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Fluid

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18 views102 pages

Fluid

t

Uploaded by

Whitney Cabangan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Fluid

Imbalances
JERLYN JOY A. NARAG, RN, MSN
Fluid Volume Deficit
This is the loss of extracellular fluid volume that
exceeds the intake of fluid. The loss of water and
electrolyte is in equal proportion.
also called HYPOVOLEMIA
Fluid Volume Deficit
It can be called in various terms- vascular, cellular or
intracellular dehydration. But the preferred term is
hypovolemia.
DEHYDRATION refers to loss of WATER alone, with
increased solutes concentration and sodium
concentration
Pathophysiology of Fluid Volume Deficit
ETIOLOGIC fACTORS RISK FACTORS
a.Vomiting
a.Diabetes Insipidus
b.Diarrhea
b.Adrenal insufficiency
c.Prolonged GI suctioning
c.Osmotic diuresis
d.Increased sweating
d.Hemorrhage
e.Inability to gain access to
e.Coma
fluids
f.Third-spacing conditions like
f.Inadequate fluid intake
ascites, pancreatitis and burns
g.Massive third spacing
Pathophysiology
Factors decreased serum osmolality
decreased blood volume
decreased cellular hydration

cellular shrinkage

wt. loss, decreased skin turgor, oliguria, hypotension,


weak pulse, etc.
Nursing Process
Fluid Volume Deficit
Assessment
Subjective Cues
Thirst
Nausea, anorexia
Muscle Weakness and
Cramps
changes in mental status
Assessment Weight loss, tented skin turgor,
dry mucus membrane, sunken
eyes
Physical
Hypotension
Examination Tachycardia
Cool, clammy & pale skin
Flat neck veins
Decreased CVP & BP
Increased body temperature
Laboratory Findings
Elevated BUN due to depletion of fluids or decreased
renal perfusion
Increased Hematocrit
Possible Electrolyte imbalances: Hypokalemia,
Hyperkalemia, Hyponatremia, hypernatremia
Urine specific gravity is increased (concentrated urine)
above 1.020
Nursing Diagnosis Fluid Volume Deficit
Planning To restore the body fluids
Implementation Assist in medical
Intervention
a. Provide Intravenous Fluid
as ordered
b. Provide a Fluid Challenge
Test as ordered
Meidcal Management
1. If fluid losses is acute or severe, IV route is
required.Isotonic solution (0.9% Sodium
Chloride) to expand the plasma volume and
NORMOTENSIVE.
2. Then hypotonic solution (0.45% sodium
chloride) to provide both electrolytes and
water for renal excretion of metabolic
wastes.
Nursing Management
1. Assess the ongoing status of the patient by doing an
accurate input and output monitoring
2. Monitor daily weights. Approximate weight loss 1
kilogram = 1liter!
3. Monitor Vital signs, skin and tongue turgor, urinary
concentration, mental function and peripheral circulation
4. Prevent Fluid Volume Deficit from occurring by
identifying risk patients and implement fluid replacement
therapy as needed promptly
Nursing Management
5. Correct fluid Volume Deficit by offering
fluids orally if tolerated, anti-emetics if with
vomiting, and foods with adequate electrolytes
6. Maintain skin integrity
7. Provide frequent oral care
8. Teach patient to change position slowly to
avoid sudden postural hypotension

Prioritize wisely
Fluid Volume Excess
Refers to the isotonic expansion of the ECF
caused by the abnormal retention of water and
sodium
There is excessive retention of water and
electrolytes in equal proportion. Serum sodium
concentration remains NORMAL
also called HYPERVOLEMIA
Pathophysiology of Fluid Volume Deficit
ETIOLOGIC fACTORS RISK FACTORS

a. Excessive fluid intake a. Congestive Heart


b. Inability to excrete fluids Failure
c. Excessive consumption of b. Renal Failure
table salts
c. Liver Cirrhosis
d.Administration of excessive
IVF
e. Abnormal Fluid Retention
Pathophysiology
Factors
excessive fluids and sodium in the body

expansion of blood
volume

wt. gain, edema , increased neck vein distention,


tachycardia, hypertension
Nursing Process
Fluid Volume Excess
Assessment
Shortness of breath
Subjective Cues
Change in mental
status

Prioritize wisely
Assessment
Physical Examination Increased weight gain
Increased Urine Output
Moist crackles in the lungs
Tachycardia
Distended neck veins
Increased CVP
Wheezes
Dependent Edema
Prioritize wisely
Laboratory Findings Albumin L 1.5
2g d
BUN and Hematocrit levels are LOW because of
dilution
Urine sodium and osmolality decreased (urine
becomes diluted)
CXR may show pulmonary congestion
Increased urea & nitrogen - Azotemia
Increased uric acid level - hyperuricemia
Prioritize wisely
Nursing Diagnosis Fluid Volume excess
Planning To restore the body fluids
Implementation Assist in medical Intervention
a. administer diuretics as
prescribed
b. Assist in hemodialysis
c. Provide dietary restrictions of
Prioritize wisely sodium and water
250mg day
Nursing Management
1.Continually assess the patient’s condition by measuring
intake and output, daily weight monitoring, edema
assessment and breath sounds
2.Prevent Fluid Volume Excess by adhering to diet
prescription of low salt- foods.
3.Detect and Control Fluid Volume Excess by closely
monitoring IVF therapy, administering medications, providing
rest periods, placing in semi-fowler’s position for lung
expansion and providing frequent skin care for the edema
Nursing Management
4. Teach patient about edema, ascites, and fluid
therapy. Advise elevation of the extremities,
restriction of fluids, necessity of paracentesis,
dialysis and diuretic therapy.
5. Instruct patient to avoid over-the-counter
medications without first checking with the
health care provider because they may contain
sodium
Prioritize wisely
Electrolytes
Electrolytes are charged ions capable of
conducting electricity and are solutes found
in all body compartments.
1. sources of electrolytes
foods and fluids ingested, medications;
IVF & TPN Solutions
2. Functions
Maintains fluid balance
Regulates acid-base balance
Needed for enzymatic secretion and activation
Needed for proper metabolism and effective
processes of muscular contraction, nerve
transmission
3. Types
CATIONS- positively charged ions; examples are
sodium, potassium, calcium
ANIONS- negatively charged ions; examples are
chloride and phosphates]

The major ICF cation is potassium (K+); the major


ICF anion is Phosphates
The major ECF cation is Sodium (Na+); the major
ECF anion is Chloride (Cl-)
Dynamics of
Electrolytes Balance
1. Distribution
ECF and ICF vary in their electrolyte
distribution and concentration
ICF has K+, PO4-, proteins, Mg+, Ca++ and
SO4-
ECF has Na+, Cl-, HCO3-
Dynamics of Electrolytes Balance
2. Excretion
These electrolytes are excessively eliminated
by abnormal fluid losses
Routes can be thru urine, feces, vomiting,
surgical drainage, wound drainage and skin
excretion
Dynamics ofElectrolytes Balance
3. Regulation
Renal Regulation - occurs by
the process of glomerular
filtration, tubular reabsorption
and tubular secretion
Electrolytes Balance
Dynamics of
3. Regulation
Endocrine Regulation - hormones play a
role in this type of regulation:
a. Aldosterone- promotes Na retention and K
excretion
b. ANF- promotes Na excretion
c. PTH- promotes Ca retention and PO4
excretion
d. Calcitonin- promotes Ca and PO4
excretion
The CATIONS
Sodium
The most abundant cation in the ECF
Normal range in the blood is 135-145 mEq/L
A loss or gain of sodium is usually accompanied by a
loss or gain of water.
Major contributor of the plasma Osmolality
Sources: Diet, medications, IVF. The minimum daily
requirement is 2 grams
Imbalances- Hyponatremia= <135 mEq/L;
Hypernatremia= >145 mEq/L
The CATIONS
Sodium
Functions:
Participates in the Na-K pump
Assists in maintaining blood volume
Assists in nerve transmission and muscle
contraction Electrochemical state
Primary determinant of ECF concentration.
Controls water distribution throughout the
body.
The CATIONS
Sodium
Functions:
Primary regulator of ECF volume.
Sodium also functions in the establishment of the
electrochemical state necessary for muscle
contraction and the transmission of nerve
impulses.
Regulations: skin, GIT, GUT, Aldosterone
increases Na retention in the kidney
Sodium Deficit
Hyponatremia
Refers to a Sodium serum level
of less than 135 mEq/L.
This may result from excessive
sodium loss or excessive water
gain.
Pathophysiology Hyponatremia
Etiologic Factors
1.Fluid loss such as from Vomiting
and nasogastric suctioning
2.Diarrhea 6 Adrenal Insufficiency
3.Sweating 7 Medications
Anticonvulsant meds
4.Use of diuretics Tegrefol
KeppRa
5.Fistula
Pathophysiology causes 5
iaphoresis

Hyponatremia iarrhea vomiting


NotsuctionFistula
Other factors H Dilutional hyponatremia
SIA
syndrome of Inappropriate
1. Dilutional hyponatremia ADH TAD H

Water intoxication, TIFIES


compulsive b
water drinking where sodium level osmolali

is diluted with increased water


intake
Pathophysiology
Hyponatremia
Other factors
2. SIADH Tumor in the hypothalamus

- Excessive secretion of ADH


causing water retention and dilutional
hyponatremia
Pathophysiology Hyponatremia
hypotonicity of
plasma

water from the intravascular space will move out going to


the interstitial then intracellular compartment

cell swelling

Water is pulled INTO the cell because of decreased


extracellular sodium level and increased intracellular
concentration
The Nursing Process in HYPONATREMIA
Assessment
Clinical Manifestations

Clinical manifestations of hyponatremia depend


on the cause, magnitude, and rapidity of onset.
Although nausea and abdominal cramping occur,
most of the symptoms are neuropsychiatric and
are probably related to the cellular swelling and
cerebral edema associated with hyponatremia.
The Nursing Process in HYPONATREMIA
Assessment
Clinical Manifestations
As the extracellular sodium level decreases, the
cellular fluid becomes relatively more
concentrated and ‘pulls” water into the cells.
In general, those patients having acute decline in
serum sodium levels have more severe symptoms
and higher mortality rates than do those with
more slowly developing hyponatremia.
The Nursing Process in HYPONATREMIA
Assessment
Clinical Manifestations
Features of hyponatremia associated with sodium
loss and water gain include anorexia, muscle
cramps, and a feeling of exhaustion.
When the serum sodium level drops below 115
mEq/L (SI: 115 mmol/L), the ff signs of increasing
intracranial pressure occurs:
The Nursing Process in HYPONATREMIA
Assessment Slsp S Stupor Coma
A anorexia
Clinical Manifestations L weaknessfatigue
lethargy
lethargy T tachycardia
Confusion L limp muscles
0 orthostatic hpn
muscular twitching
S seizures headache
focal weakness
S stomach cramping
hemiparesis hyperactive bowels
papilledema
convulsions
The Nursing Process in HYPONATREMIA
Assessment
Physical Assessment
1.Altered mental status
2.Vomiting
3.Lethargy
4.Muscle twitching and convulsions (if sodium
level is below 115 mEq/L)
5.Focal weakness
The Nursing Process in HYPONATREMIA
Assessment
Subjective Cues Laboratory findings
1.Nausea 1.Serum sodium level is less than
2.Cramps 135 mEq/L
3.Anorexia 2.Decreased serum osmolality
4.Headache 3.Urine specific gravity is LOW if
caused by sodium loss
4.In SIADH, urine sodium is high
and specific gravity is HIGH
The Nursing Process in HYPONATREMIA
Nursing Diagnosis
1. Altered Cerebral perfusion
2. Fluid Volume Excess

Implementation Treat underlying cause

Assist in Medical Intervention


the effectof ADH
Elocks
Administer lithium and demeclocycline in SIADH
Provide water restriction if with excess volume
AVP receptor antagonist moderate severe
S symp a N
The Nursing Process in HYPONATREMIA
seizures delirium
Implementation or coma

Assist in Medical Intervention

Provide sodium replacement as ordered.


Isotonic saline is usually ordered.. Infuse the
solution very cautiously. The serum sodium
must NOT be increased by greater than 12
mEq/L because of the danger of pontine
osmotic demyelination
The Nursing Process in HYPONATREMIA
Nursing Management
Provide continuous assessment by doing an
accurate intake and output, daily weights, mental
status examination, urinary sodium levels and GI
manifestations. Maintain seizure precaution
Detect and control Hyponatremia by encouraging
food intake with high sodium content, monitoring
patients on lithium therapy, monitoring input of
fluids like IVF, parenteral medication and feedings.
The Nursing Process in HYPONATREMIA
Nursing Management
Return the Sodium level to Normal by restricting
water intake if the primary problem is water
retention. Administer sodium to normovolemic
patient and elevate the sodium slowly by using
sodium chloride solution
Sodium Deficit
Hypernatremia
Refers to a Sodium serum level of
more than 145 mEq/L.
There is a gain of sodium in excess of
water or a loss of water in excess of
sodium.
Pathophysiology Hypernatremia
Etiologic Factors
1.Fluid deprivation most common
2.Water loss from Watery diarrhea, fever, and
hyperventilation
Natlcos meds
3.Administration of hypertonic solution Sodium
4.Increased insensible water loss sweating
5.Inadequate water replacement, inability to swallow
6.Seawater ingestion or excessive oral ingestion of
salts
Pathophysiology Hypernatremia
Other Factors

1.Diabetes insipidus urination dH ADH


2.Heat stroke
3.Near drowning in ocean less common
4.Malfunction of dialysis
Pathophysiology Hypernatremia
increased sodium concentration
hypertonic plasma

water will move out from the cell outside to the


interstitial space

CELL SHRINKAGE
Water pulled from cells because of increased
extracellular sodium level and decreased cellular fluid
concentration
The Nursing Process in HYPERNATREMIA
Assessment
Clinical Manifestations

primarily neurologic
Presumably the consequence of cellular
dehydration.
Hypernatremia results in a relatively concentrated
ECF, causing water to be pulled from the cells.
The Nursing Process in HYPERNATREMIA
Assessment
Clinical Manifestations
Clinically, these changes may be manifested by:
- restlessness and weakness in moderate
hypernatremia
- disorientation, delusions, and hallucinations in
severe hypernatremia.
The Nursing Process in HYPERNATREMIA
Assessment
Clinical Manifestations
Dehydration (hypernatremia) is often overlooked
as the primary reason for behavioral changes in
the elderly.
If hypernatremia is severe, permanent brain
damage can occur (especially in children). Brain
damage is apparently due to subarachnoid
hemorrhages that result from brain contraction.
The Nursing Process in HYPERNATREMIA
Assessment
A primary characteristic of hypernatremia is thirst. Thirst is
so strong a defender of serum sodium levels in normal
people that hypernatremia never occurs unless the person
is unconscious or is denied access to water; unfortunately,
ill people may have an impaired thirst mechanism. Other
signs include dry, swollen tongue and sticky mucous
membranes. A mild elevation in body temperature may
occur, but on correction of the hypernatremia the body
temperature should return to normal.
The Nursing Process in HYPERNATREMIA
Assessment test sn ousconfusedirritable
1 increased BP fluid retention
Physical Assessment E edema pitting
D decreased urine output
1.Restlessness, elevated body temperature
2.Disorientation F asFation
3.Dry, swollen tongue and sticky mucous membrane,
L lowgrade Fever
tented skin turgor T thirst
4.Flushed skin, postural hypotension
5.Increased muscle tone and deep reflexes
6.Peripheral and pulmonary edema
The Nursing Process in HYPERNATREMIA
Assessment
Subjective Cues Laboratory findings
1.Serum sodium level exceeds
1.Delusions and 145 mEq/L
hallucinations 2.Serum osmolality exceeds 295
2.Extreme thirst mOsm/kg
3.Behavioral 3.Urine specific gravity and
changes osmolality INCREASED or
elevated kidneys attempt to
conserve
The Nursing Process in HYPERNATREMIA
Nursing Diagnosis
1. Altered Cerebral perfusion
2. Fluid Volume deficit
Implementation
Assist in Medical Intervention
Administer hypotonic electrolyte solution slowly as
ordered Not level is reduced no faster than
0.5 1 meg t h
Administer diuretics as ordered
Desmopressin is prescribed for diabetes insipidus
The Nursing Process in HYPERNATREMIA
Implementation
Assist in Medical Intervention

Provide sodium replacement


sooooo as ordered. Isotonic
saline is usually ordered.. Infuse the solution very
cautiously. The serum sodium must NOT be
increased by greater than 12 mEq/L because of the
danger of pontine osmotic demyelination
The Nursing Process in HYPERNATREMIA
Nursing Management assess Medication history
Continuously monitor the patient by assessing
abnormal loses of water, noting for the thirst and
elevated body temperature and behavioral changes
Prevent hypernatremia by offering fluids regularly
and plan with the physician alternative routes if
oral route is not possible. Ensure adequate water
for patients with DI. Administer IVF therapy
cautiously
The Nursing Process in HYPERNATREMIA
Nursing Management

Correct the Hypernatremia by monitoring the


patient’s response to the IVF replacement.
Administer the hypotonic solution very slowly to
prevent sudden cerebral edema.
The Nursing Process in HYPERNATREMIA
Nursing Management
Monitor serum sodium level.
Reposition client regularly, keep side-rails up, the
bed in low position and the call bell/light within
reach.
Provide teaching to avoid over-the counter
medications without consultation as they may
contain sodium
The CATIONS
Potassium
The most abundant cation in the ICF
Normal range in the blood is 3.5-5 mEq/L
Potassium is the major intracellular electrolyte; in fact, 98% of
the body’s potassium is inside the cells.
The remaining 2% is in the ECF; it is this 2% that is all-important
in neuromuscular function.
Normal renal function is necessary for maintenance of
potassium balance, because 80-90% of the potassium is
excreted daily from the body by way of the kidneys. The other
less than 20% is lost through the bowel and sweat glands.
The CATIONS
Potassium
Functions:
Maintains ICF Osmolality
Important for nerve conduction and muscle contraction
Maintains acid-base balance alkalosis
if IIF
II he
Needed for metabolism of carbohydrates, fats and all
proteins
Potassium influences both skeletal and cardiac muscle
activity.
alkaline H
if I
The CATIONS pH acidic TH
Potassium
Functions:
Regulations: renal secretion and excretion,
Aldosterone promotes renal excretion acidosis
promotes K exchange for hydrogen
Imbalances:
- Hypokalemia <3.5 mEq/L
- Hyperkalemia >5 mEq/L
Potassium Deficit
Hypokalemia
Condition when the serum
concentration of potassium is less
than 3.5 mEq/L causes
Drugs 19B.tt is Tu oosico
Your body is trying Inadequate kt intake
to DITCH kt Too much water intake
i y e
Pathophysiology Hypokalemia Heavy fluid los
not emesis Diarrhea

Etiologic Factors
wound drainage

1.Gastro-intestinal loss of potassium


such as diarrhea and fistula
2.Vomiting and gastric suctioning
3.Metabolic alkalosis
4.Diaphoresis and renal disorders
5.Ileostomy
Pathophysiology Hypokalemia
Other factors
1.Hyperaldosteronism k wasting Adrenal
2.Heart failure Adenoma

3.Nephrotic syndrome
4.Use of potassium-losing diuretics
5.Insulin therapy kt skeletal I hepatic
6.Starvation cells
7.Alcoholics and elderly
Pathophysiology depletion
Hypokalemia magnesium
Renal KT
loss

decreased potassium in the body

impaired nerve excitation and transmission

signs and symptoms: weakness, cardiac dysrhythmias


b
M arrest
The Nursing Process in HYPOKALEMIA
Assessment
Clinical Manifestations
Potassium deficiency can result in widespread
derangements in physiologic functions and especially
nerve conduction.
Most important, severe hypokalemia can result in
death through cardiac or respiratory arrest.
Clinical signs rarely develop before the serum
potassium level has fallen below 3 mEq/L (51: 3
mmol/L) unless the rate of fall has been rapid.
The Nursing Process in HYPOKALEMIA
Assessment
Clinical Manifestations
Manifestations of hypokalemia include fatigue,
anorexia, nausea, vomiting, muscle weakness,
decreased bowel motility, paresthesias,
dysrhythmias, and increased sensitivity to digitalis.
If prolonged, hypokalemia can lead to impaired
renal concentrating ability, causing dilute urine,
polyuria, nocturia, and polydipsia
The Nursing Process in HYPOKALEMIA
Assessment
Physical Assessment
1.Muscle weakness
2.Decreased bowel motility and abdominal
distention
3.Paresthesias
4.Dysrhythmias
5.Increased sensitivity to digitalis
The Nursing Process in HYPOKALEMIA
Assessment 7 L's
Confusion
Subjective Cues Lethargy
Low shallow respirations
muscle contraction
Lethal M desrhythmias
1.Nausea , anorexia and vomiting
ST depression
2.Fatigue, muscles cramps shallow Twave
3.Excessive thirst, if severe prominent U wave
HYPUKALEMIA
Lots of urine
Leg cramps
Limp muscles DTR
p
The Nursing Process in HYPOKALEMIA
Assessment a low 17 level
slow low
Laboratory findings

1.Serum potassium is less than 3.5 mEq/L


2.ECG: FLAT “T” waves, or inverted T waves, depressed
ST segment and presence of the “U” wave and
prolonged PR interval. ischemia
3.Metabolic alkalosis
The Nursing Process in HYPOKALEMIA
Implementation
Assist in Medical Intervention
Provide oral or IV replacement of potassium
Infuse parenteral potassium supplement. Always
dilute the K in the IVF solution and administer with a
pump. IVF with potassium should be given no faster
than 10-20-mEq/ hour!
NEVER administer K by IV bolus or IM
The Nursing Process in HYPOKALEMIA
Nursing Management
Continuously monitor the patient by assessing the
cardiac status, ECG monitoring, and digitalis
precaution
Prevent hypokalemia by encouraging the patient to
eat potassium rich foods like orange juice,
bananas, cantaloupe, peaches, potatoes, dates and
apricots. 50
100 mEq day intake
The Nursing Process in HYPOKALEMIA
Nursing Management
Correct hypokalemia by administering prescribed IV
potassium replacement. The nurse must ensure that
the kidney is functioning properly!
Administer IV potassium no faster than 20 mEq/hour
and hook the patient on a cardiac monitor. To
EMPHASIZE: Potassium should NEVER be given IV
bolus or IM!!
A concentration greater than 60 mEq/L is not advisable
for peripheral veins.
Potassium Excess
Hyperkalemia
Serum potassium greater than 5.5
mEq/L Cellular movement II 9 E
Adrenal insufficiency laddision'snse
the body CARED too Renal failure
much about KT Excessive intake of potassium
aldactone
Drugs ACEinhibitors
Pathophysiology Hyperkalemia NSAIDS

Etiologic Factors
treatmented
a
1.Iatrogenic, excessive intake of potassium
2.Renal failure- decreased renal excretion of
potassium
3.Hypoaldosteronism and Addison’s disease
4.Improper use of potassium supplements
1k sparring
diuretics
s
Pathophysiology Hyperkalemia
Other Factors
False hyperkalemia
1.Pseudohyperkalemia- tight tourniquet and
hemolysis of blood sample, marked
Trauma thecells
leukocytosis lysis of RBC to
leading
in
possible release
of its kt content
in blood
2.Transfusion of “old” banked blood kt
the
hyperkalemia

3.Acidosis b pH level
4.Severe tissue trauma expected kt
B
Pathophysiology herapy
Hypekalemia
increased potassium concentration

causing irritability of the cardiac cells

Possible ARRHYTHMIAS
The Nursing Process in HYPERKALEMIA
Assessment
Clinical Manifestations
By far the most clinically important effect of hyperkalemia
is its effect on the myocardium.
Cardiac effects of an elevated serum potassium level are
usually not significant below a concentration of 7 mEq/L
(SI: 7 mmol/L), but they are almost always present when
the level is 8 mEq/L (SI: 8 mmol/L) or greater.
As the plasma potassium concentration is increased,
disturbances in cardiac conduction occur.
The Nursing Process in HYPERKALEMIA
Assessment
Clinical Manifestations
The earliest changes, often occurring at a serum potassium
level greater than 6 mEq/ L (SI: 6 mmol/L), are peaked
narrow T waves and a shortened QT interval.
If the serum potassium level continues to rise, the PR
interval becomes prolonged and is followed by
disappearance of the P waves.
Finally, there is decomposition and prolongation of the QRS
complex. Ventricular dysrhythmias and cardiac arrest may
occur at any point in this progression.
The Nursing Process in HYPERKALEMIA
Assessment
Clinical Manifestations
Note that in Severe hyperkalemia causes muscle
weakness and even paralysis, related to a
depolarization block in muscle.
Similarly, ventricular conduction is slowed.
Although hyperkalemia has marked effects on the
peripheral neuromuscular system, it has little effect
on the central nervous system.
The Nursing Process in HYPERKALEMIA
Assessment
Clinical Manifestations
Rapidly ascending muscular weakness leading to
flaccid quadriplegia has been reported in patients with
very high serum potassium levels.
Paralysis of respiratory muscles and those required for
phonation can also occur.
Gastrointestinal manifestations, such as nausea,
intermittent intestinal colic, and diarrhea, may occur in
hyperkalemic patients.
The Nursing Process in HYPERKALEMIA
Assessment
Jeacresed M rate
Physical Assessment
1. Diarrhea Early muscle twitching
Late ascendingweakness
2. Skeletal muscle weakness
3. Abnormal cardiac rate Arrhythmias Tallapeaked
Twaves
Subjective Cues Flat Pwares
1. Nausea prolonged PR
interval
2. Intestinal pain/colic Wide QRScomple
3. Palpitations TummyTrouble
Ily 0 e
The Nursing Process in HYPERKALEMIA
Assessment
Laboratory findings
1. Peaked and narrow T waves
2. ST segment depression and shortened QT interval
3. Prolonged PR interval
4. Prolonged QRS complex
5. Disappearance of P wave
6. Serum potassium is higher than 5.5 mEq/L
7. Acidosis
The Nursing Process in HYPERKALEMIA
Implementation
Assist in Medical Intervention

Monitor the patient’s cardiac status with cardiac


machine
Institute emergency therapy to lower potassium
level by:
a. Administering IV calcium gluconate- antagonizes
action of K on cardiac conduction
The Nursing Process in HYPERKALEMIA
Implementation
Assist in Medical Intervention
b. Administering Insulin with dextrose-causes
temporary shift of K into cells
c. Administering sodium bicarbonate-alkalinizes
plasma to cause temporary shift Of kt cell ABG
d. Administering Beta-agonists
2 Not antagonize kteffed
Albaterol to the
e. Administering Kayexalate (cation-exchange resin)-
draws K+ into the bowel
The Nursing Process in HYPERKALEMIA
Nursing Management
Provide continuous monitoring of cardiac status,
dysrhythmias, and potassium levels.
Assess for signs of muscular weakness,
paresthesias, nausea
Evaluate and verify all HIGH serum K levels
Prevent hyperkalemia by encouraging high risk
patient to adhere to proper potassium restriction
The Nursing Process in HYPERKALEMIA
Nursing Management
Correct hyperkalemia by administering carefully prescribed
drugs. Nurses must ensure that clients receiving IVF with
potassium must be always monitored and that the potassium
supplement is given correctly
Assist in hemodialysis if hyperkalemia cannot be corrected.
Provide client teaching. Advise patients at risk to avoid eating
potassium rich foods, and to use potassium salts sparingly.
Monitor patients for hypokalemia who are receiving
Lastingdiuretic
potassium-sparing
The ANIONS
Chloride
➢ The major Anion of the ECF
➢ Normal range is 95-108 mEq/L
➢ Sources: Diet, especially high salt foods, IVF (like NSS),
HCl (in the stomach)
The ANIONS
Chloride
➢ Functions:
1. Major component of gastric juice
2. Regulates serum Osmolality and blood volume
3. Participates in the chloride shift
4. Acts as chemical buffer
➢ Regulations: Renal regulation by absorption and
excretion; GIT absorption
➢ Imbalances: Hypochloremia= < 95 mEq/L;
Hyperchloremia= >108 mEq/L
The ANIONS
Phosphates
➢ The major Anion of the ICF
➢ Normal range is 2.5 to 4.5 mg/dL
➢ Sources: Diet, TPN, Bone reserves 4.5 mg/dL
The ANIONS
Phosphates
➢ Functions:
1. Component of bones, muscles and nerve tissues
2. Needed by the cells to generate ATP
3. Needed for the metabolism of carbohydrates, fats
and proteins
The ANIONS
Phosphates
4. Component of DNA and RNA
Regulations: Renal glomerular filtration, endocrinal
regulation by PTH-decreases PO4 in the blood by
kidney excretion
➢ Imbalances-
Hypophosphatemia= <2.5 mg/dL;
Hyperphosphatemia >4.5 mg/dL
THE ANIONS
Bicarbonates
Present in both ICF and ECF
Regulates acid-base balance
together with hydrogen
Normal range is 22-26 mEq/L
THE ANIONS
Bicarbonates
Sources: Diet; medications and
metabolic by-products of the cells.
Function: Component of the
bicarbonate-carbonic acid buffer
system
THE ANIONS
Bicarbonates

Imbalances:
Metabolic acidosis= <22 mEq/L;
Metabolic alkalosis= >26 mEq/
“Productivity is never an accident. It is always
the result of a commitment to excellence,
intelligent planning and focused effort.”

- Paul J. Meyer

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