Fluid, Electrolyte, and Acid-Base Management Notes. slides 4,5,6 not in test

Fluid, Electrolyte, and Acid-Base Management

Fluid and Electrolyte Objectives

  • Assess fluid and electrolyte levels in clients.

  • Implement interventions to maintain fluid and electrolyte balance.

    • Includes administration of blood products.

  • Create care plans for fluid and electrolyte management.

  • Identify signs of dehydration and electrolyte imbalances.

  • Discuss cultural influences on fluid and electrolyte management.

  • Educate clients on hydration and electrolyte balance.

Fluid Regulation

potassium- basically the heart

calcium- bones

magnesium- muscle, nerves, brain function- cramps

sodium- salt- water - hydration (strict diet)

fluid overload- increase blood pressure -cardiac arrect, and maybe stroke, kidney damaga, overload, no long compensation no sodium to hypertension or heart failure patients.

hypovolemia- low blood volume- hemorrhage/bleeding

high potassium, has to do with the heart go

  • Fluid Homeostasis: Mechanism to maintain stable internal conditions.

  • Fluid Intake and Absorption: Amount of fluid consumed and the efficiency of absorption in the body.

  • Fluid Distribution: How fluid is distributed in various body compartments.

  • Fluid Output:

    • Sensible Losses: Measurable fluid losses through urine and feces.

    • Insensible Losses: Unmeasurable losses, e.g., through skin and respiration.

  • Thirst Mechanism: Regulates the desire to drink fluids based on body water content.

  • Kidney Regulation: Kidneys play a crucial role in fluid balance via filtration and reabsorption processes.

  • Osmosis: Movement of water across semipermeable membranes, crucial for fluid balance.

Sodium and Fluid Balance

  • Sodium plays a critical role in fluid balance and the maintenance of normal blood pressure.

Electrolyte Balance

  • Intake and Absorption: Intake of electrolytes (K extsuperscript{+}, Ca extsuperscript{2+}, Mg extsuperscript{2+}, phosphate (Pi)) is essential.

  • Distribution: Plasma concentrations of electrolytes are low compared to their concentrations in cells/bone.

  • Output: Loss of electrolytes occurs through urine, feces, and sweat, and should be monitored before administering electrolytes.

  • Monitor urine output regularly.

Implementation of Fluid Management

  • Acute Care: Monitor for signs of hypovolemia and hypervolemia.

    • Enteral and parenteral replacement of fluids as necessary.

Hypovolemia

  • Causes include:

    • Hemorrhage: Blood loss from trauma or surgery.

    • GI Losses: Vomiting and diarrhea lead to significant losses.

    • Insensible Losses: Factors like fever can increase fluid loss.

    • Renal Losses: Diuretics and conditions like diabetes increase output without adequate intake.

Fluid Restriction

  • Definition: Limiting fluid intake to avert overload.

  • Indications: Heart failure, kidney failure, liver disease (ascites), and SIADH (Syndrome of Inappropriate Antidiuretic Hormone).

  • Nursing Considerations: Monitor intake and output, educate patients on restrictions, and watch for signs of dehydration.

Hypervolemia

  • Excess fluid retention can lead to:

    • Strain on the cardiovascular system and electrolyte imbalance.

    • Common causes include heart failure (RAAS activation) and renal dysfunction.

  • Symptoms: Edema, hypertension, crackles, jugular vein distention (JVD), dyspnea.

  • Interventions may include slowing/stopping IV fluids, elevating bed, and administering diuretics.

fluid overload- crackles in the lungs

excessive iv fluids

edema, hypertension, crackles in the lungs, jvd, dyspena (shortness of breath)

intervention: slow/stop iv

elevate head of bed- gravity on our side

administer diuretics if prescribed

monitor lung sounds and vitals

Initiating IV Therapy

bigger iv- more fluid.

changing iv fluids- depends on hospital policy, usually when the bag emptied or every 24hrs

priority- fall intervention, and making sure of movement

  • Key steps include verifying orders, ensuring IV access, and monitoring complications such as fluid overload and infiltration.

  • Infiltration: Leakage of IV fluid into the surrounding tissue.

    signs- swelling, pallor, coolness, pain, possible blisters (extravasation)

    intervention: stop infusion, elevate limb, apply warm cold compress, administer antidote if vesicant (

  • extravasation: 3 C’s cut off the infusion= stop it, conuteract=give antidote, contain= elevate and appy cool compress then D/c IV monitor every 15 minutes after infusion. swelling burning stinging redness

  • local infection and bleeding at iv site

    loc

  • Phlebitis: Inflammation of the vein, necessitating intervention and assessment for infection. intervention: discontinue iv, warm compress, monitor for infection . differentiate between phelebits and infection

    Lungs excrete carbonic acid.

    Kidneys excrete metabolic acids.

Blood Transfusion

  • Definition: Intravenous administration of blood components for replacement or improvement of blood functions.

  • Steps of Administration:

    1. Pre-transfusion preparation (verify orders, baseline vitals).

      verify

      check-pre transfusion lab work (blood type and cross match) - basically if the blood work is okay

      know base line vital signs. if a bad reaction vital sign heart rate and respiration, and temp will increase. they will spike a fever and checking pre-baseliine let us know if the blood affected them

      -use at least a 20 gauge iv catheter (18 for rapid transfusion)

      -use normal saline (0.9% naCL) as the only compatible iv fluid

      -obtain blood from the blood bank (must be used within 30 minutes) . once out of the fridge we have 30 minutes, the components of blood start to destabilize

      double check with another nurse, full name and identifications

      rh compatibility

      unit number and expiration date on blood bag

    2. Blood product verification with checks against patient identification.

    3. Close monitoring for reactions during the first 15 minutes after starting the transfusion.

    4. slow rate at (2ml/min for the first 15 minutes)

    5. the first 15 minutes are most reaction occur

    6. increase rate base on protocol

    7. complete transfusion withing 4 hours ( prevent contamination

    8. flush iv like with saline after tranduson to ensure no blood clot.

  • Transfusion Reactions: Identify symptoms such as febrile reactions and hemolytic reactions, requiring immediate intervention.

    febrile reaction most common- fevers, chills, headache , flushing , muscle pain

    hemolytic reaction- low back pain bc of kidneys, hypotension tachycardia, chest pain, dark urine, shock

    allergic reaction- urticaria (hives), itching, anaphaxis (severe cases

    circulatory overload

    sepsis (if bacterial contamination) - rapid onset fever, chills, hypotension shock

    what to do if reaction occurs

    stop the transfusion immediately but keep the iv line open with normal saline

    assess the patient: check vital signs, lungs sounds , urine output

    notifiy healthcare

    monitor worsening symptoms

    save blood bag and tubing

    administer medication as ordered

    iv fluids & anibiotics for sepsis

Bowel Elimination Overview

  • GI Tract Components: Includes the mouth, esophagus, stomach, intestines, and anus.

  • Functions: Absorption, secretion, elimination (peristalsis).

  • Common Problems: Include constipation, diarrhea, impaction, and incontinence.

  • Factors Influencing Bowel Health: Age, diet, fluid intake, medication effects, and anatomical conditions.

Stomas and Bowel Diversions

  • Definition: Surgical openings (stomas) created for bowel elimination; can be temporary or permanent.

  • Ostomy Care: Monitor skin around stoma, maintain hygiene, and support nutritional needs.

    stoma- should be red and moist

    vagus nerve-

    dont let it get 100% full

    change pouch 3-7 days

    nutritional considerations- ileostomies risk of dehydration

    psychological- depression, low self stream, embarrassed, they smell very bad,

    1. B

    2. B

  • B-having a bowel movement, E- amoxicillin- antibiotic which cause gi upset

    Test

    lab test

    xxx

    xxxx

    x

    xx

    xx

test

indirect visualization

bowel preparation

implementation health promotion

routine- take your time

promotional normal defecation

sitting position

privacy. safety over privacy with fall risk patients

positioning on bedpan

smaller pan (left) -fracture pan (right)

healthpromotion

prevent muscle strains and discomfort, 30-45 degrees, wear gloves

acute care

catheratics and laxatives.

cathartics- have a stronger and more rapid effects on the intestins than laxatives, suppositoes may act more quickly than oral medications

antidiarrheal agents

enemas- to get stools out stimulate peratalisis

to administer no worry on sterile

lower the enima if they start to cramp.

if enima fail, use digital removal.

have a order for digital removal

continuation and restorative care

bowel training - defecate when feel the urge

maintain fluid and food intake

fiber fluids, diarrhea low residue food- not a lot of digestive effort to pull out of

promote exercise

skin integrity- not a lot of time in the bed pan.

safety guidelines for nursing skills

instruct patients who self administer to use side lying positon

if pation

Urinary Elimination Overview

  • Anatomy: Includes kidneys, ureters, bladder, and urethra.

  • Common Issues: Include urinary retention, incontinence, UTIs, and their implications.

  • Patient Teaching: Emphasize hydration, dietary adjustments, and management of devices like catheters.

Recommendations for Practice

  • Regular checks for stomas and managing urinary diversions effectively.

  • Promote healthy fluid and dietary intake to enhance overall elimination health.

common urinary problems

urinary retention

urinary tract infection

urinary incontinence

involuntary leakage of urine

-limit

types of incontinence

overflow incontinence- incomplete bladder emptying resulting in overfilling and subsequent leakage

functional-

stress incon- stress, laugh, sneezing

urge- have the urge to urinate and leak before you reach toilet

reflex incon- comunication from brain to bladder the nurve is damage

oliguria- less than 400ml in 24 hrs or less than 30 ml/hr- normal urine output

anuria- absence of urine output 50ml in 24hrs

polyuria- excessive urine output diabetes

enuresis- bed wetting

nocturia- urination at night

urinary retention

risk factors, porstate enlargment, cytocele prostate bladder in females, neurological condition

x

x

urine studies

urinalysis- clean catch method (midstream)

test

urine culture

used to examine microbial growth

identify bactirea type and sensitivy

24 hour

refrigerate

used to test kidney function

discard first urine

blood test

creatine

ast alt- liver health

urine assesment

intake and output

clear

no odor

gravity 1.010- 1.030

we can get a urine sample from fullie, but has to be fast and

clamp fullie, pull syringe,

specimen collection and I&O

empty drainage bag ½ full of

positioning lower to prevent back flow to client

not touching the floor

take it out the bag and pour into a graduated cylinder

patient teaching

diet and hydration

2-3l a day

no caffeine, carbonated drinks, and alcohol

promote normal mictruitiction

-maintain elimination habit

-maintian adequate fiber intake

complete bladder emptying

prevent infection

management of urinary devices and catheres

bladder training

catheters

single lumen

double lumen

triple lumen

coude- male patient if they have prostate enlargement

french (fr scale

intermittent catherizatoin

in and out or straight catherization

use to drain the bladder

patient teaching

sterile technique

s&s of urinary tract infection

single use only

indwelling catherer

69

70

71

urinary diversion