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!