chapter 14
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Chapter 14 . Fluids and Electrolytes. Homeostasis. Maintaining relatively constant conditions as in fluid compartments To maintain internal balance, body must be able to regulate fluids All organs and structures of the body involved in homeostasis. Homeostasis cont’d. Intracellular fluid - PowerPoint PPT PresentationTRANSCRIPT
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Chapter 14
Fluids and Electrolytes
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Homeostasis
Maintaining relatively constant conditions as in fluid compartments
To maintain internal balance, body must be able to regulate fluids
All organs and structures of the body involved in homeostasis
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Homeostasis cont’d
Intracellular fluid Fluid within a cell Most of the body’s fluids found within the cell
Extracellular fluid Fluid outside the cell Intravascular fluid
• In blood vessels in the form of plasma or serum Interstitial fluid
• In fluid surrounding cells, including lymph
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Water
Largest portion of body weight Percentage affected by age, sex, body fat
Percentage of body water decreases with age Females have a lower percentage of body water
than males throughout adult years because women have more fat than men and fat cells contain less water than other cells
Obese have a lower percentage of body water because of the increased number of fat cells
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Solutes
Electrolyte Substance that develops an electrical charge when
dissolved in water Examples: sodium, potassium, calcium, chloride,
bicarbonate, and magnesium Maintain balance between positive and negative
charges For every positively charged cation, there is a
negatively charged anion Cations and anions combine to balance one another
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Solutes cont’d
Sodium (Na) Most abundant electrolyte; primary electrolyte in
extracellular fluid Major role in regulating body fluid volumes,
muscular activity, nerve impulse conduction, and acid-base balance
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Solutes cont’d
Potassium (K) Found mainly in the intracellular fluid; the major
intracellular cation Important in maintaining fluid osmolarity and volume
within the cell Essential for normal membrane excitability—
a critical factor in transmitting nerve impulses Needed for protein synthesis, for the synthesis and
breakdown of glycogen, and to maintain plasma acid-base balance
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Solutes cont’d
Chloride (Cl) An extracellular anion that is usually bound with
other ions, especially sodium or potassium Functions are to regulate osmotic pressure
between fluid compartments and assist in regulating acid-base balance
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Solutes cont’d
Calcium (Ca) Usually combined with phosphorus to form the
mineral salts of the bones and teeth • Of total body calcium, 99% concentrated in the bones and
teeth; 1% is in the extracellular fluid Ingested through the diet and absorbed through the
intestine Promotes transmission of nerve impulses; helps
regulate muscle contraction and relaxation
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Solutes cont’d
Magnesium (Mg2+) A cation found in bone (50% to 60%), intracellular
fluid (39% to 49%), and extracellular fluid (1%) Plays a role in the metabolism of carbohydrates and
proteins, the storage and use of intracellular energy, and neural transmission
Important in heart, nerve, and muscle function
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Solutes cont’d
Nonelectrolytes Other substances dissolved in the body fluids
• Urea, protein, glucose, creatinine, and bilirubin • These solutes do not carry an electrical charge
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Transport of Water and Electrolytes
Membranes Selectively permeable membranes
• Separate fluid compartments and control movement of water and certain solutes
• Maintain unique composition of each compartment of the body while allowing transport of nutrients and wastes to and from cells
• Some solutes cross membranes more easily than others
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Transport Processes
Diffusion The random movement of particles in all directions is for a substance to move from an area of higher
natural tendency concentration to an area of lower concentration
Facilitated diffusion • A carrier protein transports the molecules through
membranes toward an area of lower concentration
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Transport Processes cont’d
Active transport Carrier proteins transport substances from an area
of lower concentration to an area of equal or greater concentration
Requires expenditure of energy Many solutes, such as sodium, potassium, glucose,
and hydrogen, are actively transported across cell membranes
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Transport Processes cont’d
Filtration Transfer of water and solutes through a membrane
from an area of high pressure to an area of low pressure • Hydraulic pressure
A combination of pressures from the force of gravity on the fluid and the pumping action of the heart
Needed to move fluid out of capillaries into tissues and filter plasma through the kidneys
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Transport Processes cont’d Osmosis
Movement across a membrane from a less concentrated to a more concentrated solution
Involves movement of water only; sometimes force of movement across membrane carries solutes along
If a fluid compartment has less water and more sodium, water from another compartment moves to the more concentrated compartment by osmosis to create a better fluid balance
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Osmolality
Concentration of solution determined by number of dissolved particles per kg water
Controls water movement and distribution by regulating the concentration of fluid in each body fluid compartment
The osmolality of intracellular fluid and extracellular fluid tends to equalize because of the constant shifting of water
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Regulatory Mechanisms
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Kidneys Main regulators of fluid balance Control extracellular fluid by adjusting the
concentration of specific electrolytes, osmolality of body fluids, the volume of extracellular fluid, blood volume, and pH
The nephron is the functioning unit of the kidney Glomerulus is the filtering portion of the nephron, and
the tubule is responsible for secretion and reabsorption Nephrons conduct work of the kidney through filtration,
reabsorption, and secretion
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Kidneys cont’d
Filtration Blood plasma entering the kidney via the renal
artery is delivered to the glomerulus About 20% of plasma filtered into glomerular
capsule Most remaining plasma leaves kidney through the
renal vein Filtrate then moves through the tubules, where it is
transformed into urine by tubular reabsorption and secretion
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Kidneys cont’d
Tubular reabsorption A process by which most of the glomerular filtrate is
returned to the circulation Water and selected solutes move from the tubules
into the capillaries Waste products remain in tubules for excretion,
whereas most water and sodium is reabsorbed into the bloodstream
Adjusts volume and composition of the filtrate; prevents excessive fluid loss through kidneys
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Kidneys cont’d
Tubular secretion The last phase in the work of the kidneys The filtrate is transformed into urine Various substances—drugs, hydrogen ions,
potassium ions, creatinine, and histamine—pass from the blood into the tubules
Process eliminates some excess substances to maintain fluid and electrolyte balance, as well as metabolic waste products
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Hormones
Renin Hormone secreted when blood volume or blood
pressure falls Causes the release of aldosterone with subsequent
sodium and water retention Aldosterone
Acts on kidney tubules to increase reabsorption of sodium and decrease reabsorption of potassium
Because the retention of sodium causes water retention, aldosterone acts as a volume regulator
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Hormones cont’d
Antidiuretic hormone (ADH) Causes capillaries to reabsorb more water, so urine
is more concentrated and less volume is excreted Atrial natriuretic factor (ANF)
Hormone released by the atria in response to stretching of the atria by increased blood volume
Stimulates excretion of sodium and water by the kidneys, decreased synthesis of renin, decreased release of aldosterone, and vasodilation
Reduces blood volume and lowers blood pressure
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Thirst
Regulates fluid intake Increased plasma osmolality stimulates
osmoreceptors in the hypothalamus to trigger the sensation of thirst
More sodium and less water in the body make a person thirsty
Additional fluids consumed; kidneys conserve water until osmolality returns to normal
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Fluid Gains and Losses
In healthy adult, 24-hour fluid intake and output approximately equal
Fluids gained by drinking and eating and lost through the kidneys, skin, lungs, and gastrointestinal tract
The usual adult urine volume is between 1 and 2 L/day, or 1 ml/kg of body weight per hour
In kidneys, water loss varies largely with the amount of solute excreted and with the level of antidiuretic hormone
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Fluid Gains and Losses cont’d
Losses through the skin occur by sweating Water loss through the lungs by evaporation at
300 to 400 ml/day In the gastrointestinal tract, the usual loss of
fluid is about 100 to 200 ml/day
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Age-Related Changes Affecting Fluid Balance
Aging kidney slower to adjust to changes in acid-base, fluid, and electrolyte balances
Older adult often has a reduced sense of thirst and therefore may be in a state of chronic dehydration
Total body water declines with age; greatest loss from the intracellular fluid compartment
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Age-Related Changes Affecting Fluid Balance cont’d
Older person has limited reserves to maintain fluid balance when abnormal losses occur
Antihypertensives, diuretics, and antacids can also contribute to imbalances
Unless contraindicated, fluid requirements for older adults, based on ideal body weight, are
30 ml/kg for ages 55 to 65 and 25 ml/kg for 65 years and older
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Assessment of Fluid and Electrolyte Balance
Health history Determines if patient has conditions that contribute
to fluid or electrolyte imbalances• Vomiting, diarrhea, kidney diseases, diabetes, salicylate
poisoning, burns, congestive heart failure, cerebral injuries, ulcerative colitis, and hormonal imbalances; the intake of drugs, such as diuretics and cathartics; and medical interventions, such as gastric suctioning
Complaints of fatigue, palpitations, dizziness, edema, muscle weakness or cramps, dyspnea, and confusion may be associated with fluid imbalances
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Assessment of Fluid and Electrolyte Balance cont’d
Vital signs Pulse, respiration, temperature, and blood pressure
can indicate changes in fluid and electrolyte balance.
Temperature variations can be associated with fluid volume excess or deficit.
Pulse rate and quality may change in response to blood volume alterations; electrolyte changes can affect heart rate and rhythm. Blood pressure is directly related to blood volume. Respirations are minimally affected by electrolyte changes.
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Assessment of Fluid and Electrolyte Balance cont’d
Intake and output Accurate records are essential to determine whether
the patient’s intake is equal to output All fluids entering or leaving the body should be
noted A changing urine output may reflect attempts by the
kidneys to maintain or restore balance, or it may reflect a problem that causes fluid disturbances
Urine characteristics also give clues to fluid balance • Clear, pale urine in a healthy person suggests the
excretion of excess water, whereas darker, concentrated urine indicates the kidneys are retaining water
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Assessment of Fluid and Electrolyte Balance cont’d
Skin Characteristics
• Moisture, turgor, and temperature reflect fluid balance. Dry, flushed skin—dehydration. Pale, cool, clammy skin—severe fluid volume deficit that occurs with shock. Moist, edematous tissue seen with excess fluid volume
Facial characteristics• Severely dehydrated patient has a pinched, drawn facial
expression. Soft eyeballs and sunken eyes indicate severely deficient fluid volume. Puffy eyelids and fuller cheeks suggest excess fluid volume
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Assessment of Fluid and Electrolyte Balance cont’d
Skin turgor Measured by pinching the skin over the sternum,
the inner aspects of the thighs, or the forehead In patients who are dehydrated, skin flattens more
slowly after the pinch is released Edema
Reflects water and sodium retention, which can result from excessive reabsorption or inadequate secretion of sodium, as may occur with kidney failure
Pitting depression remains in the tissue after pressure is applied with a fingertip
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Assessment of Fluid and Electrolyte Balance cont’d
Mucous membranes Tongue turgor
• In well person, tongue has one longitudinal furrow. Fluid volume deficit causes additional longitudinal furrows, and the tongue is smaller. Sodium excess causes the tongue to appear red and swollen.
Moisture of the oral cavity• A dry mouth may be the result of deficient fluid volume or
mouth breathing. Veins
• Appearance of the jugular veins in the neck and the veins in the hands can suggest either a fluid volume deficit or excess.
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Diagnostic Tests and Procedures
Urine studies Urine pH
• Determines if kidneys are responding appropriately to metabolic acid-base imbalances
Urine specific gravity• A measure of urine concentration• A good indicator of fluid balance
Osmolality • Measures the number of dissolved particles in a solution • Provides more precise measurement of kidneys’ ability to
concentrate urine
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Diagnostic Tests and Procedures cont’d
Urine creatinine clearance tests Detect glomerular damage in the kidney A 24-hour specimen is required
Urine sodium Sodium intake and fluid volume status
Urine potassium A measure of renal tubular function
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Diagnostic Tests and Procedures cont’d
Blood studies Serum hematocrit
• Percentage of blood volume composed of red blood cells Serum creatinine
• A metabolic waste product • Indicator of renal function
Blood urea nitrogen (BUN) • A measure of renal function
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Diagnostic Tests and Procedures cont’d
Serum albumin A plasma protein that helps maintain blood volume
by creating colloid osmotic pressure Serum electrolytes
Sodium, potassium, chloride, and calcium
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Fluid Imbalances
Deficient fluid volume Less water than normal in the body Isotonic extracellular fluid deficit
• Hypovolemia Hypertonic extracellular fluid deficit
• Dehydration Decreased intake, abnormal fluid losses,
or both Examples: loss of water from excessive
bleeding, severe vomiting/diarrhea, severe burns
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Fluid Imbalances cont’d
Excess fluid volume An increase in body water
• Extracellular fluid excess Isotonic fluid excess
• Intracellular water excess Hypotonic fluid excess
From renal or cardiac failure with retention of fluid, increased production of antidiuretic hormone or aldosterone, overload with isotonic IV fluids, or administration of dextrose 5% in water (D5W) after surgery or trauma
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Electrolyte Imbalances
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Hyponatremia
Lower than normal sodium in the blood serum Can be actual deficiency of sodium or increase
in body water that dilutes the sodium excessively
Assessment Symptoms: headache, muscle weakness, fatigue,
apathy, confusion, abdominal cramps, and orthostatic hypotension
Take blood pressures with the patient lying or sitting and then standing to determine if a significant drop
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Hyponatremia cont’d
Medical treatment The usual treatment is restriction of fluids while the
kidneys excrete excess water Diuretic: furosemide (Lasix) Sodium replacement therapy
Nursing care Administer prescribed medications and IV fluids Measure fluid intake and output and assess mental
status
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Hypernatremia
Higher than normal concentration of sodium in the blood Very serious imbalance; can lead to death if not
corrected Occurs when excessive loss of water or excessive
retention of sodium Signs and symptoms
• Thirst, flushed skin, dry mucous membranes, low urine output, restlessness, increased heart rate, convulsions, and postural hypotension
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Hypernatremia cont’d
Medical treatment Oral or IV replacement of water to restore balance A low-sodium diet often prescribed
Nursing care Encourage patients with hypernatremia to drink
water Closely monitor the infusion of IV fluids Teach patient to track daily intake and output and to
recognize the signs and symptoms of fluid retention or depletion
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Hypokalemia
Low serum potassium May result in gastrointestinal, renal, cardiovascular,
and neurologic disturbances Can cause abnormal, potentially fatal, heart rhythm Signs and symptoms
• Anorexia, abdominal distention, vomiting, diarrhea, muscle cramps, weakness, dysrhythmias (abnormal cardiac rhythms), postural hypotension, dyspnea, shallow respirations, confusion, depression, polyuria (excessive urination), and nocturia
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Hypokalemia cont’d
Medical treatment Potassium replacement by the IV or oral route
Nursing care Monitoring at-risk patients for decreased bowel
sounds, a weak and irregular pulse, decreased reflexes, and decreased muscle tone
Cardiac monitors may be used to detect dysrhythmias
Administer oral or IV potassium Urine output should be no less than 30 ml/hr
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Hyperkalemia
High serum potassium Patients at risk: decreased renal function, in
metabolic acidosis, taking potassium supplements A serious imbalance because of the potential for life-
threatening dysrhythmias Signs and symptoms
• Explosive diarrhea and vomiting; muscle cramps and weakness, paresthesia, irritability, anxiety, abdominal cramps, and decreased urine output
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Hyperkalemia cont’d Medical treatment
Correct the underlying cause Restrict potassium intake Polystyrene sulfonate (Kayexalate) Intravenous calcium gluconate
Nursing care Patients with low urine output or those taking
potassium-sparing diuretics must be monitored carefully for signs and symptoms
Carefully monitor flow rate of IV fluids, which should not exceed 10 mEq/hr through peripheral veins
Screen the results of laboratory studies
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Chloride Imbalance
Usually bound to other electrolytes; therefore, chloride imbalances accompany other electrolyte imbalances Hyperchloremia
• Usually associated with metabolic acidosis Hypochloremia
• Usually occurs when sodium is lost because chloride most frequently bound with sodium
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Calcium Imbalance
Regulated by the parathyroid glands Hypocalcemia results from diarrhea, inadequate dietary
intake of calcium or vitamin D, and multiple blood transfusions (banked blood contains citrates that bind to calcium), in addition to some diseases, including hypoparathyroidism
Hypercalcemia results from a high calcium or vitamin D intake, hyperparathyroidism, and immobility that causes stores of calcium in the bones to enter the bloodstream
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Magnesium Imbalance
Hypomagnesemia: decreased gastrointestinal absorption or excessive gastrointestinal loss, usually from vomiting and diarrhea, or increased urinary loss
Hypermagnesemia occurs most often with excessive use of magnesium-containing medications or intravenous solutions in patients with renal failure or preeclampsia of pregnancy
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Acid-Base Disturbances
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Respiratory Acidosis
Respiratory system fails to eliminate the appropriate amount of carbon dioxide to maintain the normal acid-base balance
Caused by pneumonia, drug overdose, head injury, chest wall injury, obesity, asphyxiation, drowning, or acute respiratory failure
Medical treatment Improve ventilation, which restores partial pressure
of carbon dioxide in arterial blood (Paco2) to normal
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Respiratory Acidosis cont’d
Nursing care Assess Paco2 levels in the arterial blood Observe for signs of respiratory distress:
restlessness, anxiety, confusion, tachycardia Intervention
Encourage fluid intake Position patients with head elevated 30 degrees
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Respiratory Alkalosis
Low Paco2 with a resultant rise in pH Most common cause of respiratory alkalosis is
hyperventilation Medical treatment
• Major goal of therapy: treat underlying cause of condition; sedation may be ordered for the anxious patient
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Respiratory Alkalosis cont’d
Nursing care Intervention
• In addition to giving sedatives as ordered, reassure the patient to relieve anxiety
• Encourage patient to breathe slowly, which will retain carbon dioxide in the body
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Metabolic Acidosis
Body retains too many hydrogen ions or loses too many bicarbonate ions; with too much acid and too little base, blood pH falls
Causes are starvation, dehydration, diarrhea, shock, renal failure, and diabetic ketoacidosis
Signs and symptoms: changing levels of consciousness, headache, vomiting and diarrhea, anorexia, muscle weakness, cardiac dysrhythmias
Medical treatment: treat the underlying disorder
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Metabolic Acidosis cont’d
Nursing care Assessment of the patient in metabolic acidosis
should focus on vital signs, mental status, and neurologic status
Emergency measures to restore acid-base balance. Administer drugs and intravenous fluids as prescribed. Reassure and orient confused patients
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Metabolic Alkalosis Increase in bicarbonate levels or a loss of hydrogen
ions Loss of hydrogen ions may be from prolonged
nasogastric suctioning, excessive vomiting, diuretics, and electrolyte disturbances
Signs and symptoms: headache; irritability; lethargy; changes in level of consciousness; confusion; changes in heart rate; slow, shallow respirations with periods of apnea; nausea and vomiting; hyperactive reflexes; and numbness of the extremities
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Metabolic Alkalosis cont’d
Medical treatment Depends on the underlying cause and severity of
the condition
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Metabolic Alkalosis cont’d
Nursing care Assessment
• Take vital signs and daily weight; monitor heart rate, respirations, and fluid gains and losses
• Keep accurate intake and output records, including the amount of fluid removed by suction
• Assess motor function and sensation in the extremities; monitor laboratory values, especially pH and serum bicarbonate levels
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Metabolic Alkalosis cont’d
Intervention To prevent metabolic alkalosis, use isotonic saline
solutions rather than water for irrigating nasogastric tubes because the use of water for irrigation can result in a loss of electrolytes
Provide reassurance and comfort measures to promote safety and well-being
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