causes of respiratory acidosis
respiratory depression from anesthesia, overdose, increased intracranial pressure, airway
obstruction from decreased alveolar capillary diffusion like pneumonia, COPD, ARDS, AND PE
signs/symptoms of respiratory acidosis
hypoventilation (hypoxia), rapid, shallow respirations, decrease in BP, skin/mucous pale to
cyanotic, headache, hyperkalemia, dysrhythmias, drowsiness, dizziness, disorientation, muscle
weakness, hyperreflexia
Nursing management of respiratory acidosis: ventilator, arterial blood gas, low-dose oxygen in
chronic conditions, high-dose oxygen in acute hypoxia with acidosis, I/O, promote the release of
CO2, turn/cough/deep breathe, assume semi-high fowlers position, clear respiratory secretions,
colors of skin, mucous membranes
causes of respiratory alkalosis: high pH, low co2 and hyperventilation, initial stages of
pulmonary emboli, hypoxia, fever, pregnancy, high altitudes, and anxiety
signs/symptoms of respiratory alkalosis: seizures, deep/rapid breathing, hyperventilation,
tachycardia, decrease BP, hypokalemia, numbness/tingling in extremities, lethargy/confusion,
light headedness, N/V
nursing management of respiratory alkalosis: mask or paper bag, sedatives, monitor respiratory
rate/depth, tachycardia, low BP, serum K+ levels/ECG levels, hydration status I/O, check for
toxicities
metabolic acidosis
low ph, normal co2 and low bicarbonate
metabolic acidosis signs/symptoms: compensatory hyperventilation (kussmaul respirations),
headache, decreased BP, hyperkalemia, muscle twitching, warm/flushed skin, N/D/V, changes in
LOC,
metabolic acidosis signs/symptoms
compensatory hyperventilation (kussmaul respirations), headache, decreased BP, hyperkalemia,
muscle twitching, warm/flushed skin, N/D/V, changes in LOC,
causes of metabolic acidosis: low ph/low bicarbonate, diabetic ketoacidosis, shock, sepsis, severe
diarrhea, and renal failure
what goes up in acidosis: potassium
metabolic acidosis nursing management: BUN, creatinine, hemoglobin/hematocrit levels,
monitor hydration, turn/cough/deep breathe, ABG's, check K, Ca usually goes down, weights,
vitals
causes of metabolic alkalosis: high ph, high bicarb and severe vomiting, excessive GI suctioning,
diuretics, and excessive NaHCO3
metabolic alkalosis signs/symptoms: restlessness (lethargy), confusion, dizzy, irritable,
dysrhythmias, compensatory hypoventilation, N/V/D, tremors, muscle cramps, tingling of fingers
and toes, dehydration
metabolic alkalosis nursing management: monitor ECG's, ABG's for pH, K, Ca levels, LOC
checks for tetany, tremors, muscle cramps, tingling,
what is hyperkalemia frequently associated with: metabolic acidosis
what is hyperkalemia frequently associated with
metabolic acidosis
what is a compensatory mechanism for metabolic alkalosis: decreased respiratory rate and depth
to retain CO2 and kidney excretion of bicarbonate
decreased output causes: renal failure
fluid volume excess causes: heart failure, water intoxication, liver cirrhosis, SIADH, lung cancer,
renal failure, primary polydipsia, long term use of cortiosteroids
fluid volume excess clinical manifestations: headache, JVD, increased weight, edema, ascites,
elevated blood pressure, crackles in lungs, confusion, decreased urine specific gravity, pitting
edema, high BP, presence of s3, tachycardia, bounding pulse, changes in LOC, seizures, low
pulse ox (below 89%), seizures, coma, muscle spasms, dyspnea
fluid volume excess nursing management:
fluid volume excess clinical manifestations
headache, JVD, increased weight, edema, ascites, elevated blood pressure, crackles in lungs,
confusion, decreased urine specific gravity, pitting edema, high BP, presence of s3, tachycardia,
bounding pulse, changes in LOC, seizures, low pulse ox (below 89%), seizures, coma, muscle
spasms, dyspnea
fluid volume excess nursing management:
frequent respiratory assessments and LOC, watch for edema, cardiovascular checks, daily
weights, fluid restriction, measure intake and output, decrease sodium intake, diuretics
fluid volume deficit signs/symptoms: restlessness, drowsiness, lethargy, confusion, thirst, dry
mucous membranes, decreased skin turgor, decreased cap refill, postural hypotension, increased
pulse 120, decreased CVP, decreased urine output, concentrated urine, increased respiratory rate,
weakness, dizziness, seizures, coma, decreased BP 86/50
hypernatremia; fluid volume deficit signs/symptoms: signs of thirst, fever, dry mucous
membranes, hypotension, tachycardia, low jugular venous pressure and restlessness, weakness,
change of LOC, thready pulses
nursing management of hypernatremia: administer hypotonic solution if na known, administer
isotonic solution if na is not known, if corrected too quickly can cause cerebral edema
hypernatremia nursing interventions:
treat the cause, add water to balance sodium, or replace sodium and water, monitor I/O, urine
specific gravity greater than 1.025, pulses, tachycardia, tachypnea, changes in sensorium, daily
weights, skin turgor and mucous membranes
hyponatremia causes: sodium is less than 135 mEq/L, vomiting, diuretics, gastrointestinal
suctioning, diarrhea, inadequate salt intake, fluid shift from the ICF to the ECF by hypertonic
solutions which leads to dilutional hyponatremia
hyponatremia signs and symptoms: cell swells, lethargy, headache, confusion, apprehension,
seizures, and coma, change in LOC, muscle weakness, stupor, tendon reflexes decreases
hyponatremia interventions: administer hypertonic solutions with known Na value, monitor
patients lungs sounds, administer isotonic solutions with unknown sodium level, report LOC
changes, fluid restriction if caused by too much water
nursing management of hyponatremia: I/O, check for bounding pulses, bulging neck veins, BP
changes, signs of cerebral edema, daily weights, pitting edema with fluid excess, daily weights
and goal is to restore na and water balance and prevent complications of cerebral edema
hyperkalemia caused by life threatening, impaired renal excretion of potassium, excess intake,
metabolic acidosis and medications like beta blockers, dehydration
hyperkalemia signs/symptoms (MURDER) muscle cramps, urine abnormalities, respiratory
distress, decreased cardiac contractility, EKG changes, and reflexes
nursing management of hyperkalemia check for muscle weakness, administer diuretics, monitor
renal and respiratory status, restricted diet, increase fluid intake, administer insulin-kayexalate,
dialysis, monitor ECG, monitor blood sugar
hypokalemia is caused by increased excretion of potassium, N/V, sweating, diuretics, dialysis,
increased insulin, alkalosis, tissue repair, increased epinephrine, lack of intake
hypokalemia assessment muscle weakness and cramps, life threatening if not treated, alkalosis
on ABG, fatigue, depressed ST with a U wave, arrhythmias, thready pulse
signs/symptoms of hypokalemia (A SIC WALT) alkalosis, shallow respirations, irritability,
confusion and drownsiness, weakness and fatigue, arrhythmias, lethargy, thready pulse
hypokalemia nursing interventions watch for skeletal muscle weakness, most dangerous drug to
administer, on IV pump no more than 10 mEq/hr, causes vein irritation, ice site, lidocaine,
monitor, piggyback with normal saline, always on a pump, encourage intake from foods