Nursing Process Applied to Adults with Fluid/Electrolyte Disorders

Fluid Balance I. Regulation of fluid shifts between intravascular and interstitial spaces A. Physical principles governing fluid and solute exchange between fluid compartments 1. Simple diffusion: movement of solute from area where it is in higher concentration to area where it is in lower concentration.

2. Osmosis: movement of water from area where it is in lower concentration to an area of higher concentration; Osmotic pressure is attractive force for movement of water and it depends on number of solute molecules in solution; for example, solution with higher concentration of sodium draws water to it;

Colloid osmotic pressure a type of osmotic pressure exerted by proteins. They are large molecules & normally do not move out of vascular compartment, thus important in maintaining blood volume. 3. Filtration: movement of water and solutes through membrane from an area of higher pressure to an area of lower pressure; force behind filtration is hydrostatic pressure.

B. Fluid and solute exchange at the capillaries 1. Capillary structure: fluid and solute exchange between blood and tissue spaces occurs at capillaries; capillaries composed of layer of endothelial cells, which is permeable to solutes, water, and gasses, but impermeable to larger molecules such as proteins; substances move through small gaps between adjacent endothelial cell and some substances such as O2 and CO2 move through cells themselves.

b. At venous end of capillaries, forces (lower blood pressure and higher plasma COP resulting from fluid loss at arterial end) favor movement of fluid back into vascular compartment c. Some of fluid and solutes that leak into tissue spaces are returned to circulation by lymphatic system

2. Starling Forces; regulate fluid and solute movement at capillaries a. The hydrostatic pressure exerted by blood at arterial end of capillary forces O2, nutrients and some fluid out into interstitial spaces surrounding cells; this outward fluid movement limited by plasma colloid osmotic pressure (COP) and interstitial pressure

II. Edema A. Assessment 1. Definition: excess fluid in interstitial space, which may be localized or generalized; it is not a disease itself but rather a manifestation of a disease process; focus of this section on subcutaneous edema; however, edema: may also form in spaces such as pleural, pericardial, and peritoneal cavities and in internal organs such as brain

2. Predisposing / Precipitating factors a. Increased capillary hydrostatic pressure 1. Conditions causing venous obstruction: venous clots, right heart failure, varicosities, pressure on veins from casts or tight bandages 2. Conditions causing arteriolar dilation: local or systemic allergic reactions, inflammation

3. Increased extra cellular fluid volume: endocrine disorders or compensatory mechanisms resulting in increased aldosterone ( for example: Cushings disease, liver disease, renal ischemia); renal failure; excessive fluid administration

b. Increased capillary permeability (1) Inflammation (2) Allergic reactions (3) Burns (4) Mechanical injury

c. Decreased plasma colloid osmotic pressure (1) Conditions causing loss of albumin: burns, hemorrhage, diarrhea, nephrosis (2) Conditions causing decreased albumin production: liver disease, dietary protein deficiencies

d. Lymphatic obstruction (1) Malignant invasion of lymph nodes (2) Surgical removal of lymph nodes for cancer (3) Infection and inflammation- beta hemolytic streptococcus or filariasis

3. Signs and symptoms a. Weight gain: 1 liter of fluid weighs approximately 1 kg; several liters of fluid may be retained before edema becomes visually evident b. Elevated BP if edema associated with increased blood volume c. Skin alterations: stretched, pale, and shiny from increased tension and fluid covering blood vessels

d. Alteration in body contours (1) Pitting edema: indentation (pit) that forms over edematous area under pressure from examiners finger; pit caused by fluid translocated away from area under pressure point; roughly evaluated on 4-point scale: 1+ - edema barely detectable with slight pitting 2+ - deeper pit but fairly normal contours 3+ - deep pit and puffy appearance 4+ - excessive fluid accumulation with deep pit and frankly swollen appearance

Note, when edema becomes so severe that there is no place for fluid to be displaced, tissue become hard and unable to be indented

(2) Dependent edema: gravitational flow of edema fluid to most dependent portion of body; for example, in ambulatory clients, edema will most likely occur in feet and lower legs; in clients on bed rest, edema will most likely occur over sacrum and back

(3) Weeping edema: in very severe forms of edema, fluid leaks out of skin pores when pressure exerted over area (4) Brawny edema: caused by trapping of fluid by coagulated proteins in tissue spaces; skin becomes thick and hardened with an orangepeel appearance due to severe movement

4. Complications a. Plasma fluid volume deficit b. Plasma protein deficit c. Decubitus ulcers from breakdown of edematous d. Ischemic tissue damage because as edema fluid accumulates, it pushes cells farther away from surrounding capillaries e. Decreased movement in edematous areas

B. Planning/goals, expected outcomes 1. Cause of clients edema will be corrected or controlled 2. Clients edema will be reversed or controlled 3. Clients edematous tissues will be protected from injury 4. Client will not develop complications fro therapy for edema

C. Implementations 1. Specific implementations depend on cause of edema a. Heart failure: digitalis, diuretics, sodium and fluid restriction b. Renal failure: dialysis, sodium and fluid restriction, renal transplant c. Malnutrition: increase dietary protein d. Trauma: apply cold to injured area (up to 24 hours) to decrease amount of plasma accumulating in area

2. General implementations for management of edema a. Monitor I & O b. Administer prescribed drugs such as diuretics or albumin c. Restrict fluid and sodium intake d. Instruct client to read food labels for sodium content e. Elevate body parts prone to edema without causing pressure or sharp bends f. Use elastic support stockings and sleeves to increase resistance to outward flow of fluid

3. Keep skin over edematous tissue clean and lubricated; change clients position frequently 4. Monitor electrolytes for signs of hypokalemia or hyponatremia and administer prescribed electrolyte supplements if needed 5. Pharmacology and nutrition a. Diuretics b. Refer to section on nutrition and hypernatremia for Na+ content of foods

Diuretics: Class: a. Thiazide (benzthiazide, bendroflumethazide, chlorothiazide) b. Loop diuretics (furosemide, bumetanide, ethracynic acid) c. Potassium-sparing diuretics (amiloride, spironolactone, triamterene)

Nursing Responsibilities: 1. Administer drugs in day time. 2. Watch out for hypotension. 3. Administer prescribed K+ supplement rich foods when giving K+ losing diuretics.

D. Evaluation 1. Underlying cause has been corrected or controlled 2. I & O balanced; no further weight gain or decrease; no further increase in circumference of the edematous extremity 3. Skin integrity maintained over edematous tissue 4. Serum electrolytes normal; no signs and symptoms of electrolyte imbalance

III. Basic concepts of water metabolism A. Body water: functions and compartments 1. Body water constitutes approximately 60% of body weight in normal weight adult 2. Water crucial for survival because it is medium in which metabolic processes occur and through which CO2 and waste products are removed.

3. Approximately 2/3 of body water located intracellulary and 1/3 located in extracellular compartment, which is composed of interstitial fluid and plasma

B. Mechanisms that regulate body water to prevent dehydration 1. Physiological systems that regulate intake and urinary excretion of water respond to alterations in serum osmolarity that occur when there is water deficit or excess a. ADH released from posterior pituitary gland in response to increase in serum osmolarity or decrease in blood volume; ADH causes solute free reabsorption of water in collecting ducts of kidney

b. Thirst activated in response to increase in serum osmolarity c. Renin-angiotensin-aldosterone system activated in response to decreased blood volume or decreased NaCl concentration reaching kidneys; aldosterone causes sodium and water reabsorption in distal tubules and collecting ducts of kidney

IV. Dehydration A. Assessment 1. Definition: dehydration is deficit of body water relative to solutes; extracellular fluid becomes hypertonic causing water to move out of cells into intravascular fluid resulting in cell shrinkage and altered function

2. Precipitating / Predisposing factors a. Decreased water intake (1) Unavailability of fluids (2) Impaired thirst mechanism (for example, from head injury) (3) Impaired swallowing (4) Inability to communicate needs ( for example, aphasia, confusion, coma) (5) Debilitating disorders in which clients cannot attend to their thirst

b. Increased water loss (1) Diabetes insipidus (deficiency of ADH) (2) Severe burns (3) Osmotic diuresis (diabetic ketoacidosis) (4) Increased respiratory rate

c. Excess solute intake (1) High protein diet or tube feedings without adequate fluid intake (2) Excessive IV infusion of hypertonic solutions

3. Signs and symptoms a. Thirst b. Acute decrease in body weight over few days (1L of H2O weighs approx. 1 kg) c. Decreased urine output; increased urine osmolarity and specific gravity d. Elevated body temperature (lack of fluid for perspiration) e. Dry or cracked mucous membranes and tongue; decreased skin turgor

f. Increased serum sodium and osmolarity g. Central nervous system (CNS) alterations (from shrinkage of brain cells)- agitation, confusion, lethargy, coma h. Manifestations of decreased circulating blood volume that occur in severe dehydration postural hypotension, rapid, thready pulse, decreased vein prominence, and increased vein refill time

4. Complications a. Fever b. Dilutional hypernatremia c. Renal failure d. Shock e. Coma

Planning/goals, expected outcomes 1. Clients at risk will not become dehydrated 2. Dehydrated clients body water will be replaced 3. Client will be protected from injury if an altered level of sensorium or weakness develop 4. Clients skin & mucous membrane integrity will be preserved 5. Client will not develop complications from therapy for dehydration

Implementations 1. Monitor I & O in clients at risk; place debilitated or confused clients on regular schedule of water administration. 2. With mild to moderate water deficit (less than 10% body weight), oral fluid replacement may be sufficient; more severe water deficits (greater than 10% body weight), administer prescribed IV fluids (usually 2.5% or 5% dextrose).

3. Assist client while ambulating; use support strap when sitting; bed side rails kept up. 4. Apply skin lotion; change position frequently; keep lips and mucous membranes moist. 5. Replace body water gradually over 24 to 36 hours to prevent circulatory overload, pulmonary edema, and sudden compartmental shifts in water; monitor for signs of water intoxication Decreased serum sodium and osmolarity Polyuria

CNS alterations (disorientation, muscle twitching, and coma caused by cerebral edema); monitor for glucose overload if dextrose solutions are used, especially in diabetics

D. Evaluation 1. Body water balance maintained in clients at risk for dehydration 2. I & O balanced; body weight restored; serum sodium osmolarity normal; skin turgor normal; body temperature normal; no alteration in sensorium 3. Client has not sustained injury

D. Evaluation (cont..) 4. Clients skin and mucous membrane integrity maintained 5. No signs or symptoms of circulatory overload, glucose overload, or water intoxication

Electrolyte Imbalances I. Basic concepts of electrolyte imbalances A. Functions and regulations of electrolytes 1. Sodium (Na+), potassium (K+), calcium (Ca2+), and magnesium (Mg 2+), are the principle cations. 2. Maintenance of normal concentration and distribution of these electrolytes in body fluid compartments essential to life; specific functions of each electrolyte discussed in the following sections.

3. Adequate intake of electrolytes usually met by normal diet; electrolytes absorbed through gastrointestinal tract. 4. Excretion of electrolytes occurs primarily in urine and lesser extent in feces or perspiration. 5. Various hormones or vitamins are necessary for absorption or excretion of certain electrolyte.

B. General concepts of electrolyte imbalances 1. Deficit of an electrolyte may result from decreased intake or increased excretion or dilution of electrolyte by increased body water. 2. Excess of electrolyte may result from increased intake or decreased excretion or concentration of electrolyte by decreased body water.

3. Clinically, electrolytes are measured in serum; serum levels do not necessarily change in same direction as total body content or intracellular level of electrolyte; serum level is a measure of concentration of electrolyte in relation to volume of water in vascular compartment. 4. Usually, concentration of electrolyte in serum is related to presence or absence of associated signs and symptoms.

II. Sodium imbalances A. Basic concepts of sodium balance 1. Distribution in body a. Na+ found in all fluid compartments of body with highest concentration occurring in ECF of which Na+ is major cation. b. Normal serum Na+ = 135 145 mEq/L c. Na+ usually found in combination with Cl or another anion.

2. Sodium intake and excretion a. Minimum daily intake requirement for Na+ in adult is 2 gm, usually met in excess by normal diet which contains Na+ found naturally in foods and that added during food preparation. b. Na+ excreted primarily in urine and to a lesser extent in feces and perspiration. c. Na+ excretion regulated by aldosterone, which promotes Na+ reabsorption in distal tubules and collecting ducts of kidneys; water follows the movement of Na+

3. Functions of sodium a. Na+ regulates osmotic pressure and therefore volume of ECF (interstitial & intravascular spaces) b. Conduction of neural impulses c. Muscular contraction

B. HYPONATREMIA 1. Assessment a. Definition: decreased serum Na+ level below 135 mEq/L b. Predisposing / Precipitating factors (1) Increased Na+ loss (usually accompanied by some water loss also) (a) Renal losses (diuretics, osmotic diuresis, adrenal insufficiency, salt-wasting nephritis)

(b) Gastrointestinal losses (vomiting, diarrhea, GI suction, bile drainage, small bowel fistula) (c) Endocrine imbalances (hypopituitarism, hypoadrenalism) (d) Skin losses (excessive perspiration, burns)

(2) Dilutional Hyponatremia (excess extracellular water dilutes serum Na+) (a) Excessive ingestion of water (psychogenic polydipsia, rapid infusion of Na+- free IV solutions, ingestion of tap water to replace both Na+ and water loss) (b) Water retention (drugs that increase ADH, such as morphine or barbiturates, heart failure, cirrhosis)

(3) Decreased sodium intake (a) Overzealous dietary restriction of Na+ intake for therapeutic reasons
c. Signs and symptoms (1) Manifestations of hypovolemia if Na+ deficit occurs along with water deficit (decreased BP, weak, thready pulse, oliguria, postural hypotension)

(2) Manifestations of hypervolemia if (Na+) deficit occurs secondary to dilution by excess of water (weight gain, increased blood pressure, pulmonary edema) 3.) Manifestations of cellular swelling when decrease in (Na+) is extracellular fluid in excess of water loss because fluid moves into cells where osmolarity higher a.) Signs and symptoms of swelling of brain cells (altered level of sensorium-for example anxiety, confusion, coma)

b.) Signs and symptoms of swelling of neuromuscular cells (weakness, cramps, muscle, twitching, convulsions) c.) Signs and symptoms of swelling of GI cells (anorexia, diarrhea, abdominal cramps)

d.) Diagnostic tests 1.) History and physical to determine the underlying cause 2.) Serum Na+ concentration 3.) Serum osmolarity
e.) Complications 1.) Shock 2.) Coma 3.) Coexisting electolyte deficiencies

2.) Planning/goals, expected outcomes a.) Hyponatremia will be prevented in clients at risk b.) Underlying cause of clients hyponatremia will be identified c.) Clients sodium balance will be restored d.) Clients will not experience complications from therapy for hyponatremia e.) Client safety will be maintained in event that weakness or confusion develop

3.) Implementations a.) Prevention depends on situation (1) Advise clients working in hot environments to drink sodium-containing fluids or add salt to diet or ingest salt tablets (2) Monitor clients on diuretics for sodium depletion (3) Irrigate NG tubes with normal saline (4) Teach outpatients to recognize and report signs and symptoms of hyponatremia

b. Nursing history and assessment c. Specific implementations depend on underlying cause; listed below are common causes of hyponatremia and related implementations (1) Absolute Na+ deficit: Administer prescribed NaCl solutions; isotonic solutions used except in severe deficits, which may require more rapid reversal with a hypertonic solution such as 3% NaCl.

(2) Water retention (for example, CHF): restrict water intake, administer prescribed diuretics (3) To relieve CNS alterations from cellular swelling: administer prescribed mannitol hypertonic glucose, or urea to induce osmotic diuresis

d. Replace (Na+) slowly so that it can be distributed among body compartments; minor electrolytes to prevent overshoot hypernatremia; assess manifestation of fluid overload, especially in elderly clients and those with cardiac disorder. e. Assist client while ambulating, support for sitting; keep side rails up; observe client frequently

4. Evaluation a. Hyponatremia prevented in clients at risk b. Underlying cause of hyponatremia identified c. Serum Na+ without normal limits; no signs or symptoms of hyponatremia d. No signs or symptoms of overshoot hypernatremia or fluid overload e. Client has not sustained injury

HYPERNATREMIA 1. Assessment a. Definition: increased serum Na+ level above 145 mEq/L b. Precipitating/predisposing factors (1) Primary hypernatremia (actual Na+ gain) (a) Infusion of saline solutions (b) Salt water drowning (c) Renal disease

(d) Hyperaldosteronism (e) Cushings syndrome disease (f) Excessive Na+ intake in client with renal failure (2) Decreased extracellular water resulting in increased concentration of serum Na+ (a) Excessive water loss (diuretics, diabetes insipidus, watery diarrhea, heavy perspiration that results in more water than Na+ loss)

(b) Decreased water intake (inability to attend to thirst, difficulty swallowing, withholding water for therapeutic reasons) c. Signs and symptoms (1) Signs and symptoms associated with cell shrinkage (excess extracellular Na+ draws water out of cells causing cellular dehydration and altered function)

Thirst (b) CNS alterations (c) Dry, flushed skin (d) Dry, fissured mucous membranes (2) Signs and symptoms associated with hypovolemia if it is cause of hypernatremia (weight loss, decreased blood pressure, weak, thready pulse, increased temperature) (3) Edema, if there is both Na+ and water excess
(a)

d. Diagnostic tests (1) History and physical to determine underlying cause (2) Serum Na+ concentration (3) Serum osmolarity (4) Lab tests to detect concentration of other blood components (protein, urea, hematocrit), if there is coexisting water deficit (5) Urine specific gravity to determine if kidneys are retaining water in face of a water deficit

e. Complications (1) Manic excitement (2) Hypovolemia (3) Coma

2. Planning/goals, expected outcomes a. Hypernatremia will be prevented in clients at risk b. Underlying cause of clients hypernatremia will be identified c. Clients sodium balance will be restored d. Client will not develop complications from therapy for hypernatremia e. Client safety will be maintained in event that weakness or confusion develop

3. Implementations a. Prevention depends on situation (1) Those with decreased ability to excrete Na+ (renal failure, CHF) should have Na+ intake restricted (2) Those at risk for water deficit, such as elderly, confused, or debilitated, should be placed on regular schedule of water administration (3) Check for adequacy of renal function prior to administration of IV electrolytes

b. Nursing history and assessment c. Specific implementations depend on the underlying cause (1) Primary hypernatremia: Diuretics to remove Na+ Discontinue Na+-containing IV fluids Renal dialysis for severe hypernatremia unresponsive to other forms of therapy

(2) Decreased extracellular water-liberal administration of water after assessment of renal and cardiac function d. Monitor electrolytes to prevent overshoot hyponatremia; assess for manifestations of fluid overload in cases of water replacement therapy. e. Assist client while ambulating; support while sitting; keep side rails up; observe client frequently

Evaluation a. Hypernatremia prevented in clients at risk b. Underlying cause of hypernatremia identified c. Serum Na+ within normal limits; no signs or symptoms of hypernatremia or associated hypovolemia d. No signs or symptoms of overshoot hyponatremia or fluid overload e. Client has not sustained injury

III. Potassium imbalances A. Basic concepts of potassium balance 1. Distribution in body a. K+ found in all fluid compartments of body with highest concentration occurring in intracellular fluid of which K+ is the major cation b. Only 2% of total body K+ found in ECF compartment c. Normal serum K+= 3.5 to 5.0 mEq/L

2. Potassium intake and excretion a. Daily requirement for K+ intake 0.5 to 1.5 gm, which is supplied in slight excess by normal diet b. Urinary excretion is primary route of K+ loss, with smaller amounts of K+ excreted in feces and perspiration c. Kidneys can increase K+ excretion, via effects of aldosterone, when K+ potassium intake increases; however, kidneys cannot conserve K+ intake when intake is low

d. Acid-base balance affects K+ excretion, in acidosis, increased amounts of H+ excreted in urine and more K+ retained; opposite occurs in alkalosis; H+ and K+ compete for secretory sites in renal tubules e. Acid-base imbalances cause intercomparmental shifts in K+, in acidosis, H+ moves into cells to be buffered by intracellular proteins and K+ moves out; opposite effect occurs in alkalosis

f. Maintenance of normal intracellular concentration of K+ depends to large extent on Na+ - K+ pump, which pumps K+ into cell and Na+ out; ATP supplies energy to run this pump

3. Functions of potassium a. Regulates intracellular osmotic pressure and fluid volume b. Participates in acid-base balance c. Cofactor in metabolic reactions d. Critical in neuromuscular excitability of skeletal, cardiac, and smooth muscle

HYPOKALEMIA 1. Assessment a. Definition: decreased serum K+ below 3.5 mEq/L b. Predisposing/precipitating factors (1) Inadequate K+ intake (a) Diet or IV solutions deficient in K+ (b) Inability to eat

(2) Increased K+ loss from body (a) Renal losses (osmotic diuresis, renal tubular necrosis, K+- losing diuretics, increased aldosterone levels) (b) GI losses (vomiting, diarrhea, gastric suction, intestinal fistulas) (c) Skin losses (excessive diaphoresis burnslate stage when K+ initially lost from injured cells has been excreted in the urine)

(3) K+ shift into cells (a) Alkalosis or alkalinizing drugs (b) Insulin and glucose therapy

c. Signs and symptoms (1) Manifestations of altered cell polarization, which affects neuromuscular activity (intracellular K+ moves out to replenish extracellular K+ level) (a) CNS (confusion, irritability, lethargy, coma) (b) Altered neuromuscular activity (weakness, cramps, paresthesia, paralysis)

(c) Cardiovascular system (EKG alterations arrhythmias, prominent U wave, prolonged interval widening QRS complexes; postural hypotension) (d) Respiratory system (shallow breathing, respiratory muscle paralysis) (e) GI system (decreased bowel mobility, paralytic ileus, anorexia, nausea and vomiting)

S/Sx cont.. (2) Metabolic alkalosis (as intracellular K+ moves out to replenish extracellular K+, H+ moves into cells which increases extracellular pH) d. Diagnostic tests (1) History and physical to determine underlying cause (2) Serum K+ concentration (3) Serum pH (alkalosis causes K+ to move into cells)

e. Complications (1) Ventricular fibrillation (2) Respiratory arrest from respiratory muscle paralysis (3) Potentiation of digitalis toxicity

2. Planning/goals expected outcomes a. Hypokalemia will be prevented in clients at risk b. Underlying cause of clients hypokalemia will be identified c. Clients potassium balance will be restored d. Client will not experience complications from therapy for hypokalemia e. Clients safety will be maintained in the event that weakness or confusion develop

3. Implementations a. Prevention depends on the situation; for example, instruct clients on K+-losing diuretics to ingest foods high in K+, monitor clients on insulin therapy for hypokalemia b. Nursing history and assessment c. Replenish K+, preferably by oral route by providing foods high in K+ or administering prescribed K+ supplements; in more severe cases, administer prescribed intravenous K+

d. Monitor client for signs and symptoms of potassium toxicity (refer to section III, C, Hyperkalemia), assess adequacy of renal function prior to K+ administration, monitor EKG, pulse, muscle, strength e. Assist client while ambulating, support while sitting; keep side rails up; observe client frequently f. Pharmacology and nutrition

Potassium Supplements Liquid: Cena-K, Kaochlor Kay, Ciel, SKpotassium chloride Powder: K-Lor, Kay Ciel, Klorvess Effervescent tablets: Kaochlor-Eff, K-lyte Plain tablet: Slow K, K tab, Klotrix IV: potassium chloride, potassium gluconate Action: Treat or prevent K+ deficit

Common S/E: GI upset, Hyperkalemia Nursing Responsibilities: a. Assess adequacy of renal function. (?) b. Administer with meals. (?) c. Administer in milk or juice to disguise unpleasant taste. d. Effervescent: Dissolve immediately prior to administration.

e. Do not administer KCl IV push; mix well in IV bag; do not administer IV KCl faster than 20 mEq/hour; stop infusion if oliguria develops. g. Monitor EKG
Foods high in Potassium: Meats, Fish, Milk products, Fruits (Bananas), Vegetables

4. Evaluation a. Hypokalemia prevented in clients at risk b. Underlying cause of hypokalemia identified c. Serum K+ within normal limits; no signs or symptoms of hypokalemia d. No signs or symptoms of overshoot hyperkalemia e. Client has not sustained injury

HYPERKALEMIA 1. Assessment a. Definition: increased serum K+ above 5.5 mEq/L b. Predisposing/precipitating factors (1)Excessive K+ intake (a) Rapid infusion of K+-containing IV solutions

(2) Decreased K+ excretion (a) Decreased renal excretion (renal failure, adrenocortical insufficiency) (b) Decreased fecal excretion (intestinal obstruction) (3) K+ shift out of cells (a) Cell injury (burns, trauma, crushing injuries) (b) Acidosis or acidifying drugs

c. Signs and symptoms (1) Manifestations of altered cell polarization, which affects neuromuscular activity (a) Neural and skeletal muscle alterations (weakness, cramps, dizziness, paresthesia) (b) Cardiac alterations (arrhythmias, EKG peaked T-waves, wide QRS complex, cardiac fibrillation and arrest) (c) Smooth muscle alterations (nausea, diarrhea, vomiting, intestinal cramps)

(2) Metabolic acidosis (high extracellular K+ causes more K+ to move into cells with subsequent H+ exit from cells into extracellular fluid) d. Diagnostic tests (1) History and physical to determine the underlying cause (2) Serum K+ concentration (3) Serum pH (acidosis causes K+ to move out of the cells)

e. Complications (1) Ventricular fibrillation and arrest (2) Respiratory arrest 2. Planning/goals, expected outcomes a. Hyperkalemia will be prevented in clients at risk b. Underlying cause of clients hyperkalemia will be identified c. Clients K+ balance will be restored

d. Client will not experience complications from therapy for hyperkalemia e. Client safety will be maintained in event of weakness or dizziness 3. Implementations a. Prevention depends on situation (1) Monitor serum K+ in clients receiving K+containing medications and in clients in acidosis

(2) Avoid transfusion with old, stored blood because of cell lysis and release of K+ (3) Do not infuse IV solutions containing K+ until urine output assessed to be adequate b. Nursing history and assessment c. Instruct client to decrease intake of foods high in K+ and to avoid salt substitutes containing K+ d. Increase K+ excretion with prescribed dialysis or ion exchange resins

e. Increase cellular uptake of K+ by administering prescribed insulin and glucose f. Decrease K+ release from cells by preventing injury and infection g. Monitor client for signs and symptoms of hypokalemia h. Monitor EKG i. Safety precautions j. Pharmacology :Sodium polystyrene sulfonate (Kayexalate)

j. Action: (Kayexalate) Cation exchange resin that removes K+ from the body by exchanging it with Na+; the K+ containing resin is then excreted in the feces; used in cases of hyperkalemia Common Side effect: GI upset, Hypokalemia, Hypocalcemia, Hypernatremia

Nursing Responsibilities: a. Administer with prescribed laxative to ensure rapid movement o resin in GI tract; b. Monitor serum Na+ & instruct client on prescribed Na+ restrictions c. Monitor serum K+

Evaluation: a. Hyperkalemia prevented in clients at risk b. Underlying cause of hyperkalemia identified c. Serum K+ within normal limits; no signs or symptoms of hyperkalemia d. No signs or symptoms of overshoot hypokalemia e. Client has not sustained injury

Magnesium Imbalances A. Basic Concept of Magnesium Balance 1. Distribution in body a. Magnesium (Mg++) found in all fluid compartments of body with highest concentration occurring in ICF b. Normal serum Mg++ concentration: 1.5 to 2.5 mEq/L c. Approximately 50% of total body Mg++ located in bone

2. Functions of Magnesium a. Regulation of synaptic transmission at neuromuscular junction and in CNS b. Cofactor in variety of enzymatic reactions in metabolic pathways

HYPOMAGNESEMIA 1. Assessment a. Definition: decreased serum Mg++ level below 1.5 mEq/L b. Predisposing/precipitating factors (1) Inadequate intake (a) Malnutrition or starvation (b) High dietary intake of Ca2+ without increasing Mg2+ intake

(c) Prolonged IV infusion of Mg2+-free IV solutions without oral Mg2+ intake (2) Decrease absorption of Mg2+ (a) Diarrhea (b) Genetic Mg2+ absorption defect (c) Malabsorption syndromes (d) Presence of high Ca2+, fat, or phosphorus in GI tract

(3) Excessive excretion or fluid loss (a) Diuretics (b) Diabetic ketoacidosis (c) Prolonged GI suction (d) Hyperaldosteronism

Signs and Symptoms: (1) Manifestations of increased CNS and neuromuscular excitability resulting from increased acetylcholine release (a) CNS alterations (agitation, confusion, convulsions, insomnia) (b) Neuromascular alterations (hyperactive reflexes, positive Chvosteks sign and Trouseaus sign, cramps, nystagmus, muscle tremors and twitching)

(2)Cardiovascular alterations (a) Arrhythmias (b) Hypertension (c) Tachycardia d. Diagnostic tests (1) History and physical to determine underlying cause (2) Serum Mg++ level e. Complications (1) Convulsions (2) Cardiac arrhytmias

2. Planning/goals expected outcomes a. Hypomagnesemia will be prevented in clients at risk b. Underlying cause of clients hypomagnesemia will be identified c. The magnesium balance of client will be restored d. Client will not experience complications from therapy for hypomagnesemia e. Client safety will be maintained in event that confusion or convulsions occur

3. Implementations a. Prevention depends on situation (1) Encourage malnourished client to ingest foods high in Mg++ (green vegetables, nuts, seafood, whole grains, dried beans, cocoa) (2) Decrease Ca++ intake in client on high dietary Ca++ (3) Administer prescribed magnesium supplements to clients at risk

Magnesium supplement: Magnesium sulfate Action: treat severe hypomagnesemia; use IV to control convulsions Common side effects: diarrhea (oral form); hypermagnesemia S/Sx (respiratory and cardiac depression, muscle weakness, sedation, hypotension, diaphoresis, confusion)

b. Nursing history and assessment c. Increase dietary intake of Mg++; administer prescribed Mg++ supplements d. Monitor client for manifestations of Mg++ excess (refer to section on signs and symptoms of hypermagnesemia, section IV, C) e. Have calcium gluconate available because it antagonizes the sedative effects of Mg++ f. Safety and seizure precautions g. Pharmacology

Magnesium supplement: Nursing Responsibilities: a. Assess renal function prior to administration. b. Keep calcium gluconate available in case of cardiotoxicity c. For IM injection, give deep IM and massage to enhance absorption d. IV Mg2+ (test DTR, monitor cardiac & renal function and RR). Stop if: client becomes hypotensive, excessively diaphoretic, or reflexes become weak or absent

4. Evaluation a. Hypomagnesemia prevented in clients at risk b. Underlying cause of hypomagnesemia identified c. Serum Mg++ within normal; no signs or symptoms of hypomagnesemia d. No signs or symptoms of overshoot of hypermagnesemia e. Client has not sustained injury

HYPERMAGNESEMIA 1. Assessment a. Definition: increased serum Mg2+ greater than 2.5 mEq/L; associated S/Sx usually do not occur until Mg2+ exceeds 4 mEq/L b. Predisposing/precipitating factors (1) Decreased renal excretion (a) Renal insufficiency (b) Severe dehydration causing oliguria (c) Adrenal insufficiency

(2) Increased intake or absorption (a) Excessive IV Mg2+ administration (b) Salt water drowning (c) Overuse of Mg2+-containing antacids or cathartics Note: Increased Mg2+ intake usually results in hypermagnesemia if there is coexisting decreased renal output.

Signs and Symptoms: (1) Manifestations of neuromuscular depression (a) CNS (lethargy, sedation, confusion) (b) Skeletal muscles (flaccid paralysis, weak or absent reflexes, respiratory depression) (c) Cardiovascular system (vasodilation causing a sensation of warmth and hypotension, cardiac arrhythmias)

Diagnostic tests: (1) History and physical to determine underlying cause (2) Serum Mg2+ level
Complications: (1) Oversedation (2) Respiratory depression (3) Cardiac arrhythmias and arrest (4) Coma (if Mg2+ greater than 15 20 mEq/L)

2. Planning/goals, expected outcomes a. Hypermagnesemia will be prevented in clients at risk b. Underlying cause of the clients hypermagnesemia will be identified c. Clients magnesium balance will be restored d. Client will not experience complications from therapy for hypermagnesemia e. Client safety will be maintained in event that sedation or confusion occur

3. Implementations a. Prevention depends on situation (1) Do not administer Mg2+-containing medication if renal function inadequate (2) Provide adequate fluids to dehydrated client to ensure adequate urine excretion (3) Teach client proper use of antacids and cathartics containing Mg2+ b. Nursing history and assessment c. Decrease intake of foods high in Mg2+

d. Withhold Mg2+-containing medications e. Provide adequate fluid intake f. Conduct prescribed dialysis procedure g. Administer prescribed Ca2+ gluconate to antagonize cardiotoxic and sedative effects of Mg2+ h. Monitor client for manifestations of Mg2+ deficit or calcium toxicity (if treated with calcium gluconate) i. Safety precautions

4. Evaluation a. Hypermagnesemia prevented in clients at risk b. Underlying cause of hypermagnesemia c. Serum Mg2+ within normal; no S/Sx of Mg2+ excess d. No S/Sx of overshoot hypomagnesemia or hypercalcemia e. Client has not sustained injury

Calcium and Phosphorous imbalances A. Basic concepts of calcium & phosphorous balance 1. Relationship between Ca2+ and P04= a. Inverse relationship in their serum levels b. Increase or decrease in Ca2+ accompanied by opposite change in P04=

2. Distribution in body a. Approximately 99 % of body Ca2+ and P04= is in bone and teeth b. Normal serum Ca2+ level: 9 to 11 mg/dl or 4.5 to 5.8 mEq/L c. Normal serum P04= level: 3 to 4.5 mg/dl or 1.7 to 2.6 mEq/L

3. Ca2+ and P04= is equal to intake and excretion a. Approximately 75% of Ca2+ and P04= intake derived from milk and milk products, the rest from vegetables and fruits b. Vitamin D increases absorption of Ca2+ and renal excretion of P04= c. When blood Ca2+ low, parathyroid hormone secreted & it increases Ca2+ absorption from GI tract and Ca2+resorption from bone

d. When blood Ca2+ increased, calcitonin secreted, causing bone to take up Ca2+, thereby decreasing its serum level e. Increased in serum P04= stimulates bone uptake of Ca2+

Functions of Ca2+ and P04= a. Ca2+ and P04= essential components of bone and teeth b. P04= involved in metabolic reactions and cellular energy production c. P04= functions in acid-base balance by assisting in renal excretion of H+ d. Ca2+ regulates membrane permeability and nerve transmission

e. Ca2+ triggers muscle contraction f. Ca2+ involved in blood coagulation g. Ca2+ essential for hormone secretion
Note: Alterations in Ca2+ and P04= are discussed with focus on primary alteration in Ca2+, which then causes a secondary and inverse alteration in P04=.

HYPOCALCEMIA 1. Assessment a. Definition: decreased serum Ca2+ below 9 mg/dl or 4.5 mEq/L b. Predisposing/precipitating factors: (1) Decreased dietary Ca2+ (2) Decreased Ca2+ absorption (a) Vitamin D deficiency (b) Overuse of antacids

(3) Increased calcium losses (a) GI losses (diarrhea, intestinal fistulas, pancreatitis) (b) Loss in exudates (burns, infection, peritonitis) (4) Decreased availability of physiologically active free Ca2+ (a) Alkalosis (more Ca2+ bound to protein) (b) Massive transfusions with citrated blood (citrate binds Ca2+) (5) Hypoparathyroidism

Signs and symptoms (1) Manifestations of increased neuromuscular excitability (when serum Ca2+ decreases, nerve and muscle cell membrane permeability to Na+ increases leading to cell depolarization) (a) Numbness and tingling (b) Muscle spasms, tetany, cramps, convulsions (c) Positive Trousseaus sign and Chvosteks sign (d) Laryngospasm

Signs and symptoms (cont.) (2) Manifestations of depressed cardiac contractility (lack of Ca2+ to sustain strong cardiac contractions) (a) Weak cardiac contractions (b) Cardiac arrhythmias d. Diagnostic tests (1) History and physical to determine underlying cause (2) Serum Ca2+ concentration

e. Complications (1) Convulsions (2) Respiratory arrest from laryngospasm (3) CHF (4) Cardiac arrest (5) Pathological fractures

2. Planning/goals, expected outcomes a. Hypocalcemia will be prevented in clients at risk b. Underlying cause of clients hypocalcemia will be identified c. Clients calcium balance will be restored d. Client will not experience complications from therapy for hypocalcemia e. Client safety will be maintained in event that muscle spasms or convulsions develop f. Fractures will be prevented

Implementations a. Prevention depends on the situation (1) Instruct clients with poor nutritional habits regarding importance of adequate Ca2+ and vitamin D intake (2) Monitor clients who have potential Ca2+ loss in exudates for hypocalcemia (3) Monitor alkalotic clients for hypocalcemia (4) Keep calcium gluconate available for emergency use for clients after thyroid surgery (possibility of injury to parathyroid glands)

b. Nursing history and assessment c. Replenish Ca2+ preferably by oral route by increasing clients dietary intake of Ca2+ and vitamin D; if oral route not appropriate, administer prescribed IM or IV CA2+ supplements d. Monitor client for signs and symptoms of hypercalcemia; assess adequacy of renal function prior to administration of IV Ca2+

e. Assist client while ambulating; keep side rails up; support while sitting; seizure precautions f. Pharmacology and nutrition (1) Ca2+ supplements (2) Dietary sources of calcium are milk and milk products, green leafy vegetables, and sardines, clams and oysters

Calcium supplements Calcium chloride (IV), Calcium gluceptate (IV or IM), Calcium gluconate (oral or IV), Calcium lactate (oral) Action and use: To prevent hypocalcemia or to replenish Ca2+ S/E: Tingling sensation, metallic taste, local tissue irritation and burning; after IV infusions- sensation of heat, vasodilation, hypotension, dysrhythmia, cardiac arrest

Nursing Implications 1. Monitor ECG and BP. 2. Advise client to remain in bed during IV infusion; 3. Observe digitalized client for S/Sx of digitalis toxicity; 4. Observe infusion site closely to avoid extravasation, which causes cellulitis & necrosis 5. Avoid oxalate rich foods (spinach, beets, almonds, cashews, cocoa) in client on oral Ca2+ supplements since these foods interfere with Ca2+ absorption

4. Evaluation a. Hypocalcemia prevented in clients at risk b. Underlying cause of hypocalcemia identified c. Serum Ca2+ within normal limits; no signs or symptoms of hypocalcemia d. No signs or symptoms of overshoot hypercalcemia e. Client has not sustained injury

HYPERCALCEMIA 1. Assessment a. Definition: an increased serum Ca2+ above 11 mg/dl or 5.8 mEq/L b. Predisposing/precipitating factors (1) Excess Ca2+ or vitamin D intake (2) Hyperparathyroidism

(3) Increased Ca2+ mobilization from bone (a) Multiple fractures (b) Prolonged immobilization (c) Bone tumors (d) Tumors (for example, breast, lung, kidney) secreting bone demineralizing hormones (4) Increased availability of physiologically active free Ca2+ (a) Acidosis

Signs and symptoms (1) Manifestations of decreased neuromuscular excitability (elevated Ca2+ decreases cell membrane permeability to Na+) (a) CNS: depression, altered level of sensorium (b) Muscular system: decreased DTR, muscle weakness (c) GI system: decreased motility, nausea and vomiting, constipation (d) Cardiac arrhythmias

d. Diagnostic tests (1) History and physical to determine underlying cause (2) Serum Ca2+ concentration
e. Complications (1) Renal failure (2) Cardiac arrest (3) Pathological fractures (4) Potentiation of digitalis toxicity

Planning/goals, expected outcomes a. Hypercalcemia will be prevented in clients at risk b. Underlying cause of clients hypercalcemia will be identified c. Clients Ca2+ balance will be restored d. Client will not experience complications from therapy for hypercalcemia e. Client safety will be maintained

Implementations a. Prevention depends on situation (1) Instruct clients to avoid excessive Ca2+ or vitamin D supplementation (2) Promote early ambulation for clients on bed rest; use tilt table to achieve weight bearing position in immobilized clients; encourage use of trapeze bar (3) Monitor acidotic clients for hypercalcemia b. Nursing history and assessment

c. Restrict dietary intake of Ca2+ d. Hydrate client to promote renal excretion of Ca2+ e. Administer prescribed mithramycin to decrease serum Ca2+ in clients with cancer f. Maintain an acid urine to increase Ca2+ solubility by encouraging intake of acid ash fruit juices, cranberry and prune juice

g. Prevent UTI that cause an alkaline urine and Ca2+ precipitates h. Monitor client for signs and symptoms of rebound hypocalcemia i. Safety precautions

Evaluation a. Hypercalcemia prevented in clients at risk b. Underlying cause of hypercalcemia identified c. Serum Ca2+ within normal limits; no S/Sx of hypercalcemia d. No S/Sx of overshoot hypocalcemia e. Client has not sustained injury

Chloride Imbalances A. Basic concepts of chloride balance 1. Distribution in body a. Cl found in all fluid compartments of body, with highest concentration in ECF of which it is major anion b. Normal serum Cl concentration: 96 to 106 msEq/L

2. Chloride intake and excretion a. Cl usually ingested with Na+ in form of NaCl b. Cl absorbed in intestines with only small amount lost in feces c. Because Cl combines with Na+, its excretion in urine indirectly regulated by aldosterone d. Cl usually varies in relation to Na+ and water balance

3. Functions of chloride a. Helps maintain osmotic pressure and fluid volume of extracellular compartment b. Essential for production of HCl by gastric parietal cells c. Participates in regulation of acid/base balance

HYPOCHOLOREMIA 1. Assessment a. Definition: decreased serum Cl level below 96 mEq/L b. Predisposing/precipitating factors (1) Cl lost most commonly parallels Na+ loss or dilution by excess water (2) Cl loss occurring independent of Na+ losse.g. vomiting gastric fluid (3) Decreased Cl intake most commonly occurs from NaCl restricted diet

Signs and symptoms (1)Signs and symptoms are those of hypochloremic metabolic alkalosis (when CI is decreased , HCO3 is retained to maintain electrical neutrality of body fluids); (refer to section on acid-base imbalances) (2)Signs and symptoms of hypervolemia if CI deficit caused by dilution by excess water (3)Signs and symptoms of hyponatremia, if associated with Na+ deficit

d. Diagnostic tests (1) History and physical to determine underlying cause (2) Serum CI concentration e. Complications (refer to sections II, B, Hyponatremia and V, Metabolic alkalosis) 2. Planning goals expected outcomes a. Hypochloremia will be prevented in clients at risk b. Underlying cause of clients hypochloremia will be identified c. Clients chloride balance will be restored

d. Clients will not experience complications from therapy for hypochloremia e. Client safety will be maintained 3. Implementations a. Refer to preventive measures discussed under hyponatremia (section II, B) b. Nursing history and assessment

c. Specific implementations depend on underlying cause (1) Refer to implementations discussed under hyponatremia (2) Refer to implementations discussed under metabolic alkalosis (3) Administer prescribed saline solutions, KCI or ammonium chloride d. Monitor electrolytes to prevent overshoot hyperchloremia e. Safety and seizure precautions

4. Evaluation a. Hypochloremia prevented in clients at risk b. Underlying cause of hypochloremia identified c. Serum CI

4. Evaluation a. Hypochloremia prevented in clients at risk b. Underlying cause of hypochloremia identified c. Serum CI within normal limits; no signs or symptoms of hypochloremia d. No sign or symptoms of overshoot hyperchloremia e. Client has not sustained injury

HYPERCHLOREMIA 1. Assessment a. Definition: increased serum CI above 106meq/L b. Predisposing/precipitating factors (1) Primary hyperchloremia (a) Excessive ingestion or infusion of CIcontaining compounds such as KCI, NaCl, ammonium chloride (b) Refer to factors listed under primary hypernatremia (section II, C)

(2) Decreased extracellular water resulting in increased concentration of serum CI (a) Refer to hypernatremia) c. Signs and symptoms (1) Signs and symptoms are those of metabolic acidosis (when CI is in excess, more HCO3 excreted by kidneys); refer to section III for signs and symptoms of metabolic acidosis

(2) Signs and symptoms of hypovolemia if CI excess caused by water deficit (3) Signs and symptoms of hypernatremia if associated with Na+ excess d. Diagnostic tests History & physical to determine underlying cause Serum CI concentration

Planning/goals, expected outcomes a. Hyperchloremia will be prevented in clients at risk b. Underlying cause of clients hyperchloremia will be identified c. Clients Cl balance will be restored d. Client will not experience complications from therapy for hyperchloremia e. Client safety will be maintained

Implementations a. Refer to preventive measures discussed under hypernatremia b. Nursing history and assessment c. Monitor electrolytes to prevent overshoot hypochloremia d. Safety and seizure precautions

Evaluation a. Hyperchloremia prevented in clients at risk b. Underlying cause of the hyperchloremia c. Serum Cl within normal limits; no signs or symptoms of hyperchloremia d. No S/Sx of overshoot hypochloremia e. Client has not sustained injury

Acid-Base Balance I. Basic concepts of acid-base balance A. Acid: a substance that dissociates into ions and in so doing donates protons (H+ ions) to solution B. Base: a proton (H+ ion) acceptor; stronger base has greater affinity for H+ C. pH: a measure of the acidity of solution and equal to negative logarithm of H+ ion concentration (pH= -log H+)

D. Buffer: a mixture of a weak acid and its base, which minimizes changes in pH when either acid or base added to solution E. Types of acids produced in body 1. Volatile acids a. Can be eliminated by lungs in gaseous form as CO2 b. Source: aerobic metabolism

2. Fixed (nonvolatile) acids a. Nongaseous acids b. Eliminated by kidneys c. Source: anaerobic metabolism of glucose F. Arterial blood pH: 7.35 7.45

II. Acid-Base Imbalances a. A decreased arterial pH indicates a state of acidosis that may be of either metabolic or respiratory origin. Metabolic acidosis: serum HCO3 is below normal Respiratory acidosis: the pCO2 is elevated

b. An increased pH indicates a state of alkalosis that may be either of metabolic or respiratory origin. Metabolic alkalosis: serum HCO3 is above normal Respiratory alkalosis: the pCO2 is decreased

Metabolic acidosis A. Assessment 1. Definition: condition in which arterial blood pH below 7.35 caused by either accumulation of fixed (nonvolatile) acids or base deficit

2. Predisposing/precipitating factors a. Increase in metabolic acids (1) Excess production of metabolic acids (a) Fasting/starvation (b) Ketotic diet (c) Diabetic ketoacidosis (d) Lactic acidosis (e) Salicylate poisoning (2) Retention of metabolic acids: Renal Failure

b. Increase in bicarbonate loss (1) Diarrhea (2) GI suctioning (3) GI fistulas (4) Increased Cl levels

3. Signs and symptoms a. Nausea/vomiting b. Weakness c. Lethargy d. Coma e. Warm, flushed skin f. Compensatory signs (1) Kussmauls respirations (2) Acidic urine (3) Increased serum K+

Diagnostic tests a. History and physical to determine underlying cause of acidosis b. Blood gas, pH, and electrolyte levels Complications a. F&E loss from vomiting and diarrhea b. Cardiac dysrhythmias from elevated serum K+ c. Hypotension d. Congestive Heart Failure e. Shock

Planning/goals, expected outcomes 1. Underlying cause of clients metabolic acidosis will be identified 2. Clients acid-base balance will be restored 3. Client will not develop complications from metabolic acidosis 4. Client safety will be maintained in event of weakness or altered level of sensorium 5. Client will not develop complications from therapy for metabolic acidosis 6. Client will be comfortable

Implementations 1. Nursing history and assessment 2. Depends on the cause a. Diabetic ketoacidosis: administer prescribed insulin, fluids, and K+; instruct client on insulin and diet therapy b. Renal tubular disease: replace bicarbonate kidneys unable to reabsorb c. Lactic acidosis: improve tissue perfusion via cardiovascular support

d. Renal failure: dialysis e. Drug overdose: instruct client regarding use of salicylates, ethanol, etc. f. If therapy of underlying cause will not reverse acidosis rapidly enough, administer prescribed drugs, such as sodium bicarbonate or sodium lactate to neutralize the acid

3. Monitor I&O; replace F&E lost from vomiting, diarrhea, or osmotic diuresis 4. Assist client when mobile; use supporting straps when sitting; keep side rails up; position on side to prevent aspiration 5. Monitor client for manifestations of overshoot metabolic alkalosis; encourage foods high in K+ 6. Provide alkaline mouthwash to neutralize mouth acids; provide lemon and glycerine swabs to lubricate lips dried out from compensatory hyperpnea

7. Pharmacology of alkalinizing drugs: Sodium bicarbonate Action & use: to treat acidosis Common S/E: metabolic alkalosis, hypocalcemia, hypokalemia, gastric distention, fluid retention

Nursing Implications: Administer with caution, monitoring acid-base status, to avoid rebound alkalosis; have calcium gluconate & ammonium Cl available for therapy of tetany and alkalosis if they occur; avoid addition to IV solutions with calcium, which may result in formation of precipitates.

Sodium lactate Action and Use: used to treat acidosis; effect takes 1 to 2 hours Common S/E: metabolic alkalosis, hypocalcemia, hypokalemia Nursing Implications: administer with caution to avoid rebound alkalosis; avoid use in clients with liver disease or lactic acidosis

Evaluation 1. Underlying cause of metabolic acidosis identified 2. Blood pH and HCO3/H2CO3 and urine pH normal; no S/Sx of metabolic acidosis 3. No evidence of fluid or electrolyte imbalance 4. Client has not sustained injuries 5. Serum K+ maintained within normal limits; no evidence of overshoot metabolic acidosis

Respiratory acidosis A. Assessment 1. Definition: condition in which arterial blood pH below 7.35 caused by the retention of CO2, which combines with H2O to form carbonic acid (H2CO3). 2. Predisposing/precipitating factors a. Increased CO2 b. Decreased ventilation (1) Central nervous system depression (2) Asthma (3) COPD (4) Pulmonary edema

c. Chest trauma d. Respiratory paralysis 3. Signs and symptoms a. Headache b. Confusion/disorientation c. Tremors d. Warm, flushed skin e. Compensatory sign (1) Acid excretion in urine

Bases of S/Sx: (1) S/Sx of hypoventilation or impaired gas exchange, which is underlying cause of acidosis (2) S/Sx caused by altered cellular functions resulting from acidosis (a) Depressed neuromuscular function (b) Vasodilatory effect of CO2 on cerebral blood vessels (3) S/Sx resulting from compensatory mechanisms

Diagnostic tests a. History and physical to determine the underlying cause of the respiratory impairment b. Blood gas, pH, and electrolyte levels Complications a. Same with metabolic acidosis b. Increased ICP from vasodilatory effect of CO2 on cerebral blood vessels

Planning/goals, expected outcomes 1. Client will have adequate ventilation 2. Client will not develop complications from respiratory acidosis 3. Client will not develop complications from oxygen therapy 4. Client safety will be maintained in the event of weakness or altered level of sensorium

Implementations 1. Establish a patent airway. 2. Administer mechanical ventilatory aids as prescribed. 3. Facilitate removal of tracheobronchial secretions by teaching and encouraging client to cough and deep breathe. 4. Take in adequate fluids. 5. Perform postural drainage and clapping and manual chest vibration.

6. Prevent respiratory infections. 7. Teach client about risks associated with smoking and provide information to assist in smoking cessation. 8. Support medical therapy for specific respiratory disorders for example, administer antibiotics or bronchodilators. 9. Observe clients blood gases and S/Sx of worsening hypoventilation and acidosis. 10. Administer prescribed drugs, such as sodium bicarbonate, if necessary to neutralize excess acids.

11. Cautiously administer O2, especially to clients with chronic hypercapnia, in order to increase tissue oxygenation without causing respiratory depression: a. Monitor for signs of CO2 narcosis: respiratory depression, decreasing level of sensorium, cardiac dysrthymias b. Monitor for signs of O2 toxicity: pulmonary edema, presence of blood in tracheobronchial secretions c. Monitor use of mechanical ventilators to prevent rebound respiratory alkalosis

12. Assist client when mobile; use supporting straps when sitting; keep side rails up; position on side to prevent aspiration 13. Pharmacology a. Most effective therapy for respiratory acidosis is improvement of alveolar ventilation b. Drug therapy with alkalinizing agents may be contraindicated since increasing pH removes stimulatory effect of H+ on respiration and may therefore further reduce ventilation and increase the hypercapnia

Evaluation 1. Client effectively coughs and deep breathes; client performs postural drainage with production of sputum; client stops smoking; blood gases are normal; no signs of respiratory distress 2. Blood pH, gases, and electrolytes are normal 3. No evidence of CO2 narcosis or O2 toxicity or rebound respiratory alkalosis 4. Client has not sustained injuries

Metabolic Alkalosis A. Assessment 1. Definition: condition in which arterial blood pH greater than 7.45; caused by either loss of H+ or gain bicarbonate 2. Predisposing/precipitating factors a. Excessive bicarbonate (1) Bicarbonate antacids (2) Loss of body fluids

b. Hydrogen ion gain (1) Vomiting (2) Gastric suctioning (3) Potassium loss (a) Diuretics (b) Steroid therapy (c) Potassium loss or decreased intake

3. Signs and symptoms a. Nausea/vomiting b. Confusion c. Tetany d. Convulsions e. Compensatory signs (1) Hypoventilation (2) Increased urinary pH

4. Diagnostic tests a. History and physical to determine underlying cause of alkalosis b. Blood gas, pH, and electrolyte levels 5. Complications a. Respiratory depression from blunting of respiratory drive caused by H+ deficiency b. Tetany, convulsions c. Hypokalemia d. Decreased O2 release at tissue level secondary to shift in oxyhemoglobin association curve to left

Planning/goals, expected outcomes 1. Underlying cause of clients metabolic alkalosis will be identified 2. Clients acid-base balance will be restored 3. Client will be protected from injury in event of convulsions 4. Client will be free from complications from therapy of metabolic alkalosis

Implementations 1. Nursing history and assessment 2. Depends on the underlying cause a. Excessive ingestion of sodium bicarbonate: instruct client regarding appropriate use of sodium bicarbonate-containing drugs b. Chloride loss: administer prescribed chloride replacements c. Potassium deficit: administer prescribed potassium supplements; encourage foods high in K+

d. If therapy of underlying cause will not reverse alkalosis rapidly enough, administer prescribed acidifying drugs such as ammonium chloride or Diamox 3. Seizure precautions 4. Monitor blood gases and electrolytes during therapy to detect overshoot metabolic acidosis

Pharmacology of Acidifying Drugs Ammonium Chloride Action and Use: Ammonium (NH4+) is converted to urea in liver, resulting in release of H+ and Cl, which decreases pH; used to correct alkalosis Common S/E: GI irritation, metabolic acidosis, hypokalemia

Nursing Implications: Minimize GI irritation by administering with or immediately after meals; monitor blood gases and electrolytes to avoid overshoot acidosis; avoid use in client with liver or renal failure.

(acetazolamide) Diamox Action and Use: a carbonic anhydrase inhibitor that enhances renal bicarbonate excretion; used to correct alkalosis Common S/E: nausea/vomiting, polyuria, paresthesias, metabolic acidosis, hypokalemia, volume depletion

Nursing Implications: Minimize GI irritation by administering with or immediately after meals; monitor for overshoot acidosis; monitor I&O; instruct client to report paresthesias and drowsiness

Evaluation 1. Underlying cause of metabolic alkalosis identified 2. Blood pH, HCO3/H2CO3 normal; no signs or symptoms of alkalosis 3. Client has not sustained injuries 4. No evidence of overshoot metabolic acidosis; serum K+ within normal

Respiratory alkalosis A. Assessment 1. Definition: condition in which arterial blood pH greater than 7.45 caused by decrease in pCO2 secondary to increased alveolar ventilation

2. Predisposing/precipitating factors a. Hyperventilation (1) Salicylate poisoning (early) (2) Anxiety (3) Hypoxia (4) Increased blood ammonia

3. Signs and symptoms a. Numbness, tingling fingers and toes b. Lightheadedness c. Tetany/convulsions d. Positive Chvosteks sign and Trousseau's sign

4. Diagnostic tests a. History & physical to determine underlying cause of alkalosis b. Blood gas, pH, and electrolyte levels 5. Complications a. Tetany, convulsions b. Hypokalemia c. Decreased O2 release at tissue level secondary to shift in oxyhemoglobin association curve to left d. Dizziness and fainting

Planning/goals, expected outcomes 1. Underlying cause of respiratory alkalosis will be identified and eliminated 2. Clients acid-base balance will be restored 3. Client will be protected from injury in event of convulsions 4. Client will be from complications resulting from therapy of respiratory alkalosis

Implementations 1. Salicylate abuse: instruct client regarding appropriate use of drugs 2. Anxiety reaction: assist client to recognize and cope with situations that provoke anxiety; teach client to slow deep breaths or temporarily hold breath in situations that precipitate hyperventilation or use of rebreathing mask

3. Mechanical ventilation: monitor ventilatory settings and clients blood gases and electrolytes 4. Administer rebreathing mask or prescribed sedatives or 5% CO2 for inhalation 5. Seizure precautions 6. Monitor blood gases and electrolytes during therapy to detect overshoot metabolic acidosis 7. Pharmacology: therapy directed at underlying cause; in severe, acute cases, sedatives may be may be prescribed

Evaluation 1. Underlying cause of clients respiratory alkalosis identified and corrected 2. Blood pH, HCO3/H2CO3, and electrolytes normal; no signs or symptoms of alkalosis 3. Client has not sustained injuries 4. No evidence of overshoot metabolic acidosis