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Help maintain body temperature and cell shape
Help transport nutrients, gasses and wastes
FluidIs used to indicate that other
substances are also found in these compartments and that they influence the water balance in and between compartments.
Fluids 60% of an adult’s body weight
* 70 Kg adult male: 60% X 70= 42 Liters
Infants = more water Elderly = less water More fat = ↓water More muscle = ↑water Infants and elderly - prone to fluid
imbalance
60 %
Intracellular Fluid 40% or 2/3
Intravascular
5% or 1/4
Transcellular fluid 1-2% ie csf, pericardial,
synovial, intraocular, sweat
Arterial Arterial Fluid 2%Fluid 2%
Extracellular Fluid 20% or 1/3
Interstitial 15% or 3/4
Venous Fluid 3%
Third-space fluid shift/Third “spacing”
- loss of ECF into a space that does not contribute to equilibrium between ICF and ECF
ie ascites, burns, peritonitis, bowel obstruction, massive
bleeding
Fluid Movement From Pressure Changes
fluids from different compartments move from one compartment to the other to maintain fluid balance.
movement is dictated by the transport mechanism principle :A. PASSIVE B. ACTIVE TRANSPORT
A. Passive Transport Process
– substances transported across the membrane w/o energy input from the cell
- high to low concentration
2 Types of Passive Transport1. Diffusion – substances/solutes move from high
concentration to low concentrationie exchange of O2 and CO2 b/w pulmonary capillaries and alveoli
2. Filtration – water and solutes forced through membrane by fluid or hydrostatic pressure from intravascular to interstitial area
- solute containing fluid (filtrate) from higher pressure to lower pressure
B. Active Transport Process
- Cell moves substances across a membrane through ATP because:
1. They may be too large
2. Unable to dissolve in the fat core
3. Move uphill against their concentration gradient
Types of Active Transport
1. Active transport – requires protein carriers using ATP to energize it
ie Amino acids Sodium potassium pump – 3Na out, 2K in
2. Endocytosis – moves substances into the cell
3. Exocytosis – moves substances out of the cell
Active Transport
Osmosis
Movement of water from low solute to high solute concentration in order to maintain balance between compartments.
Osmotic pressure – amount of hydrostatic pressure needed to stop the flow of water by osmosis
Oncotic pressure – osmotic pressure exerted by proteins
Osmosis
Osmosis
Diffusion
Regulation of Body Fluid
1. The Kidney Regulates primarily fluid output by
urine formation 1.5L Releases RENIN Regulates sodium and water balance
2. Endocrine regulation thirst mechanism – thirst
center in hypothalamus ADH increase water
reabsorption on collecting duct
Aldosterone increases Sodium and water retention retention in the distal nephron
ANP Promotes Sodium excretion and inhibits thirst mechanism
Atrial Natriuretic Peptide: Regulates Na+ & H2O Excretion
ADH Regulation ADH - produced by the Hypothalamus
- stored and secreted by the posterior pituitary gland
less water in plasma, ADH secreted to conserve water by reducing urine output
fluid overload in plasma, ADH secretion stops to excrete fluid in the kidneys by increasing urine output
ADH Disorder
Abnormally high ADH concentration - SIADH reduced urine output (oliguria)water retention (fluid overload)
Abnormally low ADH – Diabetes Insipidus increased urine output (polyuria)water loss (fluid deficit)
3. Gastro-intestinal regulation
- GIT digests food and absorbs water
- Only about 200 ml of water is excreted in the fecal material per day
4. Heart and Blood Vessel Functions- pumping action of heart circulates blood through kidneys
5. Lungs – insensible water loss through respiration
Other Mechanisms
1. Baroreceptors – carotid sinus and aortic arch- causes vasoconstriction and increased blood pressure
Dec arterial pressure SNS inc cardiac rate, contraction, contractility, circulating blood volume, constriction of renal arterioles and increased aldosterone
2. Osmoreceptors – surface of hypothalamus senses changes in Na concentration
Inc osmotic pressure neurons dehydrated release ADH
Evaluation of fluid status
Osmolality – concentration of fluid that affects movement of water between fluid compartments by osmosis- measures the solute concentration per kg in blood and urine- reported as mOsm/kg- normal value= 280-300 mOsm/kg
Osmolarity – concentration of solutions- mOsm/L
Intake and Output
I and O must be equal 2.6 L per day Essential = Measurable = Sensible Non essential = estimated Measurement=
Insensible
Sources of Fluids Fluid Intake
1. Exogenous sources Fluid intake
oral liquids – 1, 300 ml water in food – 1, 000 ml water produced by metabolism – 300 ml IVF Medications Blood products
2. Endogenous sources By products of metabolism secretions
2, 600 ml
Fluid Output
Sensible loss Urine - 1, 500 ml Fecal losses – 200 ml
Insensible loss skin – 600 ml Lungs – 300 ml
2, 600 ml
I&O Imbalance
Fluid Volume Deficit
output, normal intake Normal output, intake No intake or prolonged decreased intake
Causes of FVD
Vomiting, diarrhea, GI suctioning, sweating
Diabetes Insipidus Adrenal insufficiency Osmotic diuresis Hemorrhage 3rd space fluid shift
Assessment of FVD
ICF cellular dehydration Acidosis
ITF skin poor skin turgor
IVF artery ↓BP, pulse (rapid thready)vein ↓CVP, ↓PAWP
Clinical manifestations
Weight loss Oliguria Concentrated urine Postural hypotension Flattened neck veins Increased Temp Dec CVP Thirst, anorexia Muscle weakness and cramps
Laboratory
BUN:Crea > 20:1 Inc Hct – RBC suspended in Dec plasma
volume Dec K – GI and renal losses Inc K – adrenal insufficiency Dec Na – inc thirst and ADH Inc Na – insensible losses and DI
Medical Management
Oral intake when mild IV route, acute or severe Isotonic fluids ie LR for hypotensive
patients to expand plasma volume Assess I and O, weight, CVP, LOC, breath
sounds and skin color Fluid challenge test – 100-200 ml x 15 min
Nursing Management
Monitor and measure I and O Monitor VS closely Monitor skin turgor and tongue furrows Monitor urinary concentration Monitor mental function
Fluid Volume Excess
intake, normal output Normal intake, output No output
Nursing Management
Measure intake and output Weigh daily 2 lb wt gain = 1 L fluid Assess breath sounds Monitor degree of edema
ie ambulatory – feet and ankles bedridden – sacral area
Promote rest – favors diuresis/inc venous return Administer appropriate medication
Causes of FVE
Heart failure, renal failure, cirrhosis of the liver – d/t aldosterone stimulation/Congestion
Increased consumption of table salt Excessive administration of Na containing fluids
in a patient w/ impaired regulatory mechanism SIADH
Assessment of FVE ICF
cellular edema ↓LOC pulmonary edema crackles (bibasilar), wheezing, shortness of breath, Inc RR
ITF skin bipedal pitting edema, periorbital edema and ANASARCA
IVF artery ↑BP, pulse (rapid bounding)vein ↑CVP, ↑PAWP
Clinical Manifestations
Distended neck veins Tachycardia Inc weight Increased urine output Shortness of breath and
wheezing/crackles Inc CVP
Edema common manifestation of FVE d/t inc capillary fluid pressure, decreased
capillary oncotic pressure, increased interstitial oncotic pressure
Localized or generalized Etiology: obstruction to lymph flow, plasma
albumin level < 1.5-2 g/dl, burns and infection, Na retention in ECF, drugs
Labs: Dec Hct, respiratory alkalosis and hypoxemia, dec serum Na and osmolality, inc BUN Crea, Dec Urine SG, dec urine Na level
Mgmt: diuretics, fluid restriction, elevation of extremities, elastic compression stockings, paracentesis, dialysis
Laboratory
Dec BUN Dec Hct CRF – serum osmolality and Na level dec Cxr – pulmonary congestion
Medical Management
Discontinue administration of Na solution Diuretics
ie Thiazide – block Na reabsorption in distal tubule Loop diuretics – block Na reabsorption in ascending loop of Henle
Restrict fluid and salt intake Dialysis
Types of Fluid
• Tonicity - ability of solutes to cause osmotic driving forces
Isotonic Fluid - no movement of fluid.
Isotonic Fluids
0.9% NaCl/ Normal Saline/NSS -Na=154-Cl=154-308 mOsm/L - not desirable as routine maintenance solution- only solution administered with blood productsRx: hpovolemia, shock, DKA, metabolic alkalosis, hypercalcemia, mild NA deficitCI: caution in renal failure, heart failure and edema
D5W - 5% Dextrose in water - 170 cal and free water- 252 mOsm/LRx: hypernatremia, fluid loss and dehydrationCI: early post op when ADH inc d/t stress, sole treatment in FVD (dilutes plasma), head injury (inc ICP), flid resuscitation (hyperglycemia), caution in renal and cadiac dse (fluid overload), px with NA deficiency (peripheral circulatory collapse and anuria)
10% Dextran 40 in 5% Dextrose isotonic (252 mOsm/L)
Lactated Ringer’s Solution isotonic - Na 130 mEq/L- K 4 mEq/L-Ca 3 mEq/L- Cl 109 mEq/L- 273 mOsm/L Rx:hypovelemia, burns, flids lost as bile/diarrhea, acute blood lossCI: ph>7.5, lactic acidosis, renal failure(cause HyperK)
Hypotonic Fluid- fluid will enter the cell, the cell will
swell
Hypotonic Fluids
0.45% NaCl (half strength saline) - provides Na, Cl and free water- Na 77 mEq/L- Cl 77 mEq/L- 154 mOsm/L
Rx: hypertonic dehydration, Na and Cl depletion, gastric fluid lossCI : 3rd space fluid shifts and inc ICP
Hypertonic Fluid- fluid will go out from the cell, the cell
will shrink
Hypertonic Fluids
3% NaCl (hypertonic saline)- no calories- Na 513 mEq/L- Cl 513 mEq/L-1026 mOsm/LRx: critical situations to treat HypoNa, assist in removing ICF excessCI: administered slowly and cautiously (IVF overload and pulmonary edema)
5% NaCl
D10W - 10% Dextrose in water hypertonic (505 mOsm/L)
D10W - 20% Dextrose in water hypertonic (1011 mOsm/L)
D50W - 50% Dextrose in water hypertonic (1700 mOsm/L)
D5NS - 5% Dextrose & 0.9NaCl hypertonic (559 mOsm/L)
D10NS - 10% Dextrose & 0.9NaCl hypertonic (812 mOsm/L)
D5LR - 5% Dextrose in Lactated Ringers hypertonic (524 mOsm/L
Colloid solutions
Dextran 40 in NS or 5% D5W- volume/plasma expander - decrease coagulation- remains for 6H in circulatory systemRx: hypovolemia in early shock, improve microcirculation (dec RBC aggregation)CI: hemorrhage, thrombocytopenia, renal disease and severe dehydration
ELECTROLYTES
elements or compounds when dissolved in water will dissociate into ions and are able to conduct an electric current.
FUNCTIONS:1. Regulate fluid balance and osmolality2. Transmission of nerve impulse3. Stimulation of muscle activity
ANIONS - negatively charged ions: Bicarbonate, chloride, PO4-, CHON
CATIONS - positively charged ions: Sodium, Potassium, magnesium, calcium
Regulation of Electrolyte Balance
1. Renal regulation Occurs by the process of glomerular
filtration, tubular reabsorption and tubular secretion
Urine formation If there is little water in the body, it is conserved If there is water excess, it will be eliminated
2. Endocrinal regulation Aldosterone promotes Sodium retention
and Potassium excretion ANP promotes Sodium excretion Parathormone increased bone resorption
of Ca, inc Ca reabsorption from renal tubule or GI tract
Calcitoninoppose PTH Insulin and Epinephrine – promotes uptake
of Potassium by cells
The Cations
SODIUM POTASSIUM CALCIUM MAGNESIUM
SODIUM (Na)
MOST ABUNDANT cation in the ECF 135-145 mEq/L Aldosterone increases sodium reabsorption ANP increases sodium excretion Cl accompanies Na
FUNCTIONS:1. assists in nerve transmission and muscle
contraction2. Major determinant of ECF osmolality3. Primary regulator of ECF volume
a. HYPERNATREMIA
Na > 145 mEq/L
Assoc w/ water loss or sodium gain
Etiology: inadequate water intake, excessive salt ingestion /hypertonic feedings w/o water supplements, near drowning in sea water, diuretics, Diabetes mellitus/ Diabetes Insipidus
S/SX: polyuria, anorexia, nausea, vomiting, thirst, dry and swollen tongue, fever, dry and flushed skin, restlessness, agitation, seizures, coma, muscle weakness, crackles, dyspnea, cardiac manifestations dependent on type of hypernatremia
Dx: inc serum sodium and Cl level, inc serum osmolality, inc urine sp.gravity, inc urine osmolality
Mgmt: sodium restriction, water restriction, diuretics, isotonic non saline soln. (D5W) or hypotonic soln, Desmopressin Acetate for Diabetes Insipidus
Nsg considerations History – diet, medication Monitor VS, LOC, I and O, weight, lung sounds
Monitor Na levelsOral careinitiate gastric feedings slowlySeizure precaution
b. HYPONATREMIA
Na < 135 mEq/L
Etiology: diuretics, excessive sweating, vomiting, diarrhea, SIADH, aldosterone deficiency, cardiac, renal, liver disease
Dx: dec serum and urine sodium and osmolality, dec Cl
s/sx: headache, apprehension, restlessness, altered LOC, seizures(<115meq/l),coma, poor skin turgor, dry mucosa, orthostatic hypotension, crackles, nausea, vomiting, abdominal cramping
Mgmt: sodium replacement, water restriction, isotonic soln for moderate hyponatremia, hypertonic saline soln for neurologic manifestations, diuretic for SIADH
Nsg. ConsiderationMonitor I and O, LOC, VS, serum NaSeizure precautiondiet
Hyponatremia
HypernatremiaHypernatremia
Potassium (K) MOST ABUNDANT cation in the ICF 3.5-5.5 mEq/L Major electrolyte maintaining ICF balance maintains ICF Osmolality Aldosterone promotes renal excretion of K+ Mg accompanies K
FUNCTIONS:1. nerve conduction and muscle contraction2. metabolism of carbohydrates, fats and proteins3. Fosters acid-base balance
a. HYPERKALEMIA
K+ > 5.0 mEq/L
Etiology: IVF with K+, acidosis, hyper-alimentation and excess K+ replacement, decreased renal excretion, diuretics, Cancer
s/sx: nerve and muscle irritability, tachycardia, colic, diarrhea, ECG changes, ventricular dysrythmia and cardiac arrest, skeletal muscle weakness, paralysis
Dx: inc serum K levelECG: peaked T waves and wide QRSABGs – metabolic acidosis
Mgmt: K restriction (coffee, cocoa, tea, dried fruits, beans, whole grain breads, milk, eggs)diuretics Polystyrene Sulfonate (Kayexalate)IV insulin
Beta 2 agonist IV Calcium gluconate – WOF HypotensionIV NaHCo3 – alkalinize plasmaDialysis
Nsg consideration:Monitor VS, urine output, lung sounds, Crea, BUNmonitor K levels and ECGobserve for muscle weakness and dysrythmia, paresthesia and GI symptoms
K+ < 3.5 mEq/L
Etiology: use of diuretic, corticosteroids and penicillin, vomiting and diarrhea, ileostomy, villous adenoma, alkalosis, hyperinsulinism, hyperaldosteronism
s/sx: anorexia, nausea, vomiting, decreased bowel motility, fatigue, muscle weakness, leg cramps, paresthesias, shallow respiration, shortness of breath, dysrhythmias and increased sensitivity to digitalis, hypotension, weak pulse, dilute urine, glucose intolerance
b. HYPOKALEMIA
Dx: dec serum K level ECG - flattened , depressed T waves, presence of “U”
waves ABGs - metabolic alkalosis
Medical Mgmt: diet ( fruits, fruit juices, vegetables, fish, whole grains, nuts, milk, meats)oral or IV replacement
Nsg mgmt: monitor cardiac function, pulses, renal functionmonitor serum potassium concentrationIV K diluted in saline
monitor IV sites for phlebitis
Normal ECG
Hypokalemia
Hyperkalemia
CALCIUM (Ca)
Majority of calcium - bones and teeth Normal serum range 8.5-10.5 mg/dL Ca has an inverse relationship with PO4
FUNCTIONS
1. formation and mineralization of bones/teeth
2. muscular contraction and relaxation
3. cardiac function
4. blood coagulation
5. Promotes absorption and utilization of Vit B12
Regulation: GIT absorbs Ca+ in the intestine with the help
of Vitamin D Kidney Ca+ is filtered in the glomerulus and
reabsorbed in the tubules PTH increases Ca+ by bone resorption, inc
intestinal and renal Ca+ reabsorption and activation of Vitamin D
Calcitonin reduces bone resorption, increase Ca and Phosphorus deposition in bones and secretion in urine
a. HYPERCALCEMIA
Serum calcium > 10.5 mg/dL
Etiology: Overuse of calcium supplements and antacids, excessive Vitamin A and D, malignancy, hyperparathyroidism, prolonged immobilization, thiazide diuretic
s/sx: anorexia, nausea, vomiting, polyuria, muscle weakness, fatigue, lethargy
Dx: inc serum CaECG: Shortened QT interval, ST segmentsinc PTH levels
xrays - osteoporosis
Mgmt: 0.9% NaCl
IV PhosphateDiuretics – Furosemide
IM Calcitonincorticosteroidsdietary restriction (cheese, ice cream, milk, yogurt, oatmeal, tofu)
Nsg Mgmt: Assess VS, apical pulses and ECG, bowel sounds, renal function, hydration status
safety precautions in unconscious patients inc mobility inc fluid intake
monitor cardiac rate and rhythm
b. HYPOCALCEMIA Calcium < 8.5 mg/dL
Etiology: removal of parathyroid gland during thyroid surgery, Vit. D and Mg deficiency, Furosemide, infusion of citrated blood, inflammation of pancreas, renal failure, thyroid CA, low albumin, alkalosis, alcohol abuse, osteoporosis (total body Ca deficit)
s/sx: Tetany, (+) Chovstek’s (+) Trousseaus’s, seizures, depression, impaired memory, confusion, delirium, hallucinations, hypotension, dysrythmia
Dx: dec Ca level
ECG: prolonged QT interval
Mgmt:Calcium salts
Vit Ddiet (milk, cheese, yogurt, green leafy vegetables)
Nsg mgmt monitor cardiac status, bleeding
monitor IV sites for phlebitisseizure precautionsreduce smoking
Magnesium Mg
Second to K+ in the ICF Normal range is 1.3-2.1 mEq/L
FUNCTIONS1. intracellular production and utilization of
ATP2. protein and DNA synthesis3. neuromuscular irritability4, produce vasodilation of peripheral arteries
a. HYPERMAGNESEMIA
M > 2.1 mEq/L
Etiology: use of Mg antacids, K sparing diuretics, Renal failure, Mg medications, DKA, adrenocortical insufficiency
s/sx: hypotension, nausea, vomiting, flushing, lethargy, difficulty speaking, drowsiness, dec LOC, coma, muscle weakness, paralysis, depressed tendon reflexes, oliguria, ↓RR
Mgmt: discontinue Mg supplementsLoop diuretics
IV Ca gluconateHemodialysis
Nsg mgmt:monitor VSobserve DTR’s and changes in LOCseizure precautions
b. HYPOMAGNESEMIA
Mg < 1.5 mEq/l
Etiology: alcohol w/drawal, tube feedings, diarrhea, fistula, GIT suctioning, drugs ie antacid, aminoglycosides, insulin therapy, sepsis, burns, hypothermia
s/sx: hyperexcitability w/ muscle weakness, tremors, tetany, seizures, stridor, Chvostek and Trousseau’s signs, ECG changes, mood changes
Dx: serum Mg level ECG – prolonged PR and QT interval, ST
depression, Widened QRS, flat T waves low albumin level
Mgmt:diet (green leafy vegetables, nuts, legumes, whole grains, seafood, peanut butter, chocolate)IV Mg Sulfate via infusion pump
Nsg Mgmt:seizure precautionsTest ability to swallow, DTR’sMonitor I and O, VS during Mg administration
The Anions
CHLORIDE PHOSPHATES BICARBONATES
Chloride (Cl)
The MAJOR Anion in the ECF Normal range is 95-108 mEq/L Inc Na reabsorption causes increased Cl reabsorption
FUNCTIONS1. major component of gastric juice aside from H+2. together with Na+, regulates plasma osmolality3. participates in the chloride shift – inverse relationship
with Bicarbonate4. acts as chemical buffer
a. HYPERCHLOREMIA
Serum Cl > 108 mEq/L
Etiology: sodium excess, loss of bicarbonate ions
s/sx: tachypnea, weakness, lethargy, deep rapid respirations, diminished cognitive ability and hypertension, dysrhytmia, coma
Dx: inc serum Cldec serum bicarbonate
Mgmt: Lactated Ringers solnIV Na BicarbonateDiuretics
Nsg mgmt:monitor VS, ABGs, I and O, neurologic, cardiac and respiratory changes
b. HYPOCHLOREMIA
Cl < 96 mEq/l
Etiology: Cl deficient formula, salt restricted diets, severe vomiting and diarrhea
s/sx: hyperexcitability of muscles, tetany, hyperactive DTR’s, weakness, twitching, muscle cramps, dysrhytmias, seizures, coma
Dx: dec serum Cl levelABG’s – metabolic alkalosis
Mgmt:Normal saline/half strength saline
diet ( tomato juice, salty broth, canned vegetables, processed meats and fruits
avoid free/bottled water)
Nsg mgmt:monitor I and O, ABG’s, VS, LOC, muscle strength and movement
Phosphates (PO4)
The MAJOR Anion in the ICF Normal range is 2.5-4.5 mg/L Reciprocal relationship w/ Ca PTH inc bone resorption, inc PO4 absorption
from GIT, inhibit PO4 excretion from kidney Calcitonin increases renal excretion of PO4
FUNCTIONS1. component of bones2. needed to generate ATP3. components of DNA and RNA
a. HYPERPHOSPHATEMIA
Serum PO4 > 4.5 mg/dL
Etiology: excess vit D, renal failure, tissue trauma, chemotherapy, PO4 containing medications, hypoparathyroidism
s/sx: tetany, tachycardia, palpitations, anorexia, vomiting, muscle weakness, hyperreflexia, tachycardia, soft tissue calcification
Dx: inc serum phosphorus leveldec Ca levelxray – skeletal changes
Mgmt: diet – limit milk, ice cream, cheese, meat, fish, carbonated beverages, nuts, dried food, sardinesDialysis
Nsg mgmt:dietary restrictionsmonitor signs of impending hypocalcemia and changes in urine output
b. HYPOPHOSPHATEMIA Serum PO4 < 2.5 mg/dl
Etiology: administration of calories in severe CHON-Calorie malnutrition (iatrogenic), chronic alcoholism, prolonged hyperventilation, poor dietary intake, DKA, thermal burns, respiratory alkalosis, antacids w/c bind with PO4, Vit D deficiency
s/sx: irritability, fatigue, apprehension, weakness, hyperglycemia, numbness, paresthesias, confusion, seizure, coma
Dx: dec serum PO4 level
Mgmt:
oral or IV Phosphorus correction
diet (milk, organ meat, nuts, fish, poultry, whole grains)
Nsg mgmt:
introduce TPN solution gradually
prevent infection
Acid Base Balance
Acid- substance that can donate or release hydrogen ionsie Carbonic acid, Hydrochloric acid
** Carbon dioxide – combines with water to form carbonic acid
Base- substance that can accept hydrogen ions
Ie Bicarbonate
BUFFER- substance that can accept or donate hydrogen- prevent excessive changes in pH
TYPES OF BUFFER1. Bicarbonate (HCO3): carbonic acid
buffer (H2CO3) 2. Phosphate buffer3. Hemoglobin buffer
Dynamics of Acid Base Balance
Acids and bases are constantly produced in the body
They must be constantly regulated CO2 and HCO3 are crucial in the balance A HCO3:H2CO3 ratio of 20:1 should be
maintained Respiratory and renal system are active in
regulation
Kidney
- Regulate bicarbonate level in ECF
1. RESPIRATORY/METABOLIC ACIDOSIS
- kidney excrete H and reabsorbs/generates Bicarbonate
2. RESPIRATORY/METABOLIC ALKALOSIS
- kidney retains H ion and excrete Bicarbonate
Lung
- Control CO2 and Carbonic acid content of ECF
1. METABOLIC ACIDOSIS- increased RR to eliminate CO2
2. METABOLIC ALKALOSIS- decreased RR to retain CO2
pH - measures degree of acidity and alkalinity
- indicator of H ion concentration
- Normal ph 7.35-7.45
ACIDOSIS
- decreased pH; < 7.35
- increased Hydrogen
ALKALOSIS - increased pH-; > 7.45 - decreased Hydrogen
ACUTE AND CHRONIC METABOLIC ACIDOSIS
- Low pH- Increased H ion concentration- Low plasma BicarbonateEtiology: diarrhea, fistulas, diuretics, renal
insufficiency, TPN w/o Bicarbonate, ketoacidosis, lactic acidosis
S/sx: headache, confusion, drowsiness, inc RR, dec BP, cold clammy skin, dysrrythmia, shock
Dx: ABG – low Bicarbonate, low pH, Hyperkalemia, ECG changes
Rx: Bicarbonate for pH < 7.1 and Bicarbonate level < 10monitor serum Kdialysis
ACUTE AND CHRONIC METABOLIC ALKALOSIS
High pH Decreased H ion concentration High plasma Bicarbonate
Etiology: vomiting, diuretic, hyperaldosteronism, hypokalemia, excesive alkali ingestion
s/sx: tingling of toes, dizziness, dec RR, inc PR, ventricular disturbances
Dx:ABG – pH > 7.45, serum Bicarbonate > 26 mEq/L, inc PaCO2
Rx: restore normal fluid balance correct hypokalemia
Carbonic anhydrase inhibitors
ACUTE AND CHRONICRESPIRATORY ACIDOSIS
Ph < 7.35PaCO2 > 42 mmHg
Etiology: pulmonary edema, aspiration, atelectasis, pneumothorax, overdose of seatives, sleep apnea syndrome, pneeumonia
s/sx: sudden hypercapnia produces inc PR, RR, inc BP, mental cloudinesss, feeling of fullness in head, papiledema and dilated conjunctival blood vessels
Dx: ABG – pH < 7.35PaCO2 - > 42 mmHg
Rx: improve ventilation
pulmonary hygiene
mechanical ventilation
ACUTE AND CHRONICRESPIRATORY ALKALOSIS
pH > 7.45 PaCO2 < 38 mmHg
Etiology: extreme anxiety, hypoxemia
s/sx: lightheadednes, inability to concentrate, numbness, tingling, loss of consciousness
Dx: ABG – pH > 7.45 PaCO2 < 35
dec Kdec Ca
Rx: breathe slowly sedative
ARTERIAL BLOOD GAS ANALYSIS
Parameter Normal Value
pH 7.35 – 7.45
PaCO2 35 – 45 mmHg
HCO3 22-26mEq/L
O2 saturation 93 - 98%
Evaluating ABG’s
1. Note the pH
pH = 7.35 – 7.45 (normal)pH = < 7.35 (acidosis)pH = > 7.45 (alkalosis)
compensated – normal pHuncompensated – abnormal pH
2. Determine primary cause of disturbance2.1 pH > 7.45a. PaCo2 < 40 mmHg – respiratory alkalosisb. HCO3 > 26 mEq/L – metabolic alkalosis
2.2 pH < 7.35a. PaCo2 > 40 mmHg – respiratory acidosisb. HCO3 < 26 mEq/L – metabolic acidosis
3. Determine compensation by looking at the value other than the primary disturbance
pH PaCO2 HCO3
7.20 60 mmHg
24 mEq/L
7.40 60 mmHg
37 mEq/l
Uncompensated Respiratory acidosis
Compensated Respiratory acidosis
4. Mixed acid-base disorders
pH 7.21 Dec acid
PaCO2 52 Inc acid
HCO3 13 Dec acid
Metabolic and Respiratory Acidosis
Thank You!