal joints

Component in all body cavities

[parietal, pleural fluids]

Water is the principal body fluid & essential for life.

Renal Disorders [email_address] FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES BODY FLUIDS ICF ECF 40% TBW 20% TBW P IS Distribution of Body Fluids: 50-70% of total body weight; infant [70-80%], elderly [45-50%] 60-kg man TBW = 0.6 x 60 kg = 3.6 L ICF = 0.4 x 60 kg = 24 L ECF =12 L 3L 9L

BODY FLUIDS Factors that Dictate Body Water Requirement Amount needed to give the proper osmotic concentration Amount needed to replace water lost excretion Normal Routes of water gain and loss Renal Disorders [email_address] FLUIDS and ELECTROLYTES INTAKE OUTPUT ml/day ml/day Fluid intake 1,500 Food 800 Metabolic water 300 TOTAL 2,600 Insensible loss 400 Sweat 600 Feces 100 Urine 1,500 TOTAL 2,600

Factors that Dictate Body Water Requirement

Amount needed to give the proper osmotic concentration

Amount needed to replace water lost excretion

FLUID EXCHANGE BETWEEN BODY FLUID COMPARTMENTS Osmotic Pressure Gradient Oncotic P (Colloid osmotic P) Capillary P (Hydrostatic P) Renal Disorders [email_address] FLUIDS and ELECTROLYTES ICF ECF P ISF

Control of Osmotic Pressure, Volume & Electrolyte Concentration OBLIGATORY Reabsorption occurs in the proximal tubules 178 L/day of glomerular filtrate (80% reabsorbed) 2  to solute reabsorption independent of the water requirement FACULTATIVE Reabsorption occurs in the distal & collecting tubules independent of the active solute transport dependent of body’s need of water under the control of ADH Renal Disorders [email_address] FLUIDS and ELECTROLYTES

OBLIGATORY Reabsorption

occurs in the proximal tubules

178 L/day of glomerular filtrate (80% reabsorbed)

2  to solute reabsorption

independent of the water requirement

FACULTATIVE Reabsorption

occurs in the distal & collecting tubules

independent of the active solute transport

dependent of body’s need of water

under the control of ADH

DISTURBANCES IN FLUID BALANCE EDEMA (Dropsy)  in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2° to: Increased HP [pregnancy, CHF] Decreased OP [malnutrition, end-stage liver disease, nephrotic syndrome] Renal Disorders [email_address] FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES

EDEMA (Dropsy)

 in the interstitial fluid volume of about 2 L or more due to increase transudation of fluid from capillaries 2° to:

Increased HP [pregnancy, CHF]

Decreased OP

[malnutrition, end-stage liver disease, nephrotic syndrome]

DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment fluid overload from  production of adrenal corticoid hormones [Cushing’s syndrome] Renal Disorders [email_address] FLUIDS and ELECTROLYTES

CELL OVERHYDRATION

excess of water in the ECC w/ a normal amount of solute or a deficient amount of solute

occurs in prolonged and excessive diuresis, forcing hypotonic fluids to produce diuresis in the presence of renal impairment

fluid overload from  production of adrenal corticoid hormones [Cushing’s syndrome]

DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION Symptoms Weight gain & edema Cough, moist rales, dyspnea [fluid congestion in lungs] CVP, bounding pulse, neck vein engorgement [fluid excess in the vascular system] Bulging fontanelles  Hg and Hct Nausea & vomiting Renal Disorders [email_address] FLUIDS and ELECTROLYTES

CELL OVERHYDRATION

Symptoms

Weight gain & edema

Cough, moist rales, dyspnea

[fluid congestion in lungs]

CVP, bounding pulse, neck vein engorgement [fluid excess in the vascular system]

Bulging fontanelles

 Hg and Hct

Nausea & vomiting

DISTURBANCES IN FLUID BALANCE CELL OVERHYDRATION Management Restrict fluids to lower fluid volume Diuretics or hypertonic saline Continuous assessments to prevent skin breakdown Record daily weight to assess progress of treatment Renal Disorders [email_address] FLUIDS and ELECTROLYTES

CELL OVERHYDRATION

Management

Restrict fluids to lower fluid volume

Diuretics or hypertonic saline

Continuous assessments to prevent skin breakdown

Record daily weight to assess progress of treatment

DISTURBANCES IN FLUID BALANCE CELL DEHYDRATION (DHN) loss of body fluids, particularly from the extracellular fluid compartment water loss > water intake Causes Fever Insufficient water intake Diarrhea, vomiting Excess urine output [Diabetes insipidus, diuretics] Excessive perspiration, burns Hemorrhage, shock, metabolic acidosis Renal Disorders [email_address] FLUIDS and ELECTROLYTES

CELL DEHYDRATION (DHN)

loss of body fluids, particularly from the extracellular fluid compartment

water loss > water intake

Causes

Fever

Insufficient water intake

Diarrhea, vomiting

Excess urine output [Diabetes insipidus, diuretics]

Excessive perspiration, burns

Hemorrhage, shock, metabolic acidosis

DISTURBANCES IN FLUID BALANCE CELL DEHYDRATION (DHN) Symptoms Thirst, dry mucus membranes, sunken eyeballs “ Doughy“ abdomen, dry skin w/ poor turgor  temp, weight loss  HR,  RR,  BP Restlessness,irritability, disorientation, convulsion, coma [22-30% body H 2 0 loss] Management Fluid replacement therapy & continued fluid maintenance Renal Disorders [email_address] FLUIDS and ELECTROLYTES

CELL DEHYDRATION (DHN)

Symptoms

Thirst, dry mucus membranes, sunken eyeballs

“ Doughy“ abdomen, dry skin w/ poor turgor

 temp, weight loss

 HR,  RR,  BP

Restlessness,irritability, disorientation, convulsion, coma [22-30% body H 2 0 loss]

Management

Fluid replacement therapy & continued fluid maintenance

Renal Disorders [email_address] FLUIDS and ELECTROLYTES Volume Disorders 2° Alteration in Sodium Balance Expansion Isotonic Inc N No net change Isotonic fluid ingestion Hypertonic Inc Dec ICF  ECF Sea water ingestion Hypotonic Inc Inc ECF  ICF Hypotonic IVF Contraction Isotonic Dec N No net change Diarrhea Hypertonic Dec Dec ICF  ECF Diabetes insipidus Hypotonic Dec Inc ECF  ICF Addison’s dse Volume ECF ICF Water Conditions Disorder Vol. Vol. Shift

ELECTROLYTES salts or minerals in extracellular or intracellular body fluids Sodium – major cation of ECF Potassium – major cation of ICF Chloride - major anion of ICF Protein – in ICF > ISF Renal Disorders [email_address] FLUIDS and ELECTROLYTES

ELECTROLYTES

salts or minerals in extracellular or intracellular body fluids

Sodium – major cation of ECF

Potassium – major cation of ICF

Chloride - major anion of ICF

Protein – in ICF > ISF

ELECTROLYTE Composition Electrolyte Conc Plasma (mEq/L) ISF ICF Sodium, Na + 142 141 10 Potassium, K + 5 4.1 150 Calcium, Ca ++ 5 4.1 - Magnesium, Mg ++ 3 3 40 (155) Chloride, Cl - 103 115 15 Bicarbonate, HCO 3 - 27 29 10 Biphosphate, HPO 4 - 2 2 100 Sulfate, SO 4 - 1 1 20 Protein 16 1 60 Organic foods 6 3.4 - (155) Renal Disorders [email_address] FLUIDS and ELECTROLYTES

ELECTROLYTES Functions of Electrolytes Contribute most of the osmotically active particles in body fluids Provide buffer systems for pH regulation Provide the proper ionic environment for normal neuromuscular irritability & tissue function Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Functions of Electrolytes

Contribute most of the osmotically active particles in body fluids

Provide buffer systems for pH regulation

Provide the proper ionic environment for normal neuromuscular irritability & tissue function

Hyponatremia [Na + < 135 mEq/L; Normal = 135-145 mEq/L] Causes  Na + intake  Na + excretion [diaphoresis, GI suctioning] Adrenal insufficiency Assessment N & V, abdominal cramps, weight loss Cold, clammy skin,  skin turgor Apprehension, HA, convulsions, focal neurologic deficit, coma [cerebral edema] Fatigue, postural hypotension Rapid thready pulse ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES FLUIDS and ELECTROLYTES

Hyponatremia [Na + < 135 mEq/L; Normal = 135-145 mEq/L]

Causes

 Na + intake

 Na + excretion [diaphoresis, GI suctioning]

Adrenal insufficiency

Assessment

N & V, abdominal cramps, weight loss

Cold, clammy skin,  skin turgor

Apprehension, HA, convulsions, focal neurologic deficit, coma [cerebral edema]

Fatigue, postural hypotension

Rapid thready pulse

Hyponatremia Drugs that cause decreased sodium Anti-convulsant: Carbamazepine Antidiabetics: Chlorpropramide Tolbutamide Antipsychotics: Fluphenazine Thiozoridazine Thiothixene Antineoplastics: Cyclophosphamide Vincristine Diuretics: Bumetanide Ethacrynic acid Furosemide Thiazides Sedatives: Barbiturates Morphine Renal Disorders [email_address]

Anti-convulsant:

Carbamazepine

Antidiabetics:

Chlorpropramide

Tolbutamide

Antipsychotics:

Fluphenazine

Thiozoridazine

Thiothixene

Antineoplastics:

Cyclophosphamide

Vincristine

Diuretics:

Bumetanide

Ethacrynic acid

Furosemide

Thiazides

Sedatives:

Barbiturates

Morphine

Hyponatremia [Na + < 135 mEq/L; Normal = 135-145 mEq/L] Management Provide foods high in sodium Administer NSS IV Assess blood pressure frequently [measure lying down, sitting & standing] High sodium foods Celery Cheeses Condiments Processed foods Smoked meats Snack foods ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hyponatremia [Na + < 135 mEq/L; Normal = 135-145 mEq/L]

Management

Provide foods high in sodium

Administer NSS IV

Assess blood pressure frequently

[measure lying down, sitting & standing]

High sodium foods

Celery

Cheeses

Condiments

Processed foods

Smoked meats

Snack foods

Treatment Interventions Mild Water restriction if water retention problem Increase Na in foods if loss of Na Moderate IV 0.9% NS, 0.45% NS, LR Severe 3% NS – short-term therapy in ICU setting Renal Disorders [email_address]

Interventions

Mild

Water restriction if water retention problem

Increase Na in foods if loss of Na

Moderate

IV 0.9% NS, 0.45% NS, LR

Severe

3% NS – short-term therapy in ICU setting

Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] Causes Excessive, rapid IV adm’n of NSS Inadequate water intake Kidney disease Assessment Dry, sticky mucus membranes Flushed skin Rough dry tongue, firm skin turgor Intense thirst Edema, oliguria to anuria Restlessness, irritability [cerebral DHN] ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]

Causes

Excessive, rapid IV adm’n of NSS

Inadequate water intake

Kidney disease

Assessment

Dry, sticky mucus membranes

Flushed skin

Rough dry tongue, firm skin turgor

Intense thirst

Edema, oliguria to anuria

Restlessness, irritability [cerebral DHN]

Hypernatremia S kin flushed A gitation L ow-grade fever T hirst Renal Disorders [email_address]

S kin flushed

A gitation

L ow-grade fever

T hirst

Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L] Nursing Intervention Weigh daily Assess degree of edema frequently Measure I & O Assess skin frequently & institute nursing measures to prevent breakdown Encourage sodium-restricted diet ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypernatremia [Na+ >145 mEq/L; Normal = 135-145 mEq/L]

Nursing Intervention

Weigh daily

Assess degree of edema frequently

Measure I & O

Assess skin frequently & institute nursing measures to prevent breakdown

Encourage sodium-restricted diet

Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes Renal insufficiency Adrenocortical insufficiency Cellulose damage [burns] Infection Acidotic states Rapid infusion of IV sol’n w/ potassium-conserving diuretics ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]

Causes

Renal insufficiency

Adrenocortical insufficiency

Cellulose damage [burns]

Infection

Acidotic states

Rapid infusion of IV sol’n w/ potassium-conserving diuretics

Hyperkalemia Drugs that increase potassium ACE inhibitors Antibiotics Beta blockers NSAIDs Spironolactone Chemotherapeutics Renal Disorders [email_address]

ACE inhibitors

Antibiotics

Beta blockers

NSAIDs

Spironolactone

Chemotherapeutics

Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Assessment Thready, slow pulse Shallow breathing N & V, diarrhea, intestinal colic Irritability Muscle weakness, flaccid paralysis Numbness, tingling Difficulty w/ phonation, respiration ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]

Assessment

Thready, slow pulse

Shallow breathing

N & V, diarrhea, intestinal colic

Irritability

Muscle weakness, flaccid paralysis

Numbness, tingling

Difficulty w/ phonation, respiration

Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L] Nursing Interventions Administer kayexalate as ordered Administer/monitor IV infusion of glucose & insulin Control infection Provide adequate calories & carbohydrates Discontinue IV or oral sources of K + ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hyperkalemia [K+ > 5.5 mEq/L; Normal = 3.5-5.5 mEq/L]

Nursing Interventions

Administer kayexalate as ordered

Administer/monitor IV infusion of glucose & insulin

Control infection

Provide adequate calories & carbohydrates

Discontinue IV or oral sources of K +

Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Causes Renal tubule defects Prolonged diuretic therapy Prolonged vomiting, diarrhea, laxative use, NG suctioning, severe diaphoresis Anorexia Acute alcoholism Hyperaldosteronism, excessive steroids Metabolic alkalosis Administration of potassium-deficient hyperalimentation sol’n, hypertonic glucose Excessive amounts of insulin ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]

Causes

Renal tubule defects

Prolonged diuretic therapy

Prolonged vomiting, diarrhea, laxative use, NG suctioning, severe diaphoresis

Anorexia

Acute alcoholism

Hyperaldosteronism, excessive steroids

Metabolic alkalosis

Administration of potassium-deficient hyperalimentation sol’n, hypertonic glucose

Excessive amounts of insulin

Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Assessment Thready, rapid, weak pulse Faint heart sounds  BP Skeletal muscle weakness  or absent reflexes Shallow respirations Malaise, apathy, lethargy Loss of orientation Anorexia, vomiting, weight loss Gaseous intestinal distention ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]

Assessment

Thready, rapid, weak pulse

Faint heart sounds

 BP

Skeletal muscle weakness

 or absent reflexes

Shallow respirations

Malaise, apathy, lethargy

Loss of orientation

Anorexia, vomiting, weight loss

Gaseous intestinal distention

Hypokalemia S keletal muscle weakness U -wave C onstipation; ileus T oxic effects of digoxin I rregular, weak pulse O rthostatic hypotension N umbness [paresthesia] Renal Disorders [email_address]

S keletal muscle weakness

U -wave

C onstipation; ileus

T oxic effects of digoxin

I rregular, weak pulse

O rthostatic hypotension

N umbness [paresthesia]

Hypokalemia Drugs that decrease potassium Adrenergics: Albuterol Epinephrine Antibiotics: Amphotericin B Carbenicillin Gentamicin Insulin Cisplatin Costicosteroids Diuretics: Furosemide Thiazides Laxatives [ excess use ] Renal Disorders [email_address]

Adrenergics:

Albuterol

Epinephrine

Antibiotics:

Amphotericin B

Carbenicillin

Gentamicin

Insulin

Cisplatin

Costicosteroids

Diuretics:

Furosemide

Thiazides

Laxatives [ excess use ]

Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L] Nursing Interventions Administer K + supplements to replace losses Be cautious in administering drugs that are not potassium-sparing Monitor acid-base balance Monitor pulse, BP and ECG High potassium foods Avocados Bananas Dates Oranges Potatoes Raisins ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypokalemia [K+ < 3.5 mEq/L; Normal = 3.5-5.5 mEq/L]

Nursing Interventions

Administer K + supplements to replace losses

Be cautious in administering drugs that are not potassium-sparing

Monitor acid-base balance

Monitor pulse, BP and ECG

High potassium foods

Avocados

Bananas

Dates

Oranges

Potatoes

Raisins

Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] Causes Hyperparathyroidism Immobility Increased vitamin D intake Osteoporosis & osteomalacia [early stages] Assessment N & V, anorexia, constipation Headache, confusion Lethargy, stupor Decreased muscle tone Deep bone/flank pain ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]

Causes

Hyperparathyroidism

Immobility

Increased vitamin D intake

Osteoporosis & osteomalacia [early stages]

Assessment

N & V, anorexia, constipation

Headache, confusion

Lethargy, stupor

Decreased muscle tone

Deep bone/flank pain

Hypercalcemia Drugs that increase calcium Calcium-containing antacids Calcium preparations Lithium Thiazide diuretics Vitamin A Vitamin D Renal Disorders [email_address]

Calcium-containing antacids

Calcium preparations

Lithium

Thiazide diuretics

Vitamin A

Vitamin D

Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L] Nursing Interventions Encourage mobilization Limit vitamin D intake Limit calcium intake Normal saline Administer diuretics Calcitonin ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypercalcemia [Ca > 5.8 mEq/L; Normal = 4.5-5.8 mEq/L]

Nursing Interventions

Encourage mobilization

Limit vitamin D intake

Limit calcium intake

Normal saline

Administer diuretics

Calcitonin

Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Causes Acute pancreatitis Diarrhea Hypoparathyroidism Lack of vitamin D in the diet Long-term steroid therapy Assessment Painful tonic muscle & facial spasms Fatigue, dyspnea Laryngospasm, convulsions (+) Trousseau’s and Chvostek’s signs ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]

Causes

Acute pancreatitis

Diarrhea

Hypoparathyroidism

Lack of vitamin D in the diet

Long-term steroid therapy

Assessment

Painful tonic muscle & facial spasms

Fatigue, dyspnea

Laryngospasm, convulsions

(+) Trousseau’s and Chvostek’s signs

Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L] Nursing Interventions Administer oral Ca lactate or IV CaCl 2 or gluconate Providing safety by padding side rails Administer dietary sources of calcium Vitamin D Provide quiet environment High calcium foods Milk Dairy products ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypocalcemia [Ca < 4.5 mEq/L; Normal = 4.5-5.8 mEq/L]

Nursing Interventions

Administer oral Ca lactate or IV CaCl 2 or gluconate

Providing safety by padding side rails

Administer dietary sources of calcium

Vitamin D

Provide quiet environment

High calcium foods

Milk

Dairy products

Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L] Causes Renal insufficiency, dehydration Excessive use of Mg-containing antacids or laxatives Assessment Lethargy, somnolence, confusion N & V Muscle weakness, depressed reflexes  pulse and respirations Nursing Intervention Withhold Mg-cont’g drugs/foods; Ca adm’n  fluid intake, unless CI ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hyermagnesemia [Mg > 3.0 mEq/L; Normal = 1.5-3.0 mEq/L]

Causes

Renal insufficiency, dehydration

Excessive use of Mg-containing antacids or laxatives

Assessment

Lethargy, somnolence, confusion

N & V

Muscle weakness, depressed reflexes

 pulse and respirations

Nursing Intervention

Withhold Mg-cont’g drugs/foods; Ca adm’n

 fluid intake, unless CI

Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L] Causes Low intake of Mg in the diet Prolonged diarrhea Massive diuresis Hypoparathyroidism Assessment Paresthesias, muscle spasm Confusion, hallucination, convulsions Ataxia, tremors, hyperactive deep reflexes Flushing of the face, diaphoresis Nursing Intervention Provide good dietary sources of Mg ELECTROLYTES Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Hypomagnesemia [Mg < 1.50 mEq/L; Normal = 1.5-3.0 mEq/L]

Causes

Low intake of Mg in the diet

Prolonged diarrhea

Massive diuresis

Hypoparathyroidism

Assessment

Paresthesias, muscle spasm

Confusion, hallucination, convulsions

Ataxia, tremors, hyperactive deep reflexes

Flushing of the face, diaphoresis

Nursing Intervention

Provide good dietary sources of Mg

Hypomagnesemia Drugs that decrease magnesium Aminoglycoside: Amikacin, gentamicin, streptomycin, tobramycin Amphotericin B Cisplatin Cyclosporine Insulin Laxative Loop diuretics Pentamidine isethionate Renal Disorders [email_address]

Aminoglycoside:

Amikacin, gentamicin, streptomycin, tobramycin

Amphotericin B

Cisplatin

Cyclosporine

Insulin

Laxative

Loop diuretics

Pentamidine isethionate

Hypomagnesemia S eizures T etany A norexia & arrhythmias R apid heart rate V omiting E motional lability D eep tendon reflexes increased [tremors, twitching, tetany] Renal Disorders [email_address]

S eizures

T etany

A norexia & arrhythmias

R apid heart rate

V omiting

E motional lability

D eep tendon reflexes increased

[tremors, twitching, tetany]

Dietary sources Chocolates Dry beans and peas Green, leafy vegetables Meats Nuts Seafood Whole grains Renal Disorders [email_address]

Chocolates

Dry beans and peas

Green, leafy vegetables

Meats

Nuts

Seafood

Whole grains

IV FLUID REPLACEMENT THERAPY Indications Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding] Maintenance of daily fluid & electrolyte needs Correction of fluid disorders Correction of electrolyte disorders Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Indications

Replacement of abnormal fluid & electrolyte losses [surgery, trauma, burns, GI bleeding]

Maintenance of daily fluid & electrolyte needs

Correction of fluid disorders

Correction of electrolyte disorders

IV FLUID REPLACEMENT THERAPY Types of Solutions Isotonic 0.9% sodium chloride (NSS) Lactated Ringer’s sol’n Hypotonic 5% dextrose and water (D5W) 0.45% sodium chloride 0.33% sodium chloride Hypertonic 3% NaCl Protein sol’ns Colloids Salt poor albumin Plasmanate, Dextran Renal Disorders [email_address] FLUIDS and ELECTROLYTES

Types of Solutions

Isotonic

0.9% sodium chloride (NSS)

Lactated Ringer’s sol’n

Hypotonic

5% dextrose and water (D5W)

0.45% sodium chloride

0.33% sodium chloride

Hypertonic

3% NaCl

Protein sol’ns

Colloids

Salt poor albumin Plasmanate, Dextran

BURNS wounds caused by excessive exposure to the following agents or causes: Causes of Burns: Thermal [moist or dry heat] Electrical Chemical [strong acids and strong alkali] Radiation [UV, x-rays, radium, sunburns] Renal Disorders [email_address] B U R N S

wounds caused by excessive exposure to the following agents or causes:

Causes of Burns:

Thermal [moist or dry heat]

Electrical

Chemical [strong acids and strong alkali]

Radiation [UV, x-rays, radium, sunburns]

CLASSIFICATION OF BURNS Superficial Partial thickness (1 st degree) Outer layer of dermis Erythema, pain up to 48 hrs Healing 1-2 wks [sunburn] Deep Partial thickness (2 nd degree) Epidermis & dermis Blisters & edema, frequently quite painful Healing 14-21 days Full thickness (3 rd degree) Epidermis, dermis, subcutaneous fat Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting Renal Disorders [email_address] B U R N S

CLASSIFICATION OF BURNS

Superficial Partial thickness (1 st degree)

Outer layer of dermis

Erythema, pain up to 48 hrs

Healing 1-2 wks [sunburn]

Deep Partial thickness (2 nd degree)

Epidermis & dermis

Blisters & edema, frequently quite painful

Healing 14-21 days

Full thickness (3 rd degree)

Epidermis, dermis, subcutaneous fat

Dry, pearly white or charred in appearance

Not painful

Eschar must be removed; may need grafting

STAGES OF BURNS 1 st : Shock/Fluid Accumulation Phase 1 st 48 hrs IVC  ISC Generalized DHN [fluid shifting] Hypovolemia [plasma loss],  BP,  C.O. Hemoconcentration,  Hct [liquid blood component  ISC] Oliguria [  renal perfusion], ADH release & aldosterone HyperK, hypoNa Metabolic acidosis Renal Disorders [email_address] B U R N S

STAGES OF BURNS

1 st : Shock/Fluid Accumulation Phase

1 st 48 hrs

IVC  ISC

Generalized DHN [fluid shifting]

Hypovolemia [plasma loss],  BP,  C.O.

Hemoconcentration,  Hct [liquid blood component  ISC]

Oliguria [  renal perfusion], ADH release & aldosterone

HyperK, hypoNa

Metabolic acidosis

STAGES OF BURNS 2 nd : Diuretic/Fluid Remobilization Phase After 48 hrs ISC  IVC Hypervolemia, Hemodilution,  Hct Diuresis [  renal perfusion],  ADH & aldosterone secretion HypoK, hypoNa [K moves back into the cells, Na+ still trapped in the edema fluids Metabolic acidosis Renal Disorders [email_address] B U R N S

STAGES OF BURNS

2 nd : Diuretic/Fluid Remobilization Phase

After 48 hrs

ISC  IVC

Hypervolemia,

Hemodilution,  Hct

Diuresis [  renal perfusion],  ADH & aldosterone secretion

HypoK, hypoNa [K moves back into the cells, Na+ still trapped in the edema fluids

Metabolic acidosis

STAGES OF BURNS 3 rd : Recovery Phase 5 th day onwards Hypocalcemia Ca is lost on the exudates Ca is utilized in the granulation tissue formation Negative nitrogen balance Due to stress response  protein catabolism Protein intake is lesser than the demand HypoK Renal Disorders [email_address] B U R N S

STAGES OF BURNS

3 rd : Recovery Phase

5 th day onwards

Hypocalcemia

Ca is lost on the exudates

Ca is utilized in the granulation tissue formation

Negative nitrogen balance

Due to stress response

 protein catabolism

Protein intake is lesser than the demand

HypoK

ASSESSMENT Assess extent of body surface burned Greater morbidity & mortality for burns affecting face, hands & perineum Assess for dyspnea, stridor, hoarseness Assess extent of burn injury Rule of nine – immediate appraisal Lund-Browder chart – more accurate Berkow’s method – based on client’s age & changes that occur in proportion of head & legs to the rest of the body as one grows Renal Disorders [email_address] B U R N S

ASSESSMENT

Assess extent of body surface burned

Greater morbidity & mortality for burns affecting face, hands & perineum

Assess for dyspnea, stridor, hoarseness

Assess extent of burn injury

Rule of nine – immediate appraisal

Lund-Browder chart – more accurate

Berkow’s method – based on client’s age & changes that occur in proportion of head & legs to the rest of the body as one grows

ASSESSMENT Burn Evaluation Chart Renal Disorders [email_address] B U R N S 9% 9% 9% Front= 18% Back= 18% 18% 18% 1%

ASSESSMENT 3. Assess depth of burn Major burns – 2 nd degree over 30% of body Hospitalization - eyes, face, neck, hands, perineum, genitalia 4. Assess unique contributing factors Age of client Health history Diabetes, preexisting ulcers Tetanus immunization Renal Disorders [email_address] B U R N S

ASSESSMENT

3. Assess depth of burn

Major burns – 2 nd degree over 30% of body

Hospitalization - eyes, face, neck, hands, perineum, genitalia

4. Assess unique contributing factors

Age of client

Health history

Diabetes, preexisting ulcers

Tetanus immunization

EMERGENCY MANAGEMENT Stop the burning process Remove patient from source of injury Advise client to roll on the ground if clothing is in flame [STOP-DROP-ROLL] Throw a blanket over the client to smother the flame Remove clothing only if hot or for scald burn Immerse affected part in cold water [10 min] Irrigate copiuosly w/ large amount of running water w/ chemical burns [except w/ phosphorus] Interrupt power source w/ electrical burn Renal Disorders [email_address] B U R N S

EMERGENCY MANAGEMENT

Stop the burning process

Remove patient from source of injury

Advise client to roll on the ground if clothing is in flame [STOP-DROP-ROLL]

Throw a blanket over the client to smother the flame

Remove clothing only if hot or for scald burn

Immerse affected part in cold water [10 min]

Irrigate copiuosly w/ large amount of running water w/ chemical burns [except w/ phosphorus]

Interrupt power source w/ electrical burn

MANAGEMENT Maintenance of adequate airway Promoting comfort: relieve pain Promoting fluid-electrolyte, acid-base balance Preventing infection Maintaining adequate nutrition Wound care Renal Disorders [email_address] B U R N S

MANAGEMENT

Maintenance of adequate airway

Promoting comfort: relieve pain

Promoting fluid-electrolyte, acid-base balance

Preventing infection

Maintaining adequate nutrition

Wound care

METHODS OF TREATING BURNS Open method or Exposure method Face, neck, perineum, trunk Allowing exudate to dry in 3 days Occlusive Less pain, absorption of secretion, comfort, transportability, accelerated debridement Aesthetic considerations Semi-open method Covering of wound w/ topical antimicrobials: Silver sulfadiazine 1% (Flamazine) Silver nitrate 0.5% sol’n Mafenide acetate (sulfamylon acetate) Renal Disorders [email_address] B U R N S

METHODS OF TREATING BURNS

Open method or Exposure method

Face, neck, perineum, trunk

Allowing exudate to dry in 3 days

Occlusive

Less pain, absorption of secretion, comfort, transportability, accelerated debridement

Aesthetic considerations

Semi-open method

Covering of wound w/ topical antimicrobials:

Silver sulfadiazine 1% (Flamazine)

Silver nitrate 0.5% sol’n

Mafenide acetate (sulfamylon acetate)

BIOLOGIC DRESSING (Skin Graft) Allograft Skin taken from other person [cadaver] Autograft Same person Heterograft Different species Xenograft [segment of skin from animal such as pig or dog] Renal Disorders [email_address] B U R N S

BIOLOGIC DRESSING (Skin Graft)

Allograft

Skin taken from other person [cadaver]

Autograft

Same person

Heterograft

Different species

Xenograft

[segment of skin from animal such as pig or dog]

FLUID REPLACEMENT Types of fluids: Colloids Blood Plasma & plasma expanders Electrolytes Lactated Ringers Non-electrolyte D 5 W Renal Disorders [email_address] B U R N S

FLUID REPLACEMENT

Types of fluids:

Colloids

Blood

Plasma & plasma expanders

Electrolytes

Lactated Ringers

Non-electrolyte

D 5 W

FLUID REPLACEMENT EVAN’S Formula: C – 1ml x % burns x kg BW E - 1ml x % burns x kg BW G lucose 5% for insensible loss – 2,000ml D5W Administer sol’n 1 st 24 hrs – ½ [1 st 8hrs], ½ [16hrs] BROOKE Formula: [Administer as in Evan’s] C – 0.5ml x % burn x kg BW E - 1.5ml x % burn x kg BW Water – 1000ml D5W Renal Disorders [email_address] B U R N S

FLUID REPLACEMENT

EVAN’S Formula:

C – 1ml x % burns x kg BW

E - 1ml x % burns x kg BW

G lucose 5% for insensible loss – 2,000ml D5W

Administer sol’n 1 st 24 hrs – ½ [1 st 8hrs], ½ [16hrs]

BROOKE Formula: [Administer as in Evan’s]

C – 0.5ml x % burn x kg BW

E - 1.5ml x % burn x kg BW

Water – 1000ml D5W

FLUID REPLACEMENT MOORES BURN BUDGET: 75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1% TBSA plus 2000 D 5 W HYPERTONIC RESUSCITATION Formula: Hypertonic salt containing 300 mEq of Na + , 100 mEq of Cl - , 200mEq lactate Administered to maintain urinary output of 30-40 ml/hr Renal Disorders [email_address] B U R N S

FLUID REPLACEMENT

MOORES BURN BUDGET:

75 ml of plasma, 75 ml of electrolyte-cont’g fluid for q 1% TBSA plus 2000 D 5 W

HYPERTONIC RESUSCITATION Formula:

Hypertonic salt containing 300 mEq of Na + , 100 mEq of Cl - , 200mEq lactate

Administered to maintain urinary output of 30-40 ml/hr

ACID-BASE DISORDERS Renal Disorders [email_address] Disorder Clinical manifestation Compensation Respiratory acidosis ↑ Paco 2 , ↑ or normal HCO 3 - , ↓ pH Kidneys eliminate H + and retain HCO 3 - Respiratory alkalosis ↓ Paco 2 , ↓ or normal HCO 3 - , ↑ pH Kidneys conserve H + and eliminate HCO 3 - Metabolic acidosis ↓ or normal Paco 2 , ↓HCO 3 - , ↓ pH Lungs eliminate CO 2 and conserve HCO 3 - Metabolic alkalosis ↑ or normal Paco 2 , ↑HCO 3 - , ↑ pH Lungs hypoventilate to ↑ Paco 2 , kidneys conserve H + excrete HCO 3 -

Causes of Acid-Base Disorders Metabolic acidosis Causes : DKA, uremia, starvation, diarrhea, severe infections Manifestations: Headache, nausea and vomiting Signs of hyperkalemia Seizures, coma, hyperventilation Nursing management: Administer sodium bicarbonate Monitor for signs of hyperkalemia Provide alkaline mouthwash Lubricate lips to prevent dryness I & O Institute seizure precaution Monitor ABG & electrolyte losses Renal Disorders [email_address]

Metabolic acidosis

Causes :

DKA, uremia, starvation, diarrhea, severe infections

Manifestations:

Headache, nausea and vomiting

Signs of hyperkalemia

Seizures, coma, hyperventilation

Nursing management:

Administer sodium bicarbonate

Monitor for signs of hyperkalemia

Provide alkaline mouthwash

Lubricate lips to prevent dryness

I & O

Institute seizure precaution

Monitor ABG & electrolyte losses

Causes of Acid-Base Disorders Metabolic alkalosis Causes: Severe vomiting, NGT suctioning, diuretic therapy, excessive ingestion of NaHCO 3 , biliary drainage Manifestations: Nausea and vomiting Signs and symptoms of hypokalemia Nursing management: Decreased respirations Replace fluids nad electrolytes losses I & O Assess for signs of hypokalemia Monitor ABG & electrolytes Renal Disorders [email_address]

Metabolic alkalosis

Causes:

Severe vomiting, NGT suctioning, diuretic therapy, excessive ingestion of NaHCO 3 , biliary drainage

Manifestations:

Nausea and vomiting

Signs and symptoms of hypokalemia

Nursing management:

Decreased respirations

Replace fluids nad electrolytes losses

I & O

Assess for signs of hypokalemia

Monitor ABG & electrolytes

Causes of Acid-Base Disorders Respiratory acidosis Causes: Hypoventilation: COPD, barbiturate or sedative overdose, acute airway obstruction, neuromuscular disorders Manifestations: Headache, weakness, visual disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma Nursing management: Semi-Fowler’s Patent airway Turn, cough, deep-breath Administer fluids O 2 therapy Monitor ABG Renal Disorders [email_address]

Respiratory acidosis

Causes:

Hypoventilation: COPD, barbiturate or sedative overdose, acute airway obstruction, neuromuscular disorders

Manifestations:

Headache, weakness, visual disturbances, rapid respirations, confusion, drowsiness, tachycardia, coma

Nursing management:

Semi-Fowler’s

Patent airway

Turn, cough, deep-breath

Administer fluids

O 2 therapy

Monitor ABG

Causes of Acid-Base Disorders Respiratory alkalosis Causes: Hyperventilation, mechanical overventilation, encephalitis Manifestations: Numbness and tingling of mouth and extremities Inability to concentrate Rapid respirations, dry mouth, coma Nursing management: Offer reassurance Encourage breathing into a paper bag Provide sedation as ordered Monitor mechanical ventilation and ABG Renal Disorders [email_address]

Respiratory alkalosis

Causes:

Hyperventilation, mechanical overventilation, encephalitis

Manifestations:

Numbness and tingling of mouth and extremities

Inability to concentrate

Rapid respirations, dry mouth, coma

Nursing management:

Offer reassurance

Encourage breathing into a paper bag

Provide sedation as ordered

Monitor mechanical ventilation and ABG

Interpretation Renal Disorders [email_address] UC PC FC pH ↓ or ↑ ↓ or ↑ normal HCO 3 - ↓ or ↑ normal ↓ or ↑ ↓ or ↑ Paco 2 ↓ or ↑ normal ↓ or ↑ ↓ or ↑

Nio Cruzada Noveno, RN, MAN, MSN Fluids & Electrolytes

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