fluid and electrolyte 10 r
TRANSCRIPT
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Fluid and ElectrolytesFluid and ElectrolytesJan BaznerJan Bazner--ChandlerChandler
CPNP, CNS, MSN, RNCPNP, CNS, MSN, RN
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Alteration in Fluid andAlteration in Fluid and
Electrolyte StatusElectrolyte Status
Normal routes of fluid excretion in infants and children.
Lungs
SkinUrine & feces
Ball &Bender
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Regulatory MechanismsRegulatory Mechanisms
KidneysKidneys
Gastrointestinal tractGastrointestinal tract
Thermoregulatory mechanismThermoregulatory mechanism Thirst mechanismThirst mechanism
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KidneysKidneys
Regulate fluid by their ability toRegulate fluid by their ability to
concentrate and dilute urine.concentrate and dilute urine.
When serum sodium levels are high, ADHWhen serum sodium levels are high, ADHis secreted and increases permeability ofis secreted and increases permeability of
kidneys distal tubules and ducts.kidneys distal tubules and ducts.
AngiotensinAngiotensin--reninrenin system along withsystem along with
aldosteronealdosterone assists in regulating fluids andassists in regulating fluids and
electrolytes homeostasis.electrolytes homeostasis.
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Gastrointestinal TractGastrointestinal Tract
In GI tractIn GI tract water and sodium arewater and sodium are
reabsorbed and potassium is secreted.reabsorbed and potassium is secreted.
Fluid is replaced through oral intake.Fluid is replaced through oral intake.Due to large surface area of GI tractDue to large surface area of GI tract
changed in fluid and electrolyte balancechanged in fluid and electrolyte balance
can occur rapidly.can occur rapidly.
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Thermoregulatory MechanismThermoregulatory Mechanism
Insensible lossInsensible loss passive water losspassive water loss
through skin and lungsthrough skin and lungs
No electrolytes are lostNo electrolytes are lost
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Thirst MechanismThirst Mechanism
Thirst center is located in theThirst center is located in the
hypothalamushypothalamus
Thirst is stimulated by decrease inThirst is stimulated by decrease inintravascular volumeintravascular volume
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Developmental and BiologicalDevelopmental and Biological
VariancesVariances Infants younger than 6 weeks do notInfants younger than 6 weeks do not
produce tears.produce tears.
In an infant aIn an infant a sunken fontanelsunken fontanel maymayindicate dehydration.indicate dehydration.
Infants are dependant on others to meetInfants are dependant on others to meet
their fluid needs.their fluid needs.
Infants have limited ability to dilute andInfants have limited ability to dilute and
concentrate urine.concentrate urine.
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Developmental and BiologicalDevelopmental and Biological
The smaller the child, the greater theThe smaller the child, the greater the
proportion of body water to weight andproportion of body water to weight and
proportion of extracellular fluid toproportion of extracellular fluid to
intracellular fluid.intracellular fluid.
Infants have a larger proportional surfaceInfants have a larger proportional surface
are of the GI tract than adults.are of the GI tract than adults.
Infants have a higher metabolic rate thanInfants have a higher metabolic rate than
adults. (increased HR and RR)adults. (increased HR and RR)
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Developmental and BiologicDevelopmental and Biologic
Because of immature kidney function,Because of immature kidney function,
children lack ability to adjust to majorchildren lack ability to adjust to major
changes in sodium and other electrolytes.changes in sodium and other electrolytes.
Normal urine output is 1 mL / kg / hr.Normal urine output is 1 mL / kg / hr.
More prone than adults to conditions thatMore prone than adults to conditions that
affect fluid and electrolyte status (diarrhea,affect fluid and electrolyte status (diarrhea,
vomiting, high fever).vomiting, high fever).
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Increased Water NeedsIncreased Water Needs
FeverFever
Vomiting and DiarrheaVomiting and Diarrhea
DiabetesDiabetes insipidusinsipidus BurnsBurns
Shock (Shock (hypovolemichypovolemic))
TachypneaTachypnea
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Decreased Water NeedsDecreased Water Needs
Congestive Heart FailureCongestive Heart Failure
Mechanical VentilationMechanical Ventilation
Renal failureRenal failureHead trauma / meningitisHead trauma / meningitis
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Focused Health HistoryFocused Health History
Recent fluid intake including type of fluidRecent fluid intake including type of fluid
ingestedingested
How many voids in past 12 to 24 hours.How many voids in past 12 to 24 hours.RecentRecent weight lossweight loss oror gaingain
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Focused Physical AssessmentFocused Physical Assessment
How does the child look?How does the child look?
Skin:Skin:
TemperatureTemperature
Dry skin and mucous membranesDry skin and mucous membranes
PoorPoor turgorturgor, tenting, dough, tenting, dough--like feellike feel
Sunken eyeballs; no tearsSunken eyeballs; no tears
Pale, ashen, cyanotic nail beds or mucousPale, ashen, cyanotic nail beds or mucousmembranes.membranes.
Delayed capillary refill > 2Delayed capillary refill > 2--3 seconds3 seconds
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Loss of Skin ElasticityLoss of Skin Elasticity
Loss of skin elasticityDue to dehydration.
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RespiratoryRespiratory
Change in rate or qualityChange in rate or quality
Dehydration or hypovolemiaDehydration or hypovolemia
TachypneaTachypnea ApneaApnea
Deep shallow respirationsDeep shallow respirations
Fluid overloadFluid overload Moist breath soundsMoist breath sounds
CoughCough
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WeightWeight
Weigh the child and compare withWeigh the child and compare with
previous recent weights if available.previous recent weights if available.
Substantial fluid loss or gain will beSubstantial fluid loss or gain will bereflected inreflected in weight changesweight changes..
MostMost accurateaccurate indicator of fluid status.indicator of fluid status.
In the hospitalized child daily weight mayIn the hospitalized child daily weight maybe ordered.be ordered.
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Kidney FunctionKidney Function
Urine outputUrine output
Urine specific gravityUrine specific gravity
Blood Urea NitrogenBlood Urea Nitrogen BUN > 100 mg/dl =BUN > 100 mg/dl = dehyrationdehyration
AlbuminAlbumin
CreatinineCreatinine
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Hemoglobin and HematocritHemoglobin and Hematocrit
Measures hemoglobin, the mainMeasures hemoglobin, the main
component of erythrocytes, which is thecomponent of erythrocytes, which is the
vehicle for transporting oxygen.vehicle for transporting oxygen.
HgbHgb andand hcthct will bewill be increasedincreased in extracellularin extracellular
fluid volume loss.fluid volume loss.
HgbHgb andand hcthct will bewill be decreaseddecreased in extracellularin extracellularfluid volume excess.fluid volume excess.
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Urine Specific GravityUrine Specific Gravity
Normal values:Normal values:
Neonate: 1.001 to 1.020Neonate: 1.001 to 1.020
Infant / child: 1.010 to 1.020 (infant) 1.010 toInfant / child: 1.010 to 1.020 (infant) 1.010 to1.030 in older child / adult1.030 in older child / adult
Low specific gravity = fluid excess orLow specific gravity = fluid excess or
kidney diseasekidney disease
High specific gravity = fluid deficitHigh specific gravity = fluid deficit
(hypovolemia).(hypovolemia).
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ElectrolytesElectrolytes
Electrolytes account for approximatelyElectrolytes account for approximately
95% of the solute molecules in body95% of the solute molecules in body
water.water.
SodiumSodium Na+ is the predominantNa+ is the predominant
extracellularextracellular cationcation..
PotassiumPotassium K+ is the predominantK+ is the predominant
intracellularintracellular cationcation..
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SodiumSodium
Sodium is the most abundant cation andSodium is the most abundant cation and
chief base of the blood.chief base of the blood.
The primary function is to chemicallyThe primary function is to chemicallymaintain osmotic pressure and acidmaintain osmotic pressure and acid--basebase
balance and to transmit nerve impulses.balance and to transmit nerve impulses.
Normal values: 135 to 148 mEq / LNormal values: 135 to 148 mEq / L
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HyponatremiaHyponatremia
Serum sodium levels less than 130Serum sodium levels less than 130 mEqmEq/L./L.
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Clinical ManifestationsClinical Manifestations
Anorexia, nausea, lethargy and apathyAnorexia, nausea, lethargy and apathy
More advanced symptoms: disorientation,More advanced symptoms: disorientation,
agitation, irritability,agitation, irritability, depressed reflexesdepressed reflexes,,seizuresseizures
Severe: coma and seizures: sodiumSevere: coma and seizures: sodium
concentration less than 120concentration less than 120 mEqmEq/L/L
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ManagementManagement
IV sodium and fluid replacementIV sodium and fluid replacement
Restricting water intakeRestricting water intake
Oral reOral re--hydration commercial fluidshydration commercial fluids Stop diuretic therapyStop diuretic therapy
Make sure family is preparing formulaMake sure family is preparing formula
correctlycorrectly do not overdo not over--dilutedilute
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HypernatremiaHypernatremia
Serum sodium levels exceeding 150Serum sodium levels exceeding 150
mEqmEq/L/L
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Primary Sodium ExcessPrimary Sodium Excess
Improperly mixed formula or reImproperly mixed formula or re--hydrationhydration
solutionsolution
Ingestion of sea waterIngestion of sea waterHypertonic saline IVHypertonic saline IV
High breast milk sodiumHigh breast milk sodium
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ManagementManagement
Bring sodium levels down to normal andBring sodium levels down to normal and
restore hydration gradually over 48 hours.restore hydration gradually over 48 hours.
Check for proper formula preparationCheck for proper formula preparation totolittle water mixed with formulalittle water mixed with formula
Lactation consultantLactation consultant
Do not give boiled skim milk
Do not give boiled skim milk
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PotassiumPotassium
High or low values can lead to cardiacHigh or low values can lead to cardiac
arrest.arrest.
With adequate kidney function excessWith adequate kidney function excesspotassium is excreted in the kidneys.potassium is excreted in the kidneys.
If kidneys are not functioning, theIf kidneys are not functioning, the
potassium will accumulate in thepotassium will accumulate in the
intravascular fluidintravascular fluid
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PotassiumPotassium
Adults: 3.5 to 5.3Adults: 3.5 to 5.3 mEqmEq /L/L
Child: 3.5 to 5.5Child: 3.5 to 5.5 mEqmEq / L/ L
Infant: 3.6 to 5.8Infant: 3.6 to 5.8 mEqmEq / L/ L
Panic ValuesPanic Values
< 2.5< 2.5 mEqmEq /L or > 7.0/L or > 7.0 mEqmEq / L/ L
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HyperkalemiaHyperkalemia
Defined as potassium level above 5.0Defined as potassium level above 5.0 mEqmEq/ L/ L
Causes: dehydration or renal diseaseCauses: dehydration or renal disease
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Diagnostic tests:Diagnostic tests:
Serum potassiumSerum potassium
ECGECG
BradycardiaBradycardia Heart blockHeart block
Ventricular fibrillationVentricular fibrillation
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Interdisciplinary InterventionsInterdisciplinary Interventions
CalciumCalcium gluconategluconate 10% IV to stabilize cell10% IV to stabilize cell
membranemembrane
Peritoneal dialysis until kidney function isPeritoneal dialysis until kidney function isrestoredrestored
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HypokalemiaHypokalemia
Potassium level below 3.5 mEq / LPotassium level below 3.5 mEq / L
Before administering make sure child isBefore administering make sure child is
producing urine.producing urine. A child on potassium wasting diuretics isA child on potassium wasting diuretics is
at riskat risk LasixLasix
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Clinical Manifestations:Clinical Manifestations:
HypokalemiaHypokalemia
Neuromuscular manifestations are: neckNeuromuscular manifestations are: neck
flop, diminished bowel sounds,flop, diminished bowel sounds, truncaltruncal
weakness, limb weakness, lethargy, andweakness, limb weakness, lethargy, and
abdominal distention.abdominal distention.
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Causes ofHypokalemiaCauses ofHypokalemia
Vomiting / diarrheaVomiting / diarrhea
Malnutrition / starvationMalnutrition / starvation
Stress due to trauma from injury orStress due to trauma from injury orsurgery.surgery.
Gastric suction / intestinal fistulaGastric suction / intestinal fistula
Potassium wasting diureticsPotassium wasting diuretics Ingestion of large amounts ofASAIngestion of large amounts ofASA
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Nursing AlertNursing Alert
Before administering a potassiumBefore administering a potassium
supplement make sure the child issupplement make sure the child is
producing urine.producing urine.
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Foods high in potassiumFoods high in potassium
Apricots, bananas, oranges,Apricots, bananas, oranges,
pomegranates, prunespomegranates, prunes
Baked potato with skin, spinach, tomato,Baked potato with skin, spinach, tomato,lima beans, squashlima beans, squash
Milk and yogurtMilk and yogurt
Pork, veal and fishPork, veal and fish
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Treatment ModalitiesTreatment Modalities
Peripheral IV with IVhouse.
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Intraosseous TherapyIntraosseous Therapy
Intraosseous needle in place for emergency vascular access.
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DehydrationDehydration
Significant depletion of body water. SignsSignificant depletion of body water. Signs
and symptoms include thirst, lethargy, dryand symptoms include thirst, lethargy, dry
mucosa, decreased urine output, and asmucosa, decreased urine output, and as
the degree of dehydration progresses,the degree of dehydration progresses,
tachycardia, hypotension, and shock.tachycardia, hypotension, and shock.
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Cause ofDehydrationCause ofDehydration
Most common cause is fluid loss in the GIMost common cause is fluid loss in the GI
tract from vomiting, diarrhea or both.tract from vomiting, diarrhea or both.
H
ypovolemic ShockH
ypovolemic Shock = second most= second mostcommon cause of cardiac arrest in infantscommon cause of cardiac arrest in infants
/ children/ children
Loss of FluidsLoss of Fluids
Loss of blood volumeLoss of blood volume
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DiarrheaDiarrhea
Most common cause of diarrhea in infant /Most common cause of diarrhea in infant /
child ischild is RotovirusRotovirus
WH
O recommends immunization againstWH
O recommends immunization againstRotovirusRotovirus to decrease infant deaths worldto decrease infant deaths world
wide.wide.
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DehydrationDehydration
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Treatment of Mild to ModerateTreatment of Mild to Moderate
ORTORT oral reoral re--hydration therapyhydration therapy
50 ml / kg every 4 hours50 ml / kg every 4 hours
Increase to 100 ml / kg every 4 hoursIncrease to 100 ml / kg every 4 hours
No carbonated soda, jellNo carbonated soda, jell--o, fruit juices or tea.o, fruit juices or tea.
Commercially prepared solutions are theCommercially prepared solutions are the
best.best.
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Moderate to Severe DehydrationModerate to Severe Dehydration
IV Therapyneeded
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Fluid ResuscitationFluid Resuscitation
Crystalloid Solution: used for volumeCrystalloid Solution: used for volumeresuscitation to expand the interstitialresuscitation to expand the interstitial
volume rather that the plasma volume.volume rather that the plasma volume. Isotonic Saline is the prototype crystalloidIsotonic Saline is the prototype crystalloid
fluid. 0.9%fluid. 0.9% NaClNaCl or normal saline.or normal saline.
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Fluid ReplacementFluid Replacement
Standard Orders:Standard Orders:
Normal Saline or 0.9%Normal Saline or 0.9% NaClNaCl at 20 mL / kgat 20 mL / kg
Followed by Dextrose 5% in 0.45 normalFollowed by Dextrose 5% in 0.45 normal
salinesaline
Followed by Dextrose 5% in 0.45 normalFollowed by Dextrose 5% in 0.45 normal
saline with 20saline with 20 mEqmEq KCL per 1000 mLKCL per 1000 mL
Potassium is only added to the IV when therePotassium is only added to the IV when thereis documentation of voiding.is documentation of voiding.
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Care ReminderCare Reminder
A severely dehydrated child will needA severely dehydrated child will need
more than maintenance to replace lostmore than maintenance to replace lost
fluids. 1 to 2 times maintenance.fluids. 1 to 2 times maintenance.
It is the nurses responsibility to check fluidIt is the nurses responsibility to check fluid
calculations at the beginning of the shiftcalculations at the beginning of the shift
(24 hour fluid needs / hourly IV rate)(24 hour fluid needs / hourly IV rate)
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Over hydrationOver hydration
Occurs when child receives more IV fluidsOccurs when child receives more IV fluids
that needed for maintenance.that needed for maintenance.
In preIn pre--existing conditions such asexisting conditions such as
meningitis, head trauma, kidney shutdown,meningitis, head trauma, kidney shutdown,
nephrotic syndrome, congestive heartnephrotic syndrome, congestive heart
failure, or pulmonary congestion.failure, or pulmonary congestion.
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Assessment of overAssessment of over--hydrationhydration
TachypneaTachypnea
DyspneaDyspnea
CoughCoughMoist breath soundsMoist breath sounds
Weight gainWeight gain from edemafrom edema
Jugular vein distentionJugular vein distention
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Safety PrecautionsSafety Precautions
Use small bags of fluid orUse small bags of fluid or buretrolburetrol to control fluidto control fluidvolume.volume.
Check IV solution infusion against physicianCheck IV solution infusion against physician
orders.orders. Always use infusion pump so that the rate canAlways use infusion pump so that the rate can
be programmed and monitored.be programmed and monitored.
Calculate 24 hour fluid needsCalculate 24 hour fluid needs
Record IV rate q hourRecord IV rate q hour
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AcidAcid Base ImbalancesBase Imbalances
Acidosis:Acidosis:
Respiratory acidosisRespiratory acidosis
is too much carbonicis too much carbonic
acid in body.acid in body. Metabolic Acidosis isMetabolic Acidosis is
too much metabolictoo much metabolic
acid.acid.
Alkalosis.Alkalosis.
Respiratory alkalosisRespiratory alkalosis
is too little carbonicis too little carbonic
acid.acid. Metabolic alkalosis isMetabolic alkalosis is
too little metabolictoo little metabolic
acid.acid.
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Respiratory AcidosisRespiratory Acidosis
Carbonic acid excess: CO2 is retained andCarbonic acid excess: CO2 is retained and
pH decreasespH decreases
Caused by the accumulation of carbonCaused by the accumulation of carbon
dioxide in the blood.dioxide in the blood.
Acute respiratory acidosis can lead toAcute respiratory acidosis can lead to
tachycardia and cardiac arrhythmias.tachycardia and cardiac arrhythmias.
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Causes of Respiratory AcidosisCauses of Respiratory Acidosis
Any factor that interferes with the ability ofAny factor that interferes with the ability ofthe lungs to excrete carbon dioxide canthe lungs to excrete carbon dioxide cancause respiratory acidosis.cause respiratory acidosis.
Aspiration, spasm of airway, laryngealAspiration, spasm of airway, laryngealedema, epiglottitis, croup, pulmonaryedema, epiglottitis, croup, pulmonaryedema, cystic fibrosis, andedema, cystic fibrosis, andBronchopulmonary dysplasia.Bronchopulmonary dysplasia.
Sedation overdose, head injury, or sleepSedation overdose, head injury, or sleepapnea.apnea.
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AssessmentAssessment
Respiratory distressRespiratory distress
CNS depression: disorientation, comaCNS depression: disorientation, coma
Hypoxia: restlessness, irritability,
Hypoxia: restlessness, irritability,tachycardia, arrhythmiastachycardia, arrhythmias
Muscle weaknessMuscle weakness
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Medical ManagementMedical Management
Correction of underlying causeCorrection of underlying cause
Bronchodilators: asthmaBronchodilators: asthma
Antibiotics: infection
Antibiotics: infection
Mechanical ventilationMechanical ventilation
Decreasing sedative useDecreasing sedative use
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Respiratory AlkalosisRespiratory Alkalosis
Carbonic acid deficit; not enough CO2 isCarbonic acid deficit; not enough CO2 is
retained, and pH increases.retained, and pH increases.
Excess carbon dioxide loss is caused byExcess carbon dioxide loss is caused by
hyperventilation.hyperventilation.
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Causes of hyperventilationCauses of hyperventilation
HypoxemiaHypoxemia
AnxietyAnxiety
PainPain FeverFever
Salicylate poisoning: ASASalicylate poisoning: ASA
MeningitisMeningitis
OverOver--ventilationventilation
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AssessmentAssessment
DizzinessDizziness
Numbness orNumbness or paresthesiasparesthesias of fingers andof fingers and
toestoes
TetanyTetany
ConvulsionsConvulsions
UnconsciousnessUnconsciousness
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ManagementManagement
Stress management if caused byStress management if caused by
hyperventilation.hyperventilation.
Pain control.Pain control.
Adjust ventilation rate.Adjust ventilation rate.
Treat underlying disease process.Treat underlying disease process.
Have child slow respirations, breathe into
Have child slow respirations, breathe intopaper bagpaper bag
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Metabolic AcidosisMetabolic Acidosis
Bicarbonate deficitBicarbonate deficit
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Causes:Causes:
Gain in acidGain in acid: ingestion of acids,: ingestion of acids, oliguriaoliguria,,starvation (anorexia), DKA or diabeticstarvation (anorexia), DKA or diabeticketoacidosisketoacidosis, tissue hypoxia., tissue hypoxia.
Loss ofbicarbonateLoss ofbicarbonate::diarrhea, intestinal or pancreatic fistula, ordiarrhea, intestinal or pancreatic fistula, orrenal anomaly.renal anomaly.
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AssessmentAssessment
KussmaulKussmaul respirationsrespirations slow and deepslow and deep
SOB on exertionSOB on exertion
WeaknessWeaknessDrowsiness to stuporDrowsiness to stupor
When pH is < 7.2 cardiac contractility isWhen pH is < 7.2 cardiac contractility is
reducedreduced BP will decreaseBP will decrease
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ManagementManagement
Treat and identify underlying cause.Treat and identify underlying cause.
IV sodium bicarbonate in severe cases.IV sodium bicarbonate in severe cases.
Provide lowProvide low--protein, highprotein, high--calorie dietcalorie diet Position to facilitate ventilationPosition to facilitate ventilation
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Causes:Causes:
Gain in bicarbonate:Gain in bicarbonate:
Ingestion of baking soda or antacids.Ingestion of baking soda or antacids.
Loss
ofacid:
Loss
ofacid:
Vomiting, nasogastric suctioning, diureticsVomiting, nasogastric suctioning, diuretics
massive blood transfusionmassive blood transfusion
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AssessmentAssessment
Signs similar to dehydrationSigns similar to dehydration
TachycardiaTachycardia
Hypoventilation
Hypoventilation
MuscleMuscle hypertonicityhypertonicity
Confusion, irritability, comaConfusion, irritability, coma
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TreatmentTreatment
Administer fluid containing sodium andAdminister fluid containing sodium and
potassiumpotassium
Avoid antacidsAvoid antacids
Management: Correct the underlyingManagement: Correct the underlying
conditioncondition