Disrupted Homeostasis Flashcards

Distribution of Fluid Within Body Compartments

• Solids
  • Female: 45%
  • Male: 40%
• Fluids
  • Female: 55%
  • Male: 60%
  • Intracellular fluid (ICF): 2/3
  • Extracellular fluid (ECF): 1/3
    • Interstitial fluid: 80%
    • Plasma: 20%

Mechanisms of Fluid and Electrolyte Movement

• Diffusion: Movement of solutes from an area of greater concentration to an area of lesser concentration.
• Osmosis: Movement of water from a dilute solution (low concentration of solute) to a more concentrated solution (high concentration of solute).
• Filtration: Hydrostatic pressure overcoming the opposing osmotic pressure.

Mechanism of Disruption: Fluid Imbalance

• Fluid imbalances include fluid volume deficit (FVD) and fluid volume excess (FVE).

Fluid Imbalance: Pathophysiology

• Fluid Volume Deficit (FVD)
  • Negative fluid balance leading to dehydration or volume depletion.
• Fluid Volume Excess (FVE)
  • Associated with disease states like:
    • Heart failure
    • Liver cirrhosis
    • Kidney disease/injury
  • Can also result from IV therapy.

Fluid Imbalance: Epidemiological and Etiological Risk Factors

• FVD
  • Physiologic fluid loss (GI, burns, excessive sweating, third-spacing).
  • Disease, illness, injury.
• FVE
  • Cardiac, liver, renal, and endocrine disorders.
  • Pregnancy.
  • Excessive IV fluid administration.
  • Age older than 65 with impaired renal or cardiac function at increased risk.

Fluid Imbalance: Impact on Overall Health

• FVD
  • Can lead to organ and tissue damage, cerebral hypoperfusion, and multi-organ damage/failure.
  • Impacts safety and increases morbidity.
  • Requires client education.
• FVE
  • Can lead to polydipsia and increased morbidity.
  • Requires client education.

Fluid Imbalance: Clinical Presentation

• Differences exist between FVD and FVE in relation to:
  • Cardiovascular
  • Neurologic
  • Pulmonary
  • Urologic
  • Integument
  • Musculoskeletal
  • Laboratory/diagnostics findings

Fluid Imbalance: Role of the Nurse

• FVD: Increase fluid and possibly sodium intake.
• FVE: Restrict fluid and possibly sodium intake.
• Employ fall prevention measures.
• Maintain proficiency in IV therapy administration.
• Provide client education.

Fluid Imbalance: Applying the Nursing Process – Assessment

• Recognize cues (assessment)
  • Fluid volume deficit/excess
    • History
    • Physical assessment
    • Laboratory

Fluid Imbalance: Applying the Nursing Process

• Analyze cues (analysis)
• Prioritize hypotheses (analysis)
• Generate solutions (planning)
• Take actions (implementation)
• FVD
  • Ongoing assessment
  • Hypovolemia
  • Laboratory
  • Complications
  • IV therapy

Fluid Imbalance: Applying the Nursing Process – Implementation

• Take actions (implementation)
• FVE
  • Ongoing assessment
  • Hypervolemia
  • Laboratory
  • Diuretic therapy
  • Fall precautions

Fluid Imbalance: Applying the Nursing Process – Evaluation

• Evaluate outcomes (evaluation)
• FVD
  • Urine output
  • Laboratory
  • Vital signs
• FVE
  • Respiratory
  • Edema
  • BNP

Fluid Imbalance: Discussion Question (1 of 2)

• Describe a situation when you provided care for a client experiencing fluid volume deficit.
  • What factors contributed to the fluid volume loss?
  • What symptoms did the individual experience related to the fluid volume loss?
  • What were the most effective nursing actions to correct the fluid loss?

Fluid Imbalance: Discussion Question (2 of 2)

• Describe a situation when you provided care for a client experiencing fluid volume overload.
  • What factors contributed to the fluid volume excess?
  • What symptoms did the individual experience related to the fluid volume excess?
  • What were the most effective actions to take to correct the fluid overload?

Mechanism of Disruption: Electrolyte Imbalance

• Electrolyte imbalances involve:
  • Sodium
  • Potassium
  • Magnesium
  • Calcium

Sodium Imbalance: Pathophysiology

• Hypernatremia
  • Hypertonic sodium gain
  • Pure water loss
  • Hypotonic fluid loss
• Hyponatremia
  • Hypovolemic
  • Euvolemic
  • Hypervolemic

Sodium Imbalance: Epidemiological and Etiological Risk Factors

• Hypernatremia
  • Physiologic disorders/processes
  • Medications
  • Incidence
• Hyponatremia
  • Physiologic disorders/processes
    • Hypovolemic
    • Euvolemic
    • Hypervolemic
  • Medications
  • Incidence and prevalence

Sodium Imbalance: Impact On Overall Health

• Hypernatremia
  • General symptoms and neurological issues
  • Incidence
  • Client education needed
• Hyponatremia
  • Prognosis and neurological effects
  • Incidence
  • Client education needed

Sodium Imbalance: Clinical Presentation

• Hypernatremia
  • Neurological, cardiovascular, integumentary manifestations
  • Specific laboratory findings
• Hyponatremia
  • Acute cases are medical emergencies; chronic cases may be asymptomatic
  • Neurological symptoms
  • Specific laboratory findings

Sodium Imbalance: Role of the Nurse

• Hypernatremia
  • IV and oral fluid replacement.
  • Follow sodium correction guidelines.
  • Possible sodium restriction.
  • Education.
• Hyponatremia
  • Possible fluid restriction for normovolemic hypotonic hyponatremia.
  • High protein diet for client with SIADH and malnourishment.
  • Fall prevention.
  • Education.

Sodium Imbalance: Applying the Nursing Process

• Recognize cues (assessment)
• Analyze cues (analysis)
• Prioritize hypotheses (analysis)
• Generate solutions (planning)
• Take actions (implementation)
• Evaluate outcomes (evaluation)

Potassium Imbalance: Pathophysiology

• Hypokalemia
  • Aldosterone release.
  • GI losses (N/V, suctioning).
  • Poor dietary intake.
  • Non-potassium sparing diuretics.
• Hyperkalemia
  • Potassium shift to extracellular space.
  • Metabolic acidosis (i.e., DKA).
  • Cellular damage (i.e., multiple transfusions, rhabdomyolysis).
  • Kidney disease (rarely diagnosed if kidney function is normal).
  • Iatrogenic therapy.

Potassium Imbalance: Epidemiological and Etiological Risk Factors

• Hypokalemia
  • Increased loss through kidneys and GI tract.
  • Increased loss through cellular uptake (e.g., insulin administration, alkalosis).
  • Comorbidities (e.g., cardiac and renal disorders, hypomagnesemia).
  • Age older than 65, higher incidence in females.
• Hyperkalemia
  • Renal insufficiency.
  • Diabetes.
  • Malignancies.
  • Acidosis.
  • Medications (e.g., ACE inhibitors).
  • Rhabdomyolysis.
  • Multiple blood transfusions.
  • Smoking.
  • Age older than 65, higher incidence in males.

Potassium Imbalance: Impact On Overall Health

• Hypokalemia
  • Symptoms appear when potassium less than 3 mEq/L
  • Gastrointestinal, Musculoskeletal, Cardiovascular effects
  • Client education regarding diuretics, laxatives, adequate dietary intake
• Hyperkalemia
  • Cardiovascular impact
  • Dietary restriction of potassium
  • Medical interventions for reduction and prevention
  • Medication selection and dosing
  • Potassium binders

Potassium Imbalance: Clinical Presentation

• Hypokalemia
  • Gastrointestinal, Musculoskeletal, Cardiovascular, Renal manifestations
  • Laboratory/Diagnostics
• Hyperkalemia
  • Musculoskeletal, Cardiovascular, Neurovascular manifestations
  • Laboratory/Diagnostics

Potassium Imbalance: Role of the Nurse

• Hypokalemia
  • Encourage foods high in potassium, adequate hydration.
  • Avoid mixing potassium in dextrose solutions.
  • Evaluate urine output before giving IV potassium.
  • Use an infusion pump for IV administration.
• Hyperkalemia
  • Limit dietary intake of potassium.
  • Maintain continuous cardiac monitoring.
  • Monitor intake and output
  • Client education (diet, monitoring serum potassium levels in chronic kidney disease)

Potassium Imbalance: Discussion Question

• The client hospitalized with fluid volume overload has a potassium (K+) level of 3.0 mmol/L. (Normal 3.5-5.2 mmol/L).
  • What additional information do you want know?
  • What nursing actions would you take to address the K+ level?

Magnesium Imbalance: Pathophysiology

• Hypomagnesemia
  • Poor intake and/or absorption from GI tract
    • Phytic acid, PPIs, calcium, phosphates, and fats inhibit absorption
  • Can cause cardiac dysrhythmias
  • Kidney disease with creatinine clearance less than 20 mL/min
• Hypermagnesemia
  • Uncommon imbalance, but can be fatal
    • Causing cardiac and neurologic dysfunction
  • Levels affected by sodium, vitamin D, growth hormone, parathormone, and thyroid hormone
  • Acute and chronic kidney disease

Magnesium Imbalance: Epidemiological and Etiological Risk Factors

• Hypomagnesemia
  • Decreased intake
  • Medications
  • Renal/GI losses
  • Excessive sweating
  • Age older than 65, prevalence greater in men, severity greater in women
• Hypermagnesemia
  • Excessive intake (e.g., laxatives, antacids, supplements)
  • Hyperparathyroidism
  • Hypothyroidism
  • Iatrogenic sources (e.g., magnesium infusion, hemodialysis)
  • Age older than 65, use of laxatives, antacids with impaired renal function

Magnesium Imbalance: Impact On Overall Health

• Hypomagnesemia
  • Risk of cardiac dysrhythmias especially in myocardial infarction
  • May experience delirium
  • Replenish magnesium with supplements, fluids containing electrolytes
• Hypermagnesemia
  • Confusion at levels greater than 7 mEq/L
  • Renal insufficiency increases susceptibility
  • Exercise care in use of substances containing magnesium

Magnesium Imbalance: Clinical Presentation

• Hypomagnesemia
  • Cardiovascular, Neuromuscular manifestations
  • Laboratory/Diagnostics (e.g., BMP, serum calcium, electrocardiogram)
• Hypermagnesemia
  • Cardiovascular, Respiratory, Gastrointestinal, Neurological manifestations
  • Laboratory/Diagnostics (e.g., BMP with GFR, urinalysis, ABGs, electrocardiogram)

Magnesium Imbalance: Role of the Nurse

• Hypomagnesemia
  • Encourage dietary and supplemental magnesium intake
  • Teach foods rich in magnesium, use of sports drinks for replenishment
  • Teach manifestations of magnesium toxicity
  • Monitor for magnesium toxicity during supplementation
• Hypermagnesemia
  • Restrict sources of excessive magnesium intake
  • Monitor urinary output during IV magnesium infusions
  • Use fall prevention measures if weakness, dizziness, and confusion present
  • Client education regarding sources of magnesium and symptoms of toxicity

Calcium Imbalance: Pathophysiology

• Hypocalcemia
  • Decreased parathyroid hormone
    • Injury/Removal of parathyroid
  • Hypomagnesemia
  • Alkalosis
  • Low Vitamin D
  • Calcitonin
  • Pancreatitis
• Hypercalcemia
  • Excessive parathyroid hormone
    • Malignancy
    • Hyperparathyroidism
  • Hypervitaminosis D

Calcium Imbalance: Epidemiological and Etiological Risk Factors

• Hypocalcemia
  • Renal failure most prevalent cause
  • Decreased parathyroid hormone
  • Sepsis
  • Hypomagnesemia
  • Medications (e.g., bisphosphonates, denosumab)
  • Multiple blood transfusions
  • Poor intake
  • Age older than 65
• Hypercalcemia
  • Hyperparathyroidism
  • Malignancies
  • Hypervitaminosis D
  • Acute/Chronic kidney disease
  • Prolonged immobilization

Calcium Imbalance: Impact On Overall Health

• Hypocalcemia
  • Depression, Anxiety, Osteoporosis
  • Client education, Supplementation
  • Thyroidectomy/parathyroidectomy postoperative calcium replacement
• Hypercalcemia
  • Malignancy
  • Can cause renal calculi, renal failure, bone pain

Calcium Imbalance: Clinical Presentation

• Hypocalcemia
  • Prolonged QT interval
  • Tetany (e.g., positive Chvostek’s and Trousseau’s sign)
  • Paresthesia, seizures
  • Emotional liability and depression
  • Laboratory/diagnostics: Electrolytes (e.g., magnesium and phosphorus), Vitamin D level, Parathyroid hormone level
• Hypercalcemia
  • Encephalitis at greater than 14 mg/dL
  • Life-threatening at greater than 15 mg/dL

Calcium Imbalance: Role of the Nurse

• Hypocalcemia
  • Encourage supplementation with calcium and Vitamin D
  • Use fall precautions
  • Monitor for symptoms following thyroid or parathyroid surgery
  • Educate client regarding required calcium replacement regimen
• Hypercalcemia
  • Encourage physical activity and adequate hydration
  • Use fall precautions
  • Educate client regarding restriction of calcium sources as appropriate

Mechanism of Disruption: Acid/Base Imbalance

• Acid/base imbalances can be metabolic or respiratory.

Metabolic Imbalance: Pathophysiology

• Metabolic acidosis
  • Serum bicarbonate decreased and pH below 7.35
  • Renal and GI loss of bicarbonate
  • Acid ingestion
  • Alterations in acid production and excretion
• Metabolic alkalosis
  • Serum bicarbonate increased and pH above 7.45
  • Renal and GI loss of hydrogen ions
  • Intracellular shift of hydrogen ions
  • Retention or addition of bicarbonate

Metabolic Imbalance: Epidemiological and Etiological Risk Factors

• Metabolic acidosis
  • Medications (e.g., salicylates, iron, metformin)
  • Methanol
  • Carbon monoxide poisoning
  • Kidney disease
  • Liver failure
  • Congenital lactic acidosis
• Metabolic alkalosis
  • Loss of gastric hydrogen ion (e.g., vomiting, gastric suction)
  • Excessive bicarbonate intake
  • Diuretics
  • Hyperaldosteronism
  • Common diagnosis in hospitalized clients

Metabolic Imbalance: Impact On Overall Health

• Metabolic acidosis
  • Complications (osteoporosis, worsening kidney disease, shock, death)
  • Confusion, lethargy
  • Can occur with decreased kidney function
  • Management of conditions that can cause metabolic acidosis
  • Dietary strategies
• Metabolic alkalosis
  • Cardiovascular, Neurological, Respiratory effects

Metabolic Imbalance: Clinical Presentation

• Metabolic acidosis
  • Manifestations based on underlying cause
    • Example - DKA
  • Laboratory - ABGs, BMP, urinalysis, CBC, serum lactic acid
• Metabolic alkalosis
  • Confusion, Hypoventilation, Increased bicarbonate excretion through kidneys
  • Muscle weakness, paresthesia, Tachydysrhythmias
  • Laboratory/Diagnostics – ABGs, electrolytes, BUN, creatinine, EKG

Metabolic Imbalance: Role of the Nurse

• Metabolic acidosis
  • Proficiency in ABG interpretation
  • Monitor capillary glucose during insulin administration in DKA
  • Client education regarding dietary recommendations
• Metabolic alkalosis
  • Proficiency in ABG interpretation
  • Client education
  • Dietary recommendations
  • Association between alkalosis and anxiety disorders, vomiting, alkaline substances

Metabolic Imbalance: Discussion Question

• Discuss the potential problems for clients who are experiencing metabolic acidosis.
• Discuss the potential problems for clients who are experiencing metabolic alkalosis.

Respiratory Imbalance: Pathophysiology

• Respiratory acidosis
  • Serum carbon dioxide increased and pH below 7.35
  • Hypoventilation
  • Increased physiologic dead space
• Respiratory alkalosis
  • Serum carbon dioxide decreased and pH above 7.45
  • Hyperventilation
  • Decreased carbonic acid
  • Cerebral vasoconstriction, Less oxygen to tissues, Inhibited respiratory effort

Respiratory Imbalance: Epidemiological and Etiological Risk Factors

• Respiratory acidosis
  • Acute or chronic processes causing retention of CO2
    • Acute: drugs, neurologic disorders, pneumonia, asthma, stroke, surgery
    • Chronic: heart failure, COPD
• Respiratory alkalosis
  • Hypoxemia causing hyperventilation
  • Stimulation of central nervous system causing hyperventilation
  • Respiratory disorders
  • Liver failure and sepsis
  • Medications (e.g., salicylates, progesterone)
  • Mechanical ventilation
  • Exposure to excessive heat occupationally or geographically

Respiratory Imbalance: Impact On Overall Health

• Respiratory acidosis
  • Chronic acidosis
    • Memory loss, Poor coordination, Heart failure, Polycythemia, Pulmonary hypertension, Anxiety depression
    • Persistent shortness of breath and cough
• Respiratory alkalosis
  • May not pose significant harm, treat underlying cause
  • Age older than 65 with cardiovascular and respiratory conditions at greater risk

Respiratory Imbalance: Clinical Presentation

• Respiratory acidosis
  • Dependent on causative process
    • Sleep difficulty, anxiety, shortness of breath, cyanosis, increased ICP, COPD
  • Laboratory: ABGs, serum bicarbonate
• Respiratory alkalosis
  • Dependent on causative process
    • Shortness of breath, dyspnea, orthopnea, wheezing, Fever, weakness, chills
    • Dizziness, confusion, anxiety, Numbness, paresthesia
    • Sometimes asymptomatic
  • Laboratory: ABGs, serum electrolytes, magnesium, phosphate,
  • Diagnostics: Chest x-ray, CT scan, or MRI

Respiratory Imbalance: Role of the Nurse

• Respiratory acidosis
  • COPD: tripod position
  • Implement fall precautions
  • Must recognize clinical deterioration
  • Proficiency in ABG interpretation
  • Client education: risks of oversedation, weight management, smoking
• Respiratory alkalosis
  • Calm, reassuring approach
  • Fall precautions
  • Proficiency in ABG interpretation
  • Client education: strategies to manage anxiety, increase $CO_2$

Respiratory Imbalance: Clinical Judgment

• Recognize cues
• Analyze cues
• Prioritize hypotheses
• Generate solutions
• Take actions
• Evaluate outcomes

Respiratory Imbalance: Discussion Question

• Discuss the potential problems for clients who are experiencing respiratory acidosis.
• Discuss the potential problems for clients who are experiencing respiratory alkalosis.

Case Study: Introduction

• A 72-year-old client enters the emergency room and reports shortness of breath. The client has a two pack per day smoking history for 50 years. The client states the shortness of breath has progressively worsened over the past two days. The client was diagnosed 10 years ago with COPD. Has a history of hypertension and hyperlipidemia.
  • Admitting Diagnosis: Shortness of breath, acute exacerbation, COPD

Case Study: 1200

• Assessment findings: lips and fingertips are cyanotic. Barrel-chested and uses accessory muscles during breathing. Bilateral wheezes. Alert and oriented x 4.
• Vital signs
  • B/P: 173/92
  • Pulse: 123
  • Respirations: 39
  • Temperature: 97.4
  • Ox saturation: 85% on room air
  • Pain: 0/10
• Blood gases
  • pH 7.1
  • $PaCO_2$ 49
  • $HCO_3$ 28
  • $PaO_2$ 79

Case Study: 1530

• Client has been admitted to the medical unit. Assessment findings: lips and fingertips are pale. Barrel-chested and uses accessory muscles during breathing. Lungs bilateral wheezes. Alert and oriented x 2.
• Vital signs
  • B/P: 168/902
  • Pulse: 122
  • Respirations: 20
  • Oxygen saturation: 95% on 4L oxygen per nasal cannula
  • Pain: 0/10

Self-Reflection Activity

• Imagine you were diagnosed with fluid volume overload and put on restricted fluid intake. How would this change your daily activities? How would you manage the fluid restriction?
• You are caring for an elderly client who uses an abundance of table salt when cooking. The client has been diagnosed with hypernatremia. What resources would you use to educate the client?
• Complete the above questions and submit them to your instructor.

Lesson Reflection Questions

• What are three additional questions you have after completing this lesson? How are you going to get your questions answered? What resources do you have to help answer your questions?
• What do you feel is your most important role in caring for clients with disrupted homeostasis?
• Where did you meet success in this lesson? How can you show you understand at least two of the learning objectives from this lesson?
• Complete the above questions and submit them to your instructor