Uploaded by Daniel Garibay

Fluid and electrolytes

advertisement
avid two Ira Ote cand
Mfc id BASee Inobalances S
ShiftsofPlasmatointerstitalFluid
Edema
Anaccumulation offluid intheinterstitalspaceoccursif venoushydrostatic pressure
risesplasmaoncoticpressure d orinterstitaloncoticpressurerises
Edema mayalsodevelop it an obstructionof lymphaticoutflow causes a removalof
interstitialfluids
ofAvenouspressureinclude
Causes
HF
Liverfailure
ofvenousreturntotheheart
Obstruction
Venousinsufficiency
Elevationofvenous hydrostaticpressure
Tthepressureatthevenousendofthe capillaryinhibitsfluidmovementbackintothe
capillary
Decrease in plasmaoncoticpressure
Fluidremains intheinterstitalspace if the plasmaoncoticpressureistoolowtodraw
fluidbackintothecapillary lowplasmaproteincontentd oncotic pressure
Resultsfrom
Proteinlossrenaldisorders
disease
I
I1
y u l
d
ie
Malnutrition
Elevationofinterstitalonloticpressure
Traumasbumsandinflammationcan damage capillarywallsand allowplasmaproteins
to aaumilateintheinterstitalspace
This P interstitaloncotic pressuredrawsfluidintotheinterstitalspaceandholds
it there
Shifts of interstital
fluidto Plasma
T in plasma osmotic onloticpressuredrawsfluidintotheplasmafromtheinterstital
space
Thiscouldhappen with administration of
Colloids
Dextran
Hypertonic solutions
Wearingelasticcompression gradientstockings orhowto d peripheraledema
is atherapeutic applicationofthis effect
Fluidspacing
Firstspacing
Describesthenormal distribution offluidin ICFand Elf compartments
Second spacing
refersto an abnormalaccumilation ofinterstitalfluidedema
Thirdspacing
Occurs whenexcessfluidcollects inthe nonfunctionalareabetweencells
bloodvessels
Thirdspacingoccurswithascitesfluidleakingintotheabdominalcavity
withperitonitisor pancreatitisandedema associatedwithbumstraumasepsis
Hypothalamic
PituitaryRegulation
Abodyfluiddeficitor T in plasma osmolarityactivatesosmoreceptors in the hypothalamus
whichstimulatethirstandthereleaseofADItfromtheposterior pituitaryglandADIt acts
onthedistaltubulesandcollecting ducts inthekidneybymakingthemmore permeableto
H2O
ADIt isonlyableto regulate howmuchH2othebody holdsonto
LBP nauseapainhypoglycemiaandhypoxemiastimulate ADArelease
In postoperativepatientthestress responsetosurgeryandrelieving analgesicsandanesthesia
causeADAreleaseandd osmolarity
osmolarity
Impaired or cognitivelyimpairedptis at t riskforfluiddeficitandhyper
ofaninabilitytoexpressthirstandacton it
because
RenalRegulation
Thekidneysfilterthetotalplasmavolume
Kidneysabsorbabout991offiltrateproducing 1.5Lofurineperday
Undertheinfluence ofADHaldosterone andotherhormonesselectivereabsorption
andsecretion of H2oandelectrolytes intherenaltubulesresultin urinethatis
differentincompositionand concentrationfrom plasma
Thisprocesshelpsmaintainnormal plasma osmolarityelectrolyte
balancebloodvolumeandacidbasebalance
Withseverely impairedrenalfunction
Edema
Potassium
Acidosis
retention
d p in
is
Adrenalcorticalregulation
toregulateH2Oandelectrolytes
Releaseshormones
Glucocorticoidsteroids
Cortisol
s
Mineralocorticoid
Aldosterone
Cardiacregulation
NatriureticpeptidesareantagoniststotheRAAS
bycardiomyocytes inresponseto 4Atrialpressure
They suppresssecretion ofaldosterone Renin andADIt to d bloodvolumeandpressure
Hormonesmade
GlRegulation
Oralintakeaccountsfor mostHao
Small amountseliminatedbyGltractinfeces
Diarrheaandvomitingcanleadtosignificantfluidandelectrolyteloss
Gerontologic Considerations
Structuralchanges inkidneysdecreaseabilitytoconserveH2O
Hormonalchanges
d inRenin
Aldosterone
I
Tin ADH
Pin AND
Fluid and electrolyte Imbalances
byillnessordisease
Directly caused
Bums
HF
Resultoftheraputicmeasures
Colonoscopy preparation
Diuretics
Extracellular FluidVolumeImbalances
Hyporolemia
Abnormallossof bodyfluidsinadequatefluidintake or plasma
tointerstitalfluidshift
Dehydration
Lossof
purewaterwithoutcorrespondinglossofsodium
InterprofessionalcareforEFC deficits
Correcttheunderlying causeandreplacewaterandelectrolytes
Nursingdiagnosis
Orally
Bloodproducts
Balanced
solutions
Fluidimbalance
Impairedco
Acuteconfusion
Potentialcomplication
Hyporolemic shock
I
dis
ons
Hypervolemia
offluidsorintestital to plasma
Excessintake abnormalretention
fluidshift
NursingDiagnosis
imbalance
Manifestationsweightgain Fluid
Impairedgasexchange
Potentialcomplications
pulmonaryedema
Impairedtissueintegrity
Ascities
Activityintolerance
Nursingimplementations
Disturbedbodyimage
DW orcare skincare
Ilo's RTcare skinturgo
Interprofessionalcare
tabs
safety
Removefluid w outchangingelectrolyte composition
orosmolarity
Diuretics
Fluidrestrictions
Sodium restrictions
Removal offluidtotreatascities or
plueraleffusion
hyponatremia
hyperNatremia
InadequateH2ointake
loss ofsodium containingfluids H2oexcess
Excess H2Oloss or sodiumgain
Manifestations
Primaryprotection
Mildheadache
Manifestations
Irratibility
isthirstphyyy
Changes inmentalstatus
Drowsiness
seizurescoma tachycardia
Restlessness
posturalhypotension
confusion
Sodium
Efcvolumeconcentration.MYfractility
Difficulty concentrating
Moresevere
confusion
vomiting
I rgy
gl
Editinga dbasebalance
NursingDiagnosis
s Cma
g
NursingDiagnosis
Electrolyteimbalance
Electrolyteimbalance
Fluidimbalance
Riskforinjury
Riskforinjury
Acuteconfusion
Treatment Isotonicfluids
Potentialcomplicationseizurescoma
Treatment
severecases
5 dextrose in Hao
thatblock
Vasopressorsldings
shouldnot
activityof ADH
bbymorethan1815meall in an
8 hr period
conivaptancNpreventhoex
Quicklyreducinglevelscancausecerebral
tovaptan HF
levelsshouldnottmorethance12min
Edema
perhrinthefirst24hrsandI8mEqlL
orlessperhrthefirst48hr5
hyperkalemia
hypokalemia
lowsemmktcausedby
Highsemmpotassiumcanadby
ShiftfromICF ECF
flossof ktviarenal Gl
Tshift of Kt from ECF ICF
mostcommoncauseRenalFailure
Dietaryktdeficency
impairedrenalexcretion
Manifestations
Dynamics
22397
3.5
1
Renal lossfrom diuretics
Manifestations
Fatigueconfusion
or
Tetnaymusclecramps
skeletalmuscles legs weakness
Weakparalyzed skeletalmuscles
Weaknessof Resp muscles
Abdominalcrampinganddiarrhea
tail motility
NursingDiagnosis
Hyperglycemia
I yl
g
m
g
ElectrolyteImbalance
Activityintolerance
Impairedco
Activityintolerance
Potentialcomplication
Impaired CO
Potentialcomplication
dysrhythmias
dysrhythmias
Nursing implementation
stopintake of Kt
NursingImplementation
KclsupplementsDOIN
I excretion
Diuretics Thiazide
Alwaysdilutelvka
Dialysis
NeverPushORBolusKcl
Veltessa
shouldnotexceedlomeall
Kayexalate
Usean infusionpump
ForcektfromECF ICFby
potassium
IVinsulin w dextroseanda B
a'growth
maintenanceof rhythm
necessaryfor
gation
Restingmembranepotential ofnerveand
adrenergicagonistorsodium bicarbonate
bykidneys BUNcreatinine
Regulated
StabalizeCalciumcellmembrane w
labs
urineoutput 0.5mikgperhour
calcium gluconate IV
Usecontinuous ECGmonitoring
hyperphosphatemia
hypophosphatemia
by
Highsemm Poy caused
low semm 17043 caused by
Acutekidneyinjuryor chronicdisease
malnourishment malabsorption
Excess intake of phosphate or Vitamin D
diarrhea
Hyperparathyroidism
Manifestations
Tethay
Useof phosphate bindingantiacid
30
Inadequate replacementduring
Cul5umEall
musclecramps
parentreal nutrition
Manifestations
I
y y
seizures hypocalcemia
cist
Calcified deposition in softtissuesuch
Muscleweaknessandpain
as joints arteriesskinkidneysandcomeas
Resp and HF
Ricketsand osteomalacia
causeorgan dysfunction
Management
management
Restrictintake
oral supplementatio
Oralphosphatebindingantacids
Ingestion offoods tin
phosphorus
N administration of sodiumorkt
Hemodialysis
Volumeexpansionandforced diuresis
monitorhmm calciumlevels
every 6 12hr
Correct
any hypocalcemia
Phosphate
byparathywidism
controlled
PrimaryanionICF
renal
Requiresadequate
NStunct
formusclefunctionRBC
production
Essential
AvidbasebutteringsystemATP
cellularuptakeofglucowicarbmetabolism
hypercalcemia
hypercalcemia
Highlevels of semm calciumcausedby
Hyperparathyroidism Two thirdsofcases
Cancer
Manifestations
MmmÉ
lowsemmCalciumlevelscaused
I production ofPat
by
Multiplebloodtransfusions
Alkalosis
Fatigue
coma
Lethargy
Dysrhythmias
Weakness
Bonepainfractures
Postivetrousseau's orchrostels's
confusion
Nephrolithiasis
Laryngealstridor
Hallucinations
Polyuriadehydration
seizures
NursingDiagnosis
ElectrolyteImbalance
confusion
Pcalciumloss
Manifestations
Dysphasia
Numbness and
tingling around
themouthorintheextremities
Dysrhythmias
is
g
g
Impairedphysicalmobility
ElectrolyteImbalance
Potentialcomplication Dysrhythmias
Impaired breathing
ActivityIntolerance
NursingImplementation
lowcalciumdiet
Potentialcomplication fracture
Tweightbearingactivity
Resparrest
NursingImplementation
Tfluidintake
Hydration w Isotonicsalineinfusion
Treat cause
Bisphosphonates goldstandard
CalciumandVitamin D
Calcatonin
supplements
Calcium
oprenntinbones plasma
Fomationofteethandbone controlledbyparathyroid
Bloodclotting
Needvitamin1 toabsorb
Transmissionotheweimpulses ochangesinalbuminettect
levels
Myocardialcontractions musclecontractions
N calcium gluconate
Rebreatherinto paperbag
Treatpainandanxietytopreven
hyperventilationinduced Resp
Alkalosis
hypermagnesemia
hypomagnesemia
HighsemmMg caused by
LowsemmMgcanadby
Tintake ofproducts containing
Prolongedfastingorstarration
Mgwhenrenalinsufficencyor
chronicalcoholism
failureis present
Fluidlossfromattract
Excess NMg administration
Manifestations
Eql
hdmn
Prolongedparenteralnutritionwout
supplementation
hypotension.hnflushing13
Diuretics PPI's
Lethargy
Hyperglycemic osmoticdiuresis
Nauseaandvomiting
manifestations
impaireddeeptendonreflexes
Resembleshypocalcemia
Muscleparalysis
Muscle crampstremors
Cardiacarrest
tendon
I
p
ai
Management
dp
Chrosteksitrousnan's
signs
Restrict Mgintake
contusionVertigoseizures
NCactorcalciumgluconateit
Dysrhythmias
Management
symptomatic
FluidsandNfurosemidetopromote
oralsupplements
urinaryexcretion
Adietaryintake
Parenteral NorIM magnesium
Dialysis
magnesium
bykidneys
metabolism
cofactorinenzymefor
ofcarbs DNAproteinsynthesis
Bloodglucosecontrol BP
regulation
Myoneuraljunction
excreted
Nomalerfunctionoabroybefinal
whensevere
Download