fluids, gut

8/3/2019 Fluids, Gut

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Average daily water intake and outputof normal adult

water in food- 1000 Urine- 1500

water ingested- 1200 Feces-150

water from oxidation- 300 Lungs -350

2500 Skin-500

2550

W a t e r

Water cons titute s ov er 50% of a n ind iv id uals w eightInf a n t- 70-80% Ad ult 50-60%

G eriatri c 45-55%Water requireme n t= 2500cc/d ay; min imum of 1500 cc/d ay


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Fluid compartments1. Intracellular - within cells- 70% bodywater 2. Extra cellular - outside cells -30% bodywater

a. interstitial- area around cells- 24%

body water b. intravascular- area within body

vessels- 6% body water


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Electrolytes (mEq)

salts or minerals in body fluids

contain electrically charged particles called ions

principal source of osmotic forces which control volume or

location of fluid

Cations- positively charged; Na, K, Ca, Mg

Anions- negatively charged; CL, HCO3, PO4


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T ypes of Solution

1. Hypertonic- exerts greater concentration of particlesoutside than inside the cell; cells shrink

e.g. D51/2NS, D5 NS, D5 LR, 3%NS, 5%NS

2. Hypotonic- exerts lesser concentration of particles outsidethan inside the cells; cells swell

eg. 1/2 NS, 1/4 NS, 1/3 NS, 2.5% Dextrose, D5W

3. Isotonic- same concentration of particles inside and outside

the cell; no change on size and shape of cellseg. Normal Saline, Lactated Ringers


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Care of Clients withBurns

Earl Francis R. Sumile, RNInstructor, College of Nursing

University of Santo T omas


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Burns

wounds caused by excessive exposure tothermal, electrical, chemical and

radioactive materialsusually secondary to carelessness or

ignorance


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Nursing Assessment

1. ABCsAge

Burn Location

Coverage

2. T etanus immunization


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3. T BSA- T otal Body Surface Area

a. Berkow formulacalculated on the basis of the clients age

changes that occur in proportion of the head and legs to the restof the body as the individual grows

arms and trunk have a fixed proportion throughout life

Eg. Head: 1yo = 19%; 1-4yo = 17%; 5-9yo =13%;

10-14yo = 11%; 15yo = 9%; adult = 7%


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B. Lund and Browder Chart

thought to be more accurate

takes into account changes in % of burned surface at variousstages of development

C. Rule of Nine

useful for immediate appraisal of the burned area

body is divided into areas, each represents 9% of or multiples

of 9; inaccurate


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Classifications of Burns:

1. Major- partial thickness> 25% or full thickness > 10%2. Moderate- partial thickness 15-25% or full thickness


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Categories of burn depth:

1. Partial thicknessa. Superficial Partial T hickness (First degree)

depth: epidermis

cause: sunburn, splashes of hot liquidsensation: painful

characteristic: erythema, blanching on pressure,

no vesicles


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B. Deep Partial T hickness (second degree)

depth: epidermis and dermis

cause: flash, scalding or flame burn

sensation: very painful

characteristic: fluid filled vesicles, red, shiny, wetafter vesicle rupture


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2. Full thickness (third and fourth degree)

depth: all skin layers and nerve endings, mayinvolve muscles, tendons and bones

cause:flame, chemicals, scalding, electric current

sensation: little or no pain

characteristic:wound dry, white, leathery, or

hard tissue

*eschar- leathery or hard tissue due to loss of blood supply


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Nursing Management in Different Stages of Burns:

1. Emergent phase- remove person from source of burngoals: relief of pain, minimize contamination, transport

a. T hermal- stop, drop and roll; flame off

b. Smoke inhalation- ensure patent airwayc. Chemical- remove clothing that contains chemical;

lavage with copious amounts of water

d. Electrical- shut off source of electricity; note entry or exit wound


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Nursing Interventions:

a. Ensure patent airway

b. Wrap in dry, clean sheet or blanket or prevent contaminationof wound

c. Provide warmth

d. Provide IV route if possible

e. T etanus prophylaxis

f. T ransport immediately


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2. Shock Phase- 1 st 24-48 hrs post burns

a. Fluid shift from plasma to interstitial fluid= hypovolemia;fluid also moves to areas that normally have little or no fluid(third spacing)

b. Dehydration, decreased BP, increased pulse, decreasedurinary output, thirst

c. Hyperkalemia, hyponatremia, increased hematocrit,metabolic acidosis, loss of HCO 3 ions


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3. Fluid remobilization or Diuretic phase (2-5 days post-burns)

a. Interstitial fluid returnsto vascular compartments

b. Increased BP, increased urinary output

c. Hypokalemia

4. Convalescent phase

a. Starts when diuresis is completed and wound healing begins

b. Dry, waxy-white appearance of full-thickness burn changingto dark brown; wet, shiny, serous exudate in partial thickness

c. Hyponatremia


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1. Provide relief or control pain

2. Administer analgesic or narcotics (morphine sulfate) 30 mins before wound care

3. Position burns to alignment

4. Monitor alterations in fluid-electrolyte balance5. Monitor foley catheter output hourly (30 cc/hr)

6. Weigh daily

7. Administer water or colloids8. Promote maximal nutritional status

9. Wound care done 1hr before meals

10. Prevent wound infection


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Biologic dressing- used to cover large denuded areas

Grafts- autograft, allograft, xenograft or heterograft

11. Controlled sterile environment

12. Hydrotherapy not more than 30 mins to prevent electrolyteloss

13. Sulfamylon, silvadene, silver nitrate, betadine, gentamycinapplied using sterile technique

14. Prevent GI complications

15. Provide client teaching and discharge plan

Escharotomy- lengthwise incision through eschar to allowexpansion of skin as edema forms

Fasciotomy- surgical incision done on underlying tissues or

muscles to explore for viability


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Care of Client with ProblemsRelated to the Genitourinary

System

Earl Francis R. Sumile, RNInstructor, College of Nursing

University of Santo T omas


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Renal functions: Homeostasis

1. Maintain constancy of internal environment by regulatingwater and electrolyte content and acid base balance

2. Conserve appropriate amounts of essential substances vitalto normal cell function

3. Excrete waste products of metabolism, toxic substances, anddrugs in urine

4. Endocrine role- production of renin, erythropoietin and prostaglandin

5. Metabolism of vitamin D


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Manifestations of impaired renal function:

1. Abnormal urinary volume

a. Oliguria-< 500ml/24hr

b. Anuria- 2000ml/24hr

d. Pollakuria- abnormally frequent urination

e. Nocturia- frequent urination at night

f. Isosthernuria- kidneys cannot concentarte urine

g. Strangury- desire to pass urine but not received by micturition

h. Incontinence- true, false, paradoxical overflow; stress related


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2. Abnormal urine color Abnormal constituents in urine

3. Abnormal constituents in urinea. Albuminuria- presence of albuminin the urine secondary to

inflammation and damage to glomeruli

b. Hematuria- presence of blood (RBC) in urine

4. Azotemia- metabolic wastes accumulated in blood,increased urea, craetinine and uric acid

a. Uremia- symptomatic elevation of metabolic waste productsin urine; a state or complex of symptoms reflecting failure of kidneys to excrete metabolic wastes and excess substances


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5. Fluid, electrolyte and pH imbalance- edema, metabolicacidosis- failure of kidneys to excrete hydrogen ions withincreased sodium, phosphate and ammonia

6. Vital signs- increased BP in renal insufficiency; pulse weak,dyspnea in pulmonary edema; kussmaul breathing in

acidosis; breath- uremic or ammoniacal odor in advancedrenal failure, fever

7. Gastrointestinal- anorexia, nausea or vomiting, diarrhea,hiccups in advanced renal failure

8. Headache- secondary hypertension and cerebral edema


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9. Visual disturbances- papilledema and retinalhemorrhages

10. Neurological- irritability, lethargic and drowsy,disoriented to comatose; convulsion

11. Skin changes- yellowish brown discoloration drynessor scaliness, pruritus and urea frost (uremic frost)excreted by sweat glands

12. Hematological- dec erythropoeisis leading to anemiaand bleeeding tendencies- petechiae, purpura


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Diagnostic Assessments

1. Urine examination or analysis

a. Routine- midstream first voided urine

b. Sterile or catheterized

c. 24 hours- collection starts at second voided urine

d. Residual

2. Blood examination or chemistry

a. CBC

b. BUN

c. Creatinine

d. Uric acid

e. Electrolytes


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3. Radiologic

a. KUB (Kidneys, Ureters, Bladder)- identifies number and sizeof kidney, ureters, bladder, tumors, malformation,. Calculi

b. IVP (Intravenous Pyelography)- fluoroscopic visualization of kidney after dye injection via IV

c. Cystography or cystoscopy

Prep- NPO 6-8 hrs with premedications like nubain, valium

d. PSP (phenolsuphthalein)- checks the secretory ability of the

kidneys; urine expected to be red4. Renal angiography

5. Percuatneous renal biopsy


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Common Disorders:

1. Urolithiasis- presence of stones anywhere in the urinary tract;often in men 20- 55yo; more in summer

Predisposing Factors:

a. Diet- large amount of calcium, oxalate, uric acid

b. Increased uric acid levels

c. Sedentary lifestyle, immobility

d. Family history of gout or calculi or hyperparathyroid

e. Genetic- xanthine, cystine stone


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Signs and Symptoms:

a. Abdominal or flank pain b. Renal colic

c. Hematuria

d. Cool moist skin


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a. Strain all urine with gauze or strainer

b. Crush all clots

c. Force fluids 3000-4000cc/ day

d. Encourage ambiulation to prevent stasis

e. Relieve pain by analgesics or moist heat

f. I and O


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Classification of Stones:

a. Acid stones- uric acid, cystine. Xanthine b. Alkaline stones- phosphate, calcium, oxalate


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Nursing Management:

1. Modified dieta. Alkaline ash- for acid stones; vegetables, fruits, except

prunes, plums and cranberries

b. Acid ash- for alkaline stones; cranberries, prunes and plums,meat fish, eggs, whole grain; limit milk

*avoid oxalates- tea, chocolate, spinach

*avoid purine- liver,brain, kidneys, shell fish, legumes


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2. Allopurinol or zyloprim- decrease uric acid production;enhance excretion of uric acid

3. Lithotripsy- crushing of stone

a. ESWL- Extracorporeal Shock Wave Lithotripsy

b. Electrohydraulic Lithotripsy

4. Surgery

a. Lithopalaxy

b. Pyelithotomy, Nephrolithotomy, Utero-lithotomy,Cystolithotomy


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2. Bladder Cancer- most common Ca in urinary tract; incidence-men 50-70 yrs

Predisposing Factors: exposure to chemical especially, aniline dye,cigarette smoking and chronic bladder infection

Nursing Management

a. SurgeryCystectomy

Uterosigmoidostomy

Ileal conduit b. Radiation

c. Chemotherapy


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4. Benign Prostatic Hypertrophy- hyperplasia and overgrowth of smooth muscles and connective tissues of the prostate glaned;

most common problem of male reproductive system

Incidence: 50% men over 50; 75% men over 75

Cause: hormonal mechanism

Signs and Symptoms- nocturia, frequency, decrease force andamount of urinary system, hesitancy, hematuria, increasedalkaline phophatase

Nursing mgt:

a. Antibiotics

b. Proscar

c. Prostacatheter


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d. Surgery

T URP T rans Urethral Resection of ProstateSuprapubic Prostatectomy

Retropubic Prostatectomy

Perineal Prostatectomy


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4. Renal Failure- state of total or nearly total loss of kidneyfunction

Acute Renal Failure- sudden inability of the kidneys to regulatefluid and electrolyte balance and remove toxic products from the

body; reversible

Causes:

a. Pre-renal- factors interfering with perfusion and resulting indecreased blood flow and glomerular filtrate,ischemia andoliguria

b. Intra-renal- conditions that cause damage to nephrons

c. Postrenal- mecanical obstruction from tubules to urethra


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Phases:

1. Onset- period precipitating event to development of oliguria2. Oliguria ( to anuria)- urinary output less 400ml

3. Diuretic- gradual return of GFR and BUN level

4. Convalescent- renal function stabilizeswith gradualimprovement in 3-12 months


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Signs and Symptoms:

a. oliguria to anuria b. edema

c. anorexia

d. nausea or vomitinge. lekocytosis

f. anemia

g. bleeding tendenciesh. drowsy

i. Muscle twitching and coma (uremic encephalopathy)


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Nursing Management

a. Fluid and nutrition- limited fluids to 500ml to replaceobligatory loss from lungs or skin

b. Low protein diet

c. Rest

d. Precautions: side rails up

e. Mouth or skin care

f. Pharmacotherapeutics- diuretics

g. Dialysis


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Chronic Renal Failure- progressive irreversible destruction of kidneys that continues until nephrons are replaced with scar tissues

Predisposing Factors: recurrent infections, exacerbations of nephritis, urinary tract obstructions, diabetes, hypertension

Signs and Symptoms:a. Electrolyte imbalance

b. Cardiovascular- hypertension,left ventricular hypertrophy,CHF

c. Hematologic- anemia, decreased erythropoeitin, increasedhematocrit and bleeding tendencies


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d. Gastro-intestinal- anorexia, nausea, vomiting

e. Respiratory- fluid overload, pulmonary edema: uremic lung

f. Orthopedic- increased Ca elimination, decreased serum Ca,osteodystrophy or osteomalacia

g. Dermatological- excoriation or dry skin, uremic frost

h. Neurologic- peripheral neuropathy, burning feet; CNSnystagmus, twitching, seizure

i.Reproductive-menstrual irregularities impotence, testicular atrophy and decreased sperm count

j. Psychological- behavioral and personality changes

k. impaired immunologic system- increased susceptibility toinfection


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Stages of CRF:

1. Renal impairment2. Renal insufficiency

3. Renal failure

4. End stage of Renal disease


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Nursing Management:

1. Conservative- assess uremia, mental function and supportive;avoid undue fatigue

2. Advanced renal failure- oliguric or uremic phase

a. peritoneal dialysis

b. hemodialysis

c. kidney transplant

3. Dietary- early- no restriction

- advanced- low protein

Giordano or Giovanette diet- low protein with amino acids


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Dialysis- removal by artificial means of metabolic wastes, excesselectrolytes and excess fluids

Principles:

-Diffusion, Osmosis, Ultrafiltration

Purposes:

1. T o remove excessive amounts of drugs or toxins in poisoning

2. T o check serious electrolyte or acid base imbalance

3. T o maintain kidney function when renal shutdown occurs

4. T o temporarily replace kidney function in patients with acuterenal failure and permanently replace in chronic renal failure


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Peritoneal Dialysis- introduction of specially prepared dialysatesolution into the abdominal cavity where the peritonem acts as asemipermeable membrane between the dialysate and blood in theabdominal vessels


a. weight, VS every 15 mins then every hour b. Patient voids

c. Warm dialysate solution to body temperature

d. Assist in trocar insertion

e. Inflow time, Dwell time and Drain time

f. Observe character of dialysate flow


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Complications:

PeritonitisRespiratory Difficulty

Protein loss

T ypes of Peritoneal Dialysis

CAPD- Continuous Ambulatory Peritoneal Dialysis

CCPD- Continuous Cycle Peritoneal Dialysis

IPD- Intermittent Peritoneal Dialysis


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Hemodialysis- shunting of blood from clients vascular systemthrough an artificial dialyzing system and return of dialyzed

blood to clients circulation

Dialysis coil- acts as a semipermeable mebrane

Access Routes:

AV shunt or cannula

AV fistula

Femoral or subclavian cannulation


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1. Auscultate for bruit and palpate thrill- check patency2. Check bleeding

3. Observe arm precaution

4. Avoid restrictive clothing or dressings over siteComplications:

1. Hypovolemic Shock

2. Dialysis disequilibrium syndrome


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Renal transplant pre-requisites

1. Evaluation of patients medical immunologic, psychologicaland social status

2. Should be identical- ABO and HLA compatible

Contraindications:

1. Acute infection

2. Malignancy

3. COPD

4. Liver disorder

5. DM

6. Atherosclerosis


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Pre-op care:

1. Dialysis to make patient non-toxic2. T reat all complications

3. Immunosuppressive drug to start 24hrs before transplant;immuran, prednisone, sandimmune

4. T ransplanted kidney placed on thigh, usually iliac fossa


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Post-op care:

1. Reverse isolation2. Monitor renal functions

3. Respiratory, therapy, deep breathing and coughingexercises

4. Aseptic wound care

5. Oral hygiene

6.NG T to prevent paralytic ileus

7. Early ambulation

8. Health adjustment process

9. Lifetime-immune suppressive drugs


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Complications:

Acute rejection

Chronic rejection

fluids, gut

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