SUTONOSub. bag. Kep. Gawat DaruratPSIK FK UGM

Menjelaskan cara asessment untuk ketidakseimbangan cairan, dan elektrolit Mengembangkan rencana asuhan keperawatan untuk mempertahankan homeostasis cairan dan elektrolit.Menjelaskan intervensi keperawatan dalam menjaga homeostasis cairan dan elektrolit.Mengevaluasi efektivitas intervensi keperawatan untuk mempromosikan keseimbangan cairan dan elektrolit.

60% of body consists of fluidIntracellular spaceExtracellular spaceElectrolytes are active ions: positively and negatively charged

Osmosis adalah difusi air disebabkan oleh gradien cairan.Difusi adalah pergerakan zat dari daerah konsentrasi tinggi ke konsentrasi yang lebih rendah.Transportasi aktif adalah pergerakan zat melintasi membran permeabel dan gradien; membutuhkan energi dan pompa. contoh Natrium / kalium pompa

Filtrasi adalah gerakan air dan zat terlarut dari area dengan tekanan hidrostatik tinggi ke daerah tekanan hidrostatik rendahOsmolalitas mencerminkan konsentrasi cairan yang mempengaruhi pergerakan air antara kompartemen cairan melalui osmosisTekanan osmotik adalah jumlah tekanan hidrostatik diperlukan untuk menghentikan aliran air oleh osmosis

Isotonik : konsentrasi zat terlarut yang sama; sama, tidak ada gerakan di seluruh membranceHipertonik / hyperosmotic - tekanan osmotik yang lebih besar (konsentrasi); air ditarik ke dalam cairan untuk menyamakan kedudukan.Hipotonik / hipo-osmotik - tekanan osmotik lebih rendah (konsentrasi); air mengeluarkan cairan untuk menyamakan

Konsentrasi Natrium di ECF lebih tinggi dari ICFSodium enters cell by diffusionPotassium exits cell into ECF

Gain solid foods, drinks; pusat hausLoss -water and electrolytes move in a variety of ways; sensible and insensible.KidneysSkinLungsGI tract

Fluid Volume Deficit (Hypovolemia)Fluid Volume Excess (Hypervolemia)

Fluid DeficitsIsotonic fluid and lytes loss equally; decline in circulating blood volumeHypertonic fluid loss exceeds loss of lytesHypotonic lytes loss exceeds loss of waterFluid ExcessIsotonic (CHF) Only ECF is expandedHypertonic rare excessive Na+ intake; fluid shifts from ICF to ECFHypotonic water intoxication; life threatening; fluid moves in ICF and all compartment expands

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

DehydrationOral fluid replacementIV TherapyCheck closely for fluid overload, check vital signs, pulse rate and I&ODrug TherapyDepends on cause: antiemetic, antidiarrhea, antibioticOther Treatment based on problemsDrug therapy-dysrhythmiasOral care, artificial tears, salivart

Isotonic Overhydration

Hypotonic Overhydration water intoxication; fluid moves into ICF

Hypertonic Overhydration fluid pulled from ICS

Drug therapy osmotic diuretics first, then loop diuretic such as LasixWeights, I&O, serum electrolytes, EKGCheck IV fluids hourlyAssessment of cardiopulmonary, renal, mental, skinVS every 4 hours and prn; I&O qshift and prnDiet 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-)

Electrolyte DeficitsTreatmentDrug SupplementsFoodsAssess complicationsRemove causeElectrolyte ExcessTreatmentAntagonistHydrationAssess complicationsRemove the cause

HyponatremiaAssess mental, muscle weakness, GI distress, hypovolemia; VSReplace Na+ slowly; saline IV infusions;If excess fluid, mannitolCheck ADH levelsMonitor electrolytesDiet therapyHypernatremiaAssess mental status, muscle twitching and irregular muscle contractions, VS, BP in hypovolemia; BP with bounding pulses in hypervolemiaIf fluid loss, hypotonic IV fluids; If fluid and Na+ loss, isotonic IV fluidRestrict Na+,

HypokalemiaHand grasp weak, hyporeflexia, muscle weakness, shallow respirations, pulse thready and weak, dysrhythmia, lethargic, confusion, coma, GI hypoactivity; VS, EKG changes; fiber and fluidsAdminister K+ oral or IV, monitor lab work, HyperkalemiaEKG changes, paresthesia, GI motilityStop K+ - oral or IV;Administer K+ excreting diuretics (lasix) and Kayexlate; dialysis if severe K+ ; insulin administration

HypocalcemiaCauses: Vitamin D deficiencyS/S: Numb and tingling fingers and circumoral region, muscle crampsHypercalcemiaCauses: osteoporosis, prolonged immobilizationS/S: decreased muscle tone, weakness, lethargy, kidney stones

Hypocalcemiavs, heart rate up or down, weak, thready pulse, active bowel soundsAdminister Calcium gluconate, foods high in calcium, assess for injurySeizure precautionsHypercalcemia Heart rate and blood pressure; severe hypercal-slow heart rate, dysrhythmiasVS, EKG T wave, QT interval Lethargic, confusion, muscle weakness, coma deep tendon reflexes without paresthesiaRenal calculi; I&O, strain urine; bowels soundsDiscontinue calcium oral or IV drugs (antacids);adm. Saline IV, Lasix diuretics, calcium binders, NSAID, dialysis

PH 7.35-7.45Acids/Bases hydrogen ionBuffer Systems promote balanceBicarbonate/ Carbonic acidAlkalosis above 7.45Acidosis below 7.35

AcidsCarbon dioxideFatty acids and ketoacidsAnaerobic lactic acid and ketoacidsImpaired cellsBicarbonateBreakdown of carbonic acid, intestinal absorption, pancreatic production, movement of cellular bicarbonate in ECF and kidney reabsorption of bicarbonate

Chemical Acid-Base ControlBicarbonate and phosphate

Respiratory Acid Base ControlCarbon dioxide

Renal Acid Base ControlBicarbonate, acids, ammonium

RespiratoryMetabolic disorders Diabetes, acute renal failurecarbon dioxide retained or excretedRenalIn lung disorders COPDFormation of acids or bicarbonate reabsorbed or excretedArterial Blood Gases (ABGs)

Overproduction of Hydrogen Ions

Underelimination of Hydrogen Ions

Underproduction of Bicarbonate Ions

Overelimination of Bicarbonate IonsRespiratory Depression

Inadequate Chest Expansions

Airway Obstruction

Reduced Alveolar-capillary diffusion

History age, cause, diet, medications, illnessPhysical AssessmentLethargic, confusion, comaMuscle 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, EKGMental status confused, uncooperativeMetabolic acidosis low bicarbonate; Respiratory acidosis elevated carbonic acid (CO2)

MetabolicHydrationTreat cause diabetic Ketoacidosis insulin; antidiarrheal for diarrheaDialysis renal failureMonitor VS, EKGAssess for complications

RespiratoryOxygen, bronchial dilators, dry pulmonary secretions, breathing exercise, postural drainageMonitor oxygen sat levels, VS, EKGAssess for complications

MetabolicBase Excess

Acid DeficitRespiratory Loss of carbonic acid in hyperventilationAnxiety, fear or improper settings on mechanical ventilatorsHyperventilation direct stimulation of CNS fever, metabolic acidosis, drugs - salicylates

Physical AssessmentCNS- agitation confusion, hyperreflexia, parathesia, Chvosteks and Trousseaus signs.Cramps, twitches, charley horses, deep tendon reflexes hyperactive, tetany, weak muscles, poor hand graspHeart rate , pulse thready, BP

Rate and depth of respirations

LaboratoryMetabolic elevated bicarbonateRespiratory low bicarbonate and carbonic acid

Treat the causeCorrect electrolyte imbalances; remove if excess or administer if lowHydrationAntiemetic for upper GI distressMonitor IV fluids, VS, ABGs, I&O, oxygen, respiratory and cardiac (EKG)Assess for complications

IsotonicHypotonicHypertonic

Systemic ComplicationsFluid overload

Air embolism

Septicemia and other infectionLocal ComplicationsInfiltration and extravasationPhlebitisThrombophlebitisHematomaClotting and Obstruction

FluidsIntracellularExtracellularExcess or deficit Electrolytes (Major cations and anions)Excess or deficit Acid Base BalancesImbalances, causes, signs and symptoms and Tx

*Hypertonic ECF expands; ICF shrinkIsotonic (hypovolemia)

Health promotion mild dehydration heavy exercise, warm environment, not replace loss of fluids; drink a lot when exercise.Moderate to severe dehydration unable to obtain fluids; require assist. IV fluids, Tube feedings, etc.*Mental status change in mental status, confusion, poor memory, anxious, restless, disoriented, etc. More obvious with hypertonic and hypotonic dehydration because of ICF shifts in brain cells, shrinkage or swelling of cells.Assess other systems cardiac, dysrhythmias, GI peristalsis increase;Fluid loss, results in decrease blood volume results in decrease oxygen level (hypoxia) and increased resp. rate to increase oxygen delivery.*Overhydration circulatory overload edema, pulmonary edema, congestive heart failure*Osmotic diuretic mannitol not cause electrolyte imbalance; Lasix K+ imbalanceAssessment mental status, skin; oral care usually for dryness in fluid deficits*Excessive Hyper electrolytes; Antagonist medication to block absorption, or binders to lytes that excrete the excess lytes via renal or GI system; last resort is dialysis.

Complications heart rate, dysrhythmias, EKG, VS

*Assess mental status, cardiovascular, Neuromuscular, GI; vs, weights, I &O if fluid excess or loss and needs monitoring.

GI distress increase motility, nausea, diarrhea, and abdominal cramping; bowel sounds hyperactive; bowels watery and frequent; Hyponatremia with hypovolemia rapid weak, thready pulse, neck veins flat, severe hypotension (diastolic down); Hypervolemia Blood pressure normal or high; pulses difficult to palpate if edema.

In hypernatremia irritability overexcited tissues; mental status seizures, memory impaired and possible attention span delay, lethargic, drowsy. Cardiovascular If hypovolemia faint peripheral pulses, hypotension, orthostatic hypertension, pulse pressure is reduced.

Diretics if excess fluids,*Same principles of hypotonic and hypertonic hydration*K+ - cause major cell excitability, in particular nerve and muscle, and cellular processes; increase cell uptake of K+(hypo K+) in metabolic alkalosis and insulin use. GI decreased peristalsis, constipation, abdominal distention- paralytic ileus;Mental status loss problem solving ability;EKG ST- segment depressed, T wave flat or inverted and ioncrease U wave; dysrhythmias can be fatal.IV K+ - severely irritating to tissues never given SQ or IM, and given in 1 liter; Oral potassium liquid, unpleasant taste. But with protocol and frequent lab monitoring, it does well to raise K+ levels.In treatment for constipation fiber, fluids; asses for respiratory distress hypoxemia ( decrease blood oxygen levels or hypercapnia increase CO2 levels)K sparing diurectics, foods high in K+; Older adults at risk due to meds, mental status, physiological changes.Hyperkalemia Tall, peak T waves, prolong PR intervals, flat or absent P waves and wide QRS high K+ levels extopic beas, complete heart block, asystole and ventricular fibrillation; paresthesia tingling numbness in hands and feet and around mouth; treat with sodium polystyrene sulfonate*Calcium (Ca2+)Cardiac conduction, blood coagulation, bone growth and formation, & muscular relaxation Value - 4 - 5 mEq/L

*

Hypocalcemia - seizuresHypercalcemia excitable tissues heart, muscles, nerves, and intestinal smooth muscles. Blood-clotting requires calcium in excessive calcium may have increase clotting especially if viscosity of blood.EKG changes in T wave and QT intervalsCalcium binders to lower serum calcium levels Mithracin; other drugs that interfere with calcium uptake NSAID, Calcimar ( inhibit calcium resorption to bones).*Normal ph slightly alkaline; more H+ more acid, less H+ more baseBuffer - promote balance because it can function like an acid provide a free hydrogen ion or like a base by reducing the amount of hydrogen ions.

One carbonic acid to 20 bicarbonate pg 275*Chemical buffers - two types; Bicarb in both ECF and ICF; Phosphate in ICF;Protein buffers in ECF (albumin and globulins) and ICF (hemoglobin in RBC)Renal Acid Base Control Formation of acids phosphate binds with hydrogen ions (H+) = H2PO4Formation of ammonium (ammonia-NH3 product of protein breakdown) pick another H+ NH4*Normal attribute of the human body to compensate if balance or homeostasis is loss.Who is most sensitive to acid-base changes older and the very young*Hypotension due to vasodilation; respiratory rate rate, depth, rhythm, ulse oximeter.Note: metabolic rate increase, deep, rapid called Kussmaul; respiratory shallow and rapid.*Bronchial dilators adrenergic agonists and methylxanthines (relax smooth muscles); bronchialdilation steroids based Dexasone, Azmacort; drying secretions Mucomyst agents called mucolytics;Caution giving Oxygen to COPD suppress respirations if CO2 lowered.Encourage healthy living to promote clean lungs.*Alkalosis actual or relative increase in amount or strength of bases; actual base is either overproduced or undereliminated; relative alkalosis amount or strength of bases not increase, acids decrease, creating acid deficit and making blood more basic than acidic.

Alkalosis increased stimulations of central nervous, neuromuscular, and cardiovascular systems.*CNS like hypcalcemia and hypokalemia*Alkalosis is upper GI disturbance; Acidosis is lower GI disturbance.*D/C IVThree types hypo, iso, hypertonic 282-283Isotonic - Lactated Ringers Solution or Normal Saline

Hypotonic - .45% NaCl

Hypertonic 5 or 10% Dextrose ( concentration)

Common complication or problem with IV fluids infectionLocal complications Infiltration and extravasation solution is a vesicant or irritant solution that will destroy surrounding tissues and cells. Treat stop infusion at once, use of antidote, warm or cold compresses. Of course, notifying MD.

Phlebitis inflammation of vein; Thrombophlebitis inflammation with blood clot. Hematoma - Air embolism another complication dyspnea, cyanosis, weak, hypotension, unresponsiveness. Page - Omit starting IV and peripheral and central and midline catheters