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Nur 105 Adult Health

 



‡ Define Key Terms associated with fluids, electrolytes and
acid base balances.
‡ Describe the assessment findings for a balance and
imbalance fluid, electrolytes and acid base.
‡ Develop a nursing care plan to maintain fluid and
electrolyte homeostasis.
‡ Describe the nursing interventions in maintaining fluid
and electrolyte homeostasis.
‡ Evaluate the effectiveness of nursing interventions to
promote fluid and electrolyte balance.
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‡ 60% of body consists of fluid

‡ Intracellular space
‡ Extracellular space
‡ Electrolytes are active ions: positively
and negatively charged
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‡ Osmosis is the diffusion of water
caused by fluid gradient.
‡ Diffusion is the movement of a
substance from area of higher
concentration to one of lower
concentration.
‡ Active Transport is the movement of
substance across permeable membrane
and gradient; requires energy and
pump. Ex. Sodium/potassium pump
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‡ Filtration is the movement of water and
solutes from an area of high hydrostatic
pressure to an area of low hydrostatic
pressure
‡ Osmolality reflects the concentration of
fluid that affects the movement of water
between fluid compartments by osmosis
‡ Osmotic pressure is the amount of
hydrostatic pressure needed to stop the
flow of water by osmosis
  

‡ Isotonic ± same solute concentration; equal; no
movement across membrance
‡ Hypertonic/hyperosmotic ± greater osmotic pressure
(concentration); water K

 fluid to equalize.
‡ Hypotonic/hypo-osmotic ± lesser osmotic pressure
(concentration); water K

  of fluid to equalize.
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‡ Sodium concentration is higher in ECF

than ICF
‡ Sodium enters cell by diffusion
‡ Potassium exits cell into ECF
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‡ Gain ± solid foods, drinks; thirst center
‡ Loss -water and electrolytes move in a
variety of ways; sensible and insensible.
± Kidneys
± Skin
± Lungs
± GI tract
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‡ Skin elasticity impaired
‡ 45% to 50% of body weight in older adults is water; loss
of muscle mass and reduced ratio of lean to total body
weight; Sites for skin turgor are:
± forehead
± sternum
± Abdomen
‡ Renal, Muscular, Neurologic, Endocrine
  


‡ Major cation for extracellular fluid ± Sodium
‡ Major cation for intracellular - Potassium

‡ Cations
± Calcium,phosphorus, magnesium
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‡ Fluid Volume Deficit (Hypovolemia)

‡ Fluid Volume Excess (Hypervolemia)



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‡ Fluid Deficits
± Isotonic ± fluid and lytes
loss equally; decline in
circulating blood volume
± Hypertonic ± fluid loss
exceeds loss of lytes
± Hypotonic ± lytes loss
exceeds loss of water
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± Isotonic (CHF) ± Only ECF is
expanded
± Hypertonic ±rare ±
excessive Na+ intake; fluid
shifts from ICF to ECF
± Hypotonic ± water
intoxication; life
threatening; fluid moves in
ICF and all compartment
expands


  

‡ Physical exam
± Assess skin elasticity (tenting), edema, skin dryness,
mucous membrance, conjunctiva,
± VS -Increase respiratory rate in response to hypoxia
± Altered mental status ± confusion, lethargic, etc.
± Neuromuscular assessment of muscle tone and strength,
movement, coordination, and tremors.
± Cardiovascular ± orthostatic hypotension
± Renal - weight loss, I &O.
± Lab data ± hemoconcentration (elevated hemoglobins,
hematocrits, glucose, protein, blood urea
 

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‡ Dehydration ‡ Other Treatment based on
± Oral fluid replacement problems

± ORT ± special formula ± Drug therapy-

dysrhythmias
± IV Therapy
± Oral care, artificial tears,
‡ Check closely for fluid salivart
overload, check vital
signs, pulse rate and
I&O
± Drug Therapy
‡ Depends on cause:
antiemetic, antidiarrhea,
antibiotic
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‡ Isotonic Overhydration

‡ Hypotonic Overhydration ± water intoxication; fluid

moves into ICF



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‡ Hypertonic Overhydration ± fluid pulled from ICS
 
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‡ Drug therapy ± osmotic diuretics first, then loop diuretic
such as Lasix
± Weights, I&O, serum electrolytes, EKG
± Check IV fluids hourly
± Assessment of cardiopulmonary, renal, mental, skin
± VS every 4 hours and prn; I&O qshift and prn
‡ Diet Therapy ± restrict fluid and sodium
 

  
± Hypo and Hypernatremia (Na+)
± Hypo and Hyperkalemia (K+)
± Hypo and Hypercalcemia (Ca+)
± Hypo and Hypermagnesemia (Mg+)
± Hypo and Hyperphosphatemia (Phos+)
± Hypo and Hyperchloremia (Cl-)
  


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‡ Electrolyte Deficits ‡ Electrolyte Excess

± Treatment ± Treatment
‡ Drug Supplements ‡ Antagonist
‡ Foods ‡ Hydration
‡ Assess complications ‡ Omit foods or
medications high in
‡ Remove cause lytes
‡ Assess complications
‡ Remove the cause
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‡ Hyponatremia
± Assess mental, muscle
weakness, GI distress,
hypovolemia; VS
± Replace Na+ slowly;
saline IV infusions;
± If excess fluid, mannitol
± Check ADH levels
± Monitor electrolytes if
Na+ K+
± Diet therapy
‡ Hypernatremia
± Assess mental status,
muscle twitching and
irregular muscle
contractions, VS, BP in
hypovolemia; BP with
bounding pulses in
hypervolemia
± If fluid loss, hypotonic
IV fluids;
± If fluid and Na+ loss,
isotonic IV fluid
± Restrict Na+,
 

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'+( (+(*
‡ Hypokalemia ‡ Hyperkalemia
± Hand grasp weak, ± EKG changes,
hyporeflexia, muscle paresthesia, GI motility
weakness, shallow
respirations, pulse ± Stop K+ - oral or IV;
thready and weak, ± Administer K+ excreting
dysrhythmia, lethargic, diuretics (lasix) and
confusion, coma, GI Kayexlate; dialysis if
hypoactivity; VS, EKG severe K+ ; insulin
changes; fiber and fluids administration
± Administer K+ oral or
IV, monitor lab work,
 

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‡ Hypocalcemia
± Causes: Vitamin D deficiency
± S/S: Numb and tingling fingers and circumoral region,
muscle cramps
‡ Hypercalcemia
± Causes: osteoporosis, prolonged immobilization
± S/S: decreased muscle tone, weakness, lethargy,
kidney stones
  
 


  
‡ Hypercalcemia
‡ Hypocalcemia ± Heart rate and blood
pressure; severe hypercal-
± h  
 
 slow heart rate, dysrhythmias

  signs, vs, ± VS, EKG ± T wave, QT interval
heart rate up or down,
weak, thready pulse,
  
active bowel sounds
± Administer Calcium
gluconate, foods high in
calcium, assess for
injury
± Seizure precautions
± 
± Lethargic, confusion, muscle
weakness, coma deep
tendon reflexes without
paresthesia
± Renal calculi; I&O, strain
urine; bowels sounds
± Discontinue calcium oral or IV
drugs (antacids);adm. Saline
IV, Lasix diuretics, calcium
binders, NSAID, dialysis
    

‡ PH 7.35-7.45
‡ Acids/Bases ± hydrogen ion
‡ Buffer Systems ± promote balance
‡ Bicarbonate/ Carbonic acid
‡ Alkalosis ± above 7.45
‡ Acidosis ± below 7.35
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‡ Acids ‡ Bicarbonate
± Carbon dioxide ± Breakdown of carbonic
acid, intestinal
± Fatty acids and absorption, pancreatic
ketoacids production, movement
± Anaerobic ± lactic acid of cellular bicarbonate in
and ketoacids ECF and kidney
reabsorption of
± Impaired cells bicarbonate
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‡ Chemical Acid-Base Control
± Bicarbonate and phosphate

‡ Respiratory Acid Base Control

± Carbon dioxide

‡ Renal Acid Base Control

± Bicarbonate, acids, ammonium
    

‡ Respiratory ‡ Renal
± Metabolic disorders ± ± In lung disorders ±
Diabetes, acute renal COPD
failure
± Formation of acids or
± carbon dioxide retained bicarbonate reabsorbed
or excreted or excreted
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‡ Overproduction of   ‡ Respiratory Depression
Ions

‡ Inadequate Chest
‡ Underelimination of
  Ions Expansions

‡ Underproduction of ‡ Airway Obstruction




 Ions

‡ Reduced Alveolar-capillary
‡ Overelimination of diffusion



 Ions
 
 
‡ History ± age, cause, diet, medications, illness
‡ Physical Assessment
± Lethargic, confusion, coma
± Muscle weakness, deep tendon reflexes, flaccid
paralysis; skin in metabolic - warm, dry, pink (due to
vasodilation); skin in respiratory ± pale to cyanotic.
± Heart rate , then in severe cases, heart rate ,
BP, monitor vs, O2 sat, EKG
± Mental status ± confused, uncooperative
± Metabolic acidosis ± lo bicarbonate; Respiratory
acidosis ± elevated carbonic acid (CO2)
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‡ Metabolic ‡ Respiratory
± Hydration
± Treat cause ± diabetic
Ketoacidosis ± insulin;
antidiarrheal for
diarrhea
± Dialysis ± renal failure
± Monitor VS, EKG
± Assess for complications
± Oxygen, bronchial
dilators, dry pulmonary
secretions, breathing
exercise, postural
drainage
± Monitor oxygen sat
levels, VS, EKG
± Assess for complications
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‡ Metabolic ‡ Respiratory
± Base Excess ± Loss of carbonic acid in
hyperventilation
± Anxiety, fear or
improper settings on
± Acid Deficit mechanical ventilators
± Hyperventilation direct
stimulation of CNS ±
fever, metabolic
acidosis, drugs -
salicylates
 
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‡ Physical Assessment ‡ Rate and depth of
respirations
± CNS- dizziness, agitation
confusion, hyperreflexia,
parathesia, Chvostek¶s
and Trousseau¶s signs. ‡ Laboratory

± Cramps, twitches, ± Metabolic ± elevated

charley horses, deep bicarbonate
tendon reflexes ± Respiratory ± low
hyperactive, tetany, bicarbonate and
weak muscles, poor carbonic acid
hand grasp
± Heart rate , pulse
thready, BP
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‡ Treat the cause
± Correct electrolyte imbalances; remove if excess or
administer if low
± Hydration
± Antiemetic for upper GI distress
± Monitor IV fluids, VS, ABG¶s, I&O, oxygen,
respiratory and cardiac (EKG)
± Assess for complications
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‡ Isotonic
‡ Hypotonic
‡ Hypertonic
   



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‡ Systemic Complications ‡ Local Complications
± Fluid overload ± Infiltration and
extravasation
± Phlebitis
± Air embolism
± Thrombophlebitis
± Hematoma
± Septicemia and other
infection ± Clotting and Obstruction
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‡ Fluids
± Intracellular
± Extracellular
± Excess or deficit
‡ Electrolytes (Major cations and anions)
± Excess or deficit
‡ Acid Base Balances
± Imbalances, causes, signs and symptoms and Tx