ABC imbalances

Adult health exam 2

What is metabolic acidosis?

A condition with decreased blood pH (below 7.35) and decreased bicarbonate

Common causes include diabetic ketoacidosis, renal failure, and severe diarrhea

What are the signs and symptoms of metabolic acidosis?

Kussmaul respirations (deep rapid breathing)

Confusion or lethargy

Headache

Weakness

Nausea and vomiting

Hypotension

Possible cardiac dysrhythmias

What are the priority nursing interventions for metabolic acidosis?

Monitor ABGs and electrolyte levels

Assess respiratory rate and depth

Monitor cardiac rhythm, especially potassium

Treat the underlying cause

Administer IV fluids as prescribed

Administer insulin for DKA as prescribed

Monitor neurological status

What is metabolic alkalosis?

A condition with increased blood pH (above 7.45) and increased bicarbonate

Common causes include prolonged vomiting, gastric suctioning, and certain diuretics

What are the signs and symptoms of metabolic alkalosis?

Muscle cramps

Muscle weakness

Tingling or numbness

Confusion

Dizziness

Hypoventilation

Possible cardiac dysrhythmias

What are the priority nursing interventions for metabolic alkalosis?

Monitor ABGs and electrolytes

Assess respiratory status

Monitor cardiac rhythm

Replace fluids and chloride as prescribed

Monitor and correct potassium levels

Treat the underlying cause

Monitor for neurological changes

What is respiratory acidosis?

A condition with decreased blood pH and increased PaCO2 due to inadequate ventilation and carbon dioxide retention

What are common causes of respiratory acidosis?

COPD exacerbation

Respiratory depression from opioids or sedatives

Airway obstruction

Severe asthma

Respiratory muscle weakness

Hypoventilation

What are the signs and symptoms of respiratory acidosis?

Headache

Confusion

Drowsiness

Shortness of breath

Hypoventilation

Increased heart rate

Decreased level of consciousness in severe cases

What are the priority nursing interventions for respiratory acidosis?

Assess airway, breathing, and oxygenation

Position patient to promote ventilation

Administer prescribed oxygen

Administer prescribed bronchodilators when indicatedPrepare for noninvasive or invasive ventilation if needed

Monitor ABGs and respiratory status

Address the underlying cause

What is respiratory alkalosis?

A condition with increased blood pH and decreased PaCO2 caused by excessive ventilation and carbon dioxide loss

What are common causes of respiratory alkalosis?

Anxiety or panic attacks

Pain

Fever

Hypoxemia

Pulmonary embolism

Excessive mechanical ventilation

What are the signs and symptoms of respiratory alkalosis?

Dizziness

Lightheadedness

Numbness or tingling around the mouth and fingers

Muscle spasms

Palpitations

Confusion

Rapid breathing

What are the priority nursing interventions for respiratory alkalosis?

Assess respiratory status and oxygenation

Identify and treat the underlying cause

Provide reassurance and reduce anxiety when appropriate

Manage pain or fever as prescribed

Monitor ABGs and electrolytes

Do not assume anxiety is the cause until dangerous conditions are assessed

What is hypovolemia?

A decreased in circulating blood volume caused by fluid loss, resulting in decreased tissue perfusion

What are common causes of hypovolemia?

Vomiting

Diarrhea

Excessive sweating

Hemorrhage

Burns

Excessive urination

Inadequate fluid intake

What are the signs and symptoms of hypovolemia?

Tachycardia

Hypotension

Weak, thready pulse

Decreased urine output

Dry mucous membranes

Thirst

Poor skin turgor

Dizziness

Delayed capillary refill

What are the priority nursing interventions for hypovolemia?

Monitor vital signs frequently

Assess for signs of shock

Monitor intake and output

Measure urine output

Establish IV access

Administer prescribed isotonic fluids

Monitor electrolytes and kidney function

Identify and control the source of fluid loss

What is hypervolemia?

An excessive amount of fluid in the circulating blood volume and extracellular spaces

What are common causes of hypervolemia?

Heart failure

Kidney failure

Excessive IV fluids

Excessive sodium intake

Liver disease

What are the signs and symptoms of hypervolemia?

Peripheral edema

Weight gain

Crackles in the lungs

Shortness of breath

Jugular venous distention

Increased blood pressure

Bounding pulses

Decreased oxygenation if pulmonary edema develops

What are the priority nursing interventions for hypervolemia?

Assess lung sounds and respiratory status

Monitor daily weights

Monitor intake and output

Assess peripheral edema

Elevate the head of the bed if short of breath

Restrict fluids and sodium as prescribed

Administer prescribed diuretics

Monitor electrolytes and kidney function

What is the most accurate way to monitor changes in fluid volume?

Daily weights using the same scale, at the same time, with similar clothing

Approximately 1 kg of weight change represents 1 liter of fluid

What is hypokalemia?

A serum potassium level below 3.5 mEq/L

Potassium is essential for normal nerve impulses, muscle contraction, and cardiac function

Common causes: diuretics, especially loop and thiazide diuretics, vomiting or diarrhea, nasogastric suctioning, poor dietary intake, excessive laxative use

What are signs and symptoms of hypokalemia?

Muscle weakness, cramps, and fatigue

Decreased bowel motility, constipation, or ileus

Weak or irregular pulse

Dysrhythmias

Shallow respirations in severe cases

ECG changes: flattened or inverted T waves, ST depression, and prominent U waves

What are priority nursing interventions for hypokalemia?

Monitor potassium levels and cardiac rhythm

Assess muscle strength, bowel function, and respiratory status

Administer prescribed potassium replacement

Encourage potassium-rich foods when appropriate, such as bananas, potatoes, spinach, and oranges

Review medications that may lower potassium

Implement fall precautions if the patient is weak

IMPORTANT: Never administer potassium by IV push. IV potassium must be dilutes and administered using an infusion pump at the prescribed rate.

What is hyperkalemia?

A serum potassium level above 5.0 mEq/L

Common causes: kidney failure or decreased renal excretion, potassium sparing diuretics, such as spironolactone, ACE inhibitors and ARBs, excessive potassium supplementation, tissue damage or cell breakdown, adrenal insufficiency

What are the signs and symptoms of hyperkalemia?

Muscle weakness or paralysis

Numbness and tingling

Nausea or diarrhea

Bradycardia or other dysrhythmias

Potentially life-threatening cardiac arrest

ECG changes may include: tall, peaked T waves, widened QRS complexes, prolonged PR interval, loss of P waves in severe cases

What are priority nursing interventions for hyperkalemia?

Assess cardiac rhythm immediately and obtain an ECG

Notify the provider promptly for significant elevations or ECG changes

Stop potassium-containing IV fluids or supplements as prescribed

Monitor potassium and renal function

Administer prescribed treatments

Possible medications and treatment: IV calcium gluconate, regular insulin with dextrose, nebulizer albuterol, sodium bicarbonate, loop diuretics or potassium binders, dialysis

What is hypocalcemia?

A serum total calcium level below approximately 8.5 mg/dL

Common causes: hypoparathyroidism, vitamin D deficiency, chronic kidney disease, pancreatitis, low magnesium levels

What are the signs and symptoms of hypocalcemia?

Numbness and tingling around the mouth and in the fingers

Muscle cramps and spasms

Tetany

Hyperactive reflexes

Seizures in severe cases

Prolonged QT interval

Positive Chvostek’s sign and Trousseau’s sign

Chvostek’s sign: facial muscle twitching when the facial nerve is tapped

Trousseau’s sign: carpal spasm when a blood pressure cuff is inflated above systolic pressure for several minutes

What are priority nursing interventions for hypocalcemia?

Monitor calcium and magnesium levels

Assess for muscle spasms, tetany, and seizures

Monitor cardiac rhythm for QT prolongation

Initiate seizure precautions when indicated

Administer prescribed calcium replacement

Administer vitamin D if prescribed to improve calcium absorption

Encourage calcium-rich foods, such as dairy products and fortified foods

IMPORTANT: IV calcium gluconate may be prescribed for severe or symptomatic hypocalcemia. Administer carefully while monitoring cardiac rhythm

What is hypercalcemia?

A serum total calcium level above ~10.5 mg/dL

Common causes: hyperparathyroidism, cancer, prolonged immobility, excessive calcium or vitamin D intake, certain medications, including thiazide diuretics

What are the signs and symptoms of hypercalcemia?

Muscle weakness

Fatigue and lethargy

Constipation

nausea and vomiting

Increased thirst and urination

Kidney stones

Confusion or altered mental status

Shortened Qt interval

Remember: hypercalcemia can cause kidney problems and cardiac dysrhythmias

What are priority nursing interventions for hypercalcemia?

Encourage oral fluids if not contraindicated

Administer prescribed IV isotonic fluids for significant dehydration

Encourage mobility and weight-bearing activity when safe

Monitor calcium levels, renal function, and cardiac rhythm

Monitor intake and output

Administer prescribed medications, such as calcitonin or bisphosphonates

Assess for confusion, weakness, and kidney stone symptoms

What is hypomagnesemia?

A serum magnesium level below approximately 1.7 mg/dL

Common causes: chronic diarrhea or malabsorption, alcohol use disorder, poor nutritional intake, certain diuretics, prolonged vomiting, some medications, including certain antibiotics and proton pump inhibitors

What are the signs and symptoms of hypomagnesemia?

Tremors and muscle twitching

Muscle cramps and weakness

Hyperactive deep tendon reflexes

Numbness and tingling

Confusion, irritability, or seizures

Cardiac dysrhythmias, including torsades de pointes

Prolonged QT interval

What are priority nursing interventions for hypomagnesemia?

Monitor magnesium, potassium, and calcium levels

Monitor cardiac rhythm, especially if the level is severely low

Assess deep tendon reflexes and neuromuscular status

Implement seizure precautions for severe symptoms

Administer prescribed magnesium replacement

Encourage magnesium-rich foods, such as nuts, seeds, leafy greens, and whole grains

Monitor renal function because impaired kidneys increase the risk of magnesium accumulation during replacement

What is hypermagnesemia?

A serum magnesium level above ~2.4 mg/dL

Common causes: kidney failure or decreased renal excretion, excessive magnesium-containing antacids or laxatives, excessive IV magnesium administration, certain obstetric magnesium treatments

What are the signs and symptoms of hypermagnesemia?

Decreased or absent deep tendon reflexes

Muscle weakness

Flushing and warmth

Nausea and lethargy

Hypotension

Bradycardia

Respiratory depression

Severe cases can cause heart block, cardiac arrest, and coma

What are priority nursing interventions for hypermagnesemia?

Stop magnesium-containing medications or infusions as prescribed

Monitor respiratory rate, oxygenation, blood pressure, and cardiac rhythm

Assess deep tendon reflexes

Monitor magnesium levels and renal function

Prepare to administer prescribed IV calcium gluconate, which antagonizes magnesiums effects

Support breathing and circulation if severe toxicity develops

Dialysis may be necessary in severe cases, especially with renal failure

Important nursing distinction: with hypomagnesemia, reflexes are often increased. with hypermagnesemia, reflexes are decreased or absent.

What are the three major types of IV solutions?

Isotonic: similar concentration to blood; expands the intravascular space

Hypotonic: lower concentration than blood; moves water into cells

Hypertonic: higher concentration than blood; pulls water out of cells and into the bloodstream

What are examples of IV solutions, and when are they used?

0.9% normal saline (NS)

Lactated Ringer’s (LR)

Uses: hypovolemia, dehydration, fluid replacement, supporting blood pressure and circulation

Nursing considerations:

Monitor blood pressure, lung sounds, edema, and urine output

Watch for fluid overload, especially in patients with heart or kidney problems

What are examples of hypotonic IV solutions, and when are they used?

0.45% normal saline (1/2 NS)

0.225% normal saline (1/4 NS)

Uses: providing free water to dehydrated cells, treating selected cases of hypernatremia

Nursing considerations:

Monitor for hypotension and signs of decreased circulating volume

Watch for cerebral edema and neurological changes

Avoid or use extreme caution in patients with increased intracranial pressure, significant burns, or hemodynamic instability

What are examples of hypertonic IV solutions, and when are they used?

3% normal saline

D5NS

D5 ½ NS

D10W

Uses depend on the specific solution and patient condition

Examples include severe symptomatic hyponatremia and selected situations requiring increased intravascular volume or calories

Nursing considerations: monitor sodium and other electrolytes, assess for fluid overload and pulmonary edema, monitor neurological status, administer carefully according to facility policy and provider orders

What are the priority nursing assessments before and during IV fluid administration?

Assess vital signs and hemodynamic status

Assess lung sounds for crackles

Check for edema and jugular venous distention

Monitor intake and output

Monitor daily weights

Review electrolytes, renal function, and relevant laboratory results

Inspect the IV site for redness, swelling, pain, leaking, or infiltration

Verify the solution, rate, patient, and prescribed order

What is IV infiltration, and what should the nurse do?

Infiltration occurs when a nonvesicant IV solution leaks into the surrounding tissue instead of entering the vein

Signs: swelling around the IV site, cool skin, pale appearance, pain or tightness, slowed or stopped infusion

Nursing interventions: stop the infusion, remove the catheter, elevate the affected extremity, apply a warm or cold compress according to the solution and facility policy, restart the IV in another appropriate location is needed, document and reassess the site

What is IV extravasation, and how is it different from infiltration?

Extravasation occurs when a vesicant medication leaks into surrounding tissue and can cause severe tissue damage or necrosis

Signs: burning or intense pain, swelling, blistering, redness or discoloration, tissue injury

Priority nursing interventions:

Stop the infusion immediately

Do not flush the IV

Leave the catheter in place initially because it may be needed to aspirate the medication or administer an antidote

Notify the provider and follow the medication-specific extravasation protocol

Administer an antidote if prescribed

Apply the appropriate compress based on the medication

Document and monitor the affected area

What is phlebitis?

Inflammation of a vein, often related to IV catheter irritation or infection

Signs: redness along the vein, warmth, pain or tenderness, swelling, a palpable cord along the vein

Nursing interventions: stop the infusion and remove the catheter, apply a warm compress if appropriate, restart the IV at another site if needed, assess for infection and document findings

What is fluid overload, and what are the priority nursing interventions?

Fluid overload occurs when the body retains or receives more fluid than it can manage

Signs:

Crackles in the lungs

Shortness of breath

peripheral edema

Jugular venous distention

Rapid weight gain

Increased blood pressure

Decreased oxygen saturation

Priority interventions:

Slow or stop the IV fluids as clinically appropriate and notify the provider

Assess airway, breathing, oxygen saturation, and lung sounds

Position the patient in high Fowler’s if short of breath

Administer oxygen as prescribed

Administer prescribed diuretics

Monitor intake and output, daily weights, electrolytes, and renal function

What is the difference between D5W and normal saline?

D5W (5% dextrose in water): initially isotonic in the IV bag, but becomes physiologically hypotonic after the dextrose is metabolized. It provides free water and some calories

0.9% NS: Isotonic and expands the extracellular fluid and intravascular volume

Nursing considerations:

D5W is not appropriate for initial fluid resuscitation in hypovolemia or shock

Monitor blood glucose when administering dextrose-containing solutions

Use caution with D5W in patients at risk for increased intracranial pressure or hyponatremia

Why is an IV infusion pump used?

Delivers fluids and medications at a controlled rate

Helps prevent accidental rapid infusion

Provides greater accuracy for medications requiring precise administration

Alerts the nurse to occlusions and other infusion problems

Nursing responsibilities:

Verify the ordered rate and total volume

Check the pump settings against the provider’s order

Respond to alarms rather than simply silencing them

Reassess the IV site and patient during administration

What are signs of an IV site infection?

Redness

Warmth

Pain or tenderness

Swelling

Drainage or pus

Fever or chills, potentially indicating systemic infection

Nursing interventions:

Stop the infusion and remove the catheter when infection is suspected, following facility policy

Notify the provider as appropriate

Assess for systemic infection

Maintain aseptic technique during IV insertion and care

Document findings and interventions

What should the nurse monitor when administering IV fluids to a patient with kidney or heart problems?

Lung sounds for crackles

Oxygen saturation and respiratory effort

Blood pressure and heart rate

Peripheral edema and jugular venous distention

Intake and output

Daily weight

Renal function and electrolytes

These patients are at increased risk for fluid overload because they may have difficulty eliminating excess fluid or managing increased circulating volume