hello class this is professor streb and today i'm going to go over care of the patient with fluid and electrolyte imbalances and care of the patient with acid-base imbalances unit 4 covers chapters 11 and 12 the assessment of care patients for the flu imbalance and the ones with the acid-base imbalance um the next slide this this is basically what your syllabus tells you to to know so make sure you get in your syllabus and look at the page numbers and know exactly where they want you to read in the book fluid imbalances encompass a lot you could have fluent volume deficit or you have fluid volume overload there are numerous health problems that can disrupt your body's fluid balance um dehydration is probably the biggest one that we think about it's the most common and it's truly a serious fluid imbalance if you don't have enough circulating volume we'll call that hypovolemia and that can cause workload of the heart to go up and just cause a multitude of problems this can be caused by numerous things dehydration is typically caused by a lack of oral intake of fluids diuretics such as lasix um could also cause you to have instance just a lot of water loss vomiting diarrhea are also common culprits that lead to dehydration there are other multiple things you can think about but fevers burns diabetes insipidus we'll talk about that more when we get to the endocrine system but dehydration manifests in a few different ways and it's important to understand these because the disease process doesn't necessarily matter as much as understanding what you know why or that somebody is dehydrated so you know a rapid weight loss consistent thirsts vital signs if you're hypovolemic you'll be hypotensive you'll have tachycardia you'll have to take ipnia as well and you'll probably be febrile because you'll have a temperature because your body can't regulate its temperature um because of that when you're dehydrated you'll have uh flat jugular veins they will not be distended when you're laying at that 30 degree angle your mucous membranes will be dry as well you'll have reduced skin turtle and don't forget mental status changes weakness things of that nature make sure you understand labs when you look at us morality um you were talking about it it's just more concentrated the same with urine specific gravity when you're dehydrated your urine is more concentrated you'll also see the bun will go up as well and that is a sign that you are dehydrated it's also a sign that you might have some kidney malfunction so if they're dehydrated that's probably the cause of an elevated b win all right so what do you need to know as a nurse as a nurse there's a lot of things you have to think about you need to worry about eyes and nose make sure that your patient is taking in enough fluid the book talks about two two and a half liters of fluid in a 24 hour period and making sure that the urine output is greater than 0.5 mls per kilogram per hour so it's not just that 30 mls an hour which is our standard and what we're looking for but when somebody's dehydrated and we're trying to rehydrate them this is just another way um stable vital signs we know that increases in weight if you're dehydrated we expect you to gain a half a pound a pound a day just things to think about right through there so when you're going to weigh your patient make sure you weigh them every morning prior to eating you want to be very consistent so you get a very accurate reading throughout their time in your care and then make sure you're paying attention to their mental status if their mental status is improving is probably indicative of them getting hydrated again so that's a big key to understanding hydration and you know proper perfusion is that mental status interventions as nurses you do have to do your assessments think about this though when you're giving all this fluid because your patient is dehydrated you also need to think about the flip side is if you're giving them all this fluid you need to monitor for high giving too much well you can have volume fluid volume overload it is possible to over correct um so you want to watch for some of those things you want to watch the vital signs you want to do your physical assessments you know if your patient's laying down and they have just in the neck veins if you set them up to 30 degrees those distended neck veins should go away if they are over hydrated or they have fluid volume overload you would see that as well so make sure you're you're you're thinking about your patient in that aspect also the safety concerns of you know standing up too rapidly and getting orthostatic hypotension now we kind of continue with this fluids can be found in different places the ones we talk about for the most part though we talk about intercellular meaning it's inside the cell but when we think about our patients who might have fluid volume overload or things like that we look about fluid that is intravascular which is in your bloodstream and if it gets too much pressure inside your vessels it will start the third space and it goes to your interstitial areas which would be just the area surrounding the cell so it's kind of in that adipose tissue and the surrounding tissue adipose itself but the interstitial surrounding areas around the cells themselves so make sure you kind of take note of what that looks like all right fluid volume overload this is just the opposite of dehydration called this hypervolemia which is not really something we talk about we don't use that word a lot but it is hypervolumia it just means that you have fluid volume excess and overload this is exactly what i was talking about when somebody has fluid volume overload you expect to see some third spacing which is in the fluid that's intervascular starts to seep out of the vasculature system and goes into the interstitial spaces so the the tissue surrounding your cells that's what causes that pitting edema so just like i said make sure you're looking for signs and symptoms associated with this you check the lung sounds because we know if you have too much fluid volume it'll go into your it'll also do that third spacing in your lungs it'll go from the intervascular area into the interstitial spaces which would be your alveolar sacs and then you would have that you would have pity edema you'd have dyspnea while you're sitting there you would have rapid respirations trying to get more oxygen and gas exchange going on weight gain so it's kind of the same thing for both of these patients the way you're going to monitor them daily weights etc all right electrolyte imbalances we're going to talk about uh quite a few of them uh the electrolytes are just the ions they're either negative or positive you know we think about potassium we think about calcium magnesium sodium these are the ones that typically come to mind and we're going to look at those a little more in depth it's going to be important for you to understand a few things about each one of these so when you're studying make sure you know the the lab values themselves first it's hard to take an exam and do well on it when you don't know the lab values themselves so if we're thinking about hyponatremia you have to know that the normal volume the normal levels is 135 to 145 so a hyponatremia is less than 135 so if you were to see that on an exam question your mind should go to oh hyponatremia and you need to start thinking about a person who's like hyponatremia what kind of signs and symptoms might they uh have how would i recognize hyponatremia in the patient um so if you don't have enough sodium you think about sodium and fluid and how they kind of go together if you don't have enough you'll probably be dehydrated as well you your results in in some certain things so if you have less sodium you're going to have a a movement of fluid so when we think about this is dirt it's directly related to changes in fluid volume status right so sodium moves in the cell and potassium moves into the extracellular areas which results in intracellular edema so as you get this swelling you can get swelling inside your brain as well with hyponatremia and one of the big signs of that would be headache this apprehension anxiety anxiousness as the sodium continues to decrease and it gets lower and lower you'll start seeing confusion hallucinations seizure coma and potentially even death so that's why it's important for you to be able to recognize when the lab is too high or too low it's not your job to fix it you'll let the provider know but you're the one who recognizes certain things and it's important that you understand you know if you see this lab value what would you expect to see in the patient that's what we're trying to get you to understand all right hyper neutrinia it's just the opposite if it's over 145 that would be something that is problematic we know that as your sodium levels get too high it can be associated with uh higher mortality rates and it's not a very common um imbalance that we that we deal with a lot but when we do it's usually associated with water loss i like diarrhea something like that or you have too much sodium ingestion but that watery diarrhea if you lose all your water you get something called dilutional hypernatremia you might not have gained more sodium but now that you have less water in your system you have less volume the amount of of sodium compared to the amount of water becomes excessively high so these are things we have to worry about once again monitoring the vital signs lung sounds body weight things of that nature all right the next one we're going over here is hypokalemia this we're talking about potassium um make sure you know your lab values when we think about hypokalemia we're looking at something that's less than 3.5 that's typically where most labs fall in with hypokalemia it depends on where you work but for galen make sure you're using your galen lab values that are posted in canvas that always give you the best idea of where we're at but nclex is not going to get real close they're going to give you a pretty good difference you know you know 3 or 2.9 it's going to be pretty obvious that there's some kind of problem so think about patients who are at risk for developing um hypokalemia we think about people who are confused or restrained or malnourished because they're not getting the food they need um some people who are on lace like somebody who's on a diuretic if it's a potassium wasting diuretic uh that could cause you to have hypokalemia there's other medications that can be there as well so make sure you understand what some of the causes are and not just basic causes but understand why is it important it's important for you to understand the medications because we give medications to patients all the time so um if they're if they're taking steroids or digitalis or things of that nature this too could cause you to have hypokalemia lasix is probably the most common cause of hypokalemia because it is a potassium wasting diuretic and these patients who are on that medication will require supplements for sure but make sure that you understand there are combination medications out there as well i i think about things that treat blood pressure like hydro chlorothiazide that has a potassium wasting diuretic effect as well so you'd want to really kind of think about that if a patient is you know on that um make sure you're checking make sure you're checking your patient hypokalemia can also cause the cardiac problems right it can lead to respiratory failure it can cause hypoactive bowel sounds there's a lot of problems that are associated with low potassium levels so make sure when you're thinking about patient safety you might need to hold certain medications if your patient is already dizzy if they have to give them walk you might want to you know think about where you're at here because hypokalemia can cause a lot of different issues make sure you're checking the apical pulse rate and the depth of respirations because of the potential for cardiac and respiratory problems and before you ever give potassium we talked about this in lab when your patient has low potassium levels you're going to have to give them replacement and we typically get that via iv but before you ever give iv potassium you definitely want to check and make sure you have good vasculature access you never want to have iv potassium you know have an infiltrated iv and get into the surrounding tissue because it can cause serious damage to that tissue all right the other side would be hyperkalemia this is when it's typically above five um that that's what we're looking at here so make sure if you see patients who are you know higher than that your mind starts thinking about oh we have hyperkalemia going on [Music] patients with kidney failure are typically the ones we see in the hospital who have this problem more often than most others so hyperkalemia is definitely associated with renal failure um retention of potassium is why you know if you're not mixerating and your kidneys aren't working you're going to retain that so that is a problem also if you have some kind of trauma or you have an excessive intake of potassium this could also lead to hyperkalemia so make sure you're out there paying attention when it starts to creep up it's very problematic um they i if you're if your potassium level is less than 5.5 diuretics can be used to correct the imbalance so if it's just slightly high we can give a potassium wasting diuretic like lasix which is totally fine that would be the intended side effect of that medication but once it starts getting higher than that you know six six and above that is something you're gonna have to probably talk with your provider about to figure out what you're going to do so you can be a little more aggressive in the therapy maybe given ib solutions diuretics that way but you definitely want to make sure you contact the provider because if you don't it can lead to you know fatal dysrhythmias in your patient who has hyperkalemia uh we have uh calcium and magnesium be the next two when we think about calcium for me calcium is definitely associated with um your parathyroid gland so we'll kind of talk about that in a minute as well so hypocalcemia less than 4.5 you're just going to have to memorize lab values there's no easy way around it as long as you know the ballpark range you're probably going to be okay so we know with calcium um hypocalcemia usually includes insufficient intakes of calcium or vitamin d they go together one helps absorb the other so if you have a if you have a vitamin deficiency in either one um you know vitamin d could lead to hypocalcemia as well or people who have parathyroid disease and we'll kind of talk about that when we get the endocrine system as well we know that a lot of clients who don't really have issues but it just kind of depends on you know if they are mildly hypocalcemic not a real big issue you can just take more food eat oral calcium supplements with vitamin d supplements as well you need to take it with milk for that absorption so these are things like nclex and ati might kind of lead to more than than us but they do pop up on exams so something to think about when you are hypocalcemic you have this neuromuscular excitability your myocardial contractions are a lot less strong so you get less cardiac output and then severe muscle spasms i'm sure you've all heard of the vascular sign or i mean the monitoring for chovastic where you touch the side of the face on the muscle and it starts having a reaction or you can do the drazo sign where you put on the blood pressure cup and when you raise it above the normal blood pressure it will cause you to have your hand do some flexion so these are just things that we'll see more on ati and nclex i'm sure hypercalcemia can be problematic as well um this is typically if you have a client who has hyper parathyroidism uh it's just producing too much so greater than 5.5 what are we going to do about it think about patient education there's not a lot we can do as nurses but we do think about high calcium foods trying to avoid those try trying to avoid foods that will increase uric acid and things like that and you can see them listed here on the screen all right magnesium is just another one we think about magnesium could be hypo or hyper as well this is the beauty of any of our electrolytes they can be too high or too low or just right in the middle so hypomagnesium is less than the 1.5 it depends upon about milli equivalents or deciliters so it could be 1.5 million equivalents per liter or 1.8 milligrams per deciliter just depends on what they're talking about either way we know patients who are alcoholics or have heart disease diabetes things like that could have hypomagnesium why do we care so much because when you don't have enough magnesium it can cause you to have depression and confusion but it can cause seizures it also can just cause some very um bad gi upset nausea anorexia as well hyper magnesium is one of the ones that i worry about more than the hypo yes they're they're both bad don't get me wrong because i don't want them to have seizures but in my mind when i start thinking about hyperglyc hyper magnesium ism you know when it starts getting up high you know normal range is up to 2.5 but when it gets you know two to three times that probably two times that one and a half two times up to like four or so um in my mind these these patients um who have some kind of renal problem or excessive use of lace acids or laxatives they can have some issues or potassium sparing diuretics that kind of save too much the problem with this is muscle weakness and it's not just muscle weakness like in your arms the muscle weakness in your in your respiratory efforts as well as in your myocardial tissue so these patients are often very sleepy they have they're just kind of drowsy they have a very weak pulse bradycardic that's a problem when we think about hyper magnesium so make sure you understand if you saw a patient who had a certain level of these electrolytes your job is to understand that it's just that this is the problem and this is what i have to worry about [Music] all right um acid-base imbalances this is one i did a whole lecture on so please go back and um watch the other lecture that i gave it's in your supplemental stuff um it just says mr strebs acid base imbalance and it goes through how to determine if you're in acidosis versus alkalosis and if it's metabolic versus respiratory and then compensated versus uncompensated so i'm not going to do that here but this is just the basics when you think about the acid-base balance we're talking about a ph which is your astral the acid base if you will in your blood a normal ph is 7.35 to 7.45 the lower that number goes the more acidic it is the higher that number goes the more alkalinity it is acidosis occurs when we're less than 7.35 alkalosis above 7.45 so we already know this um what i want you to remember is that when we think about acids i always think about carbon dioxide carbon dioxide is the acid that we're really talking about with these chemical buffers and that's associated with respiratory so when we're thinking about um these patients think of respiratory co2 and then we'll talk about bicarb as well on the next slide i'm kind of we're talking about here though so anytime that your co2 levels start to increase that is going to drop the ph balance and make it more acidic so it's going to be up to you to understand that um when you when you look at a co2 level the normal level is 35 to 45 the higher your co2 levels go up the more acidic they become because it is an acid the lower they go the more alkalitic it is so it just it's it's less it's not more alkalinic or less alkalinic co2 is acid regardless but the more acid you get there above 45 the more acidic your body is more likely to be so but we think about breathing the the the less you breathe um if you have a obstructed airway that's going to help you retain or make you retain co2 so like our copd patients and stuff are going to have a lot of acid buildup their co2 levels are high and that puts them in respiratory acidosis bicarb is something that the kidneys use so metabolic or renal component when we look at the abg's the bicarb or hco3 is usually 22-26 whatever the book says whatever galen's lab values are that's fine it's always going to be in that range somewhere each each book has a different range but when we think about what this means as your bicarb goes up it will increase the ph level making it more alkalitic as the bipart goes down it will it will decrease your beat your ph making it more acidic so it's kind of it's different than respiratory one of the biggest things that i think help more than anything else is when we talk about um when we talk about this is i think about rome rome is rome is something that we are going to talk about um meaning respiratory opposite metabolic equal and what that means to you is if you're if your um co2 level goes up your ph will go down respiratory opposite if your co2 level goes down your ph will go up respiratory opposite metabolic is equal if your bicarb goes up your ph goes up if your bicarb goes down your ph goes down so think about rome respiratory opposite metabolic equal it'll help you as you kind of go through all right give me one second all right there are four types of main imbalances respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis you are going to have to determine what your patient is in based on laboratory findings when you think about respiratory acidosis this results when you have a decrease in your ph so you have too much acid in the body um it's typical to see respiratory acid doses in a patient who has respiratory depression so if you just came back from like surgery and you had anesthesia on board and it caused you to breathe less the less you breathe the less co2 you breathe out that means you're retaining co2 airway obstruction reduce alveolar um capacity right so if you have fluid in the lungs you know you have heart failure you have a patient with copd these are all going to lend themselves to be in respiratory acidosis because you cannot get enough air in to replace the co2 in the alveoli on the hemoglobin so it's going to lead to more respiratory acidosis if you look on the bottom here this is a prime example of what a ph i'm sorry an abg would look like for somebody respiratory acidosis you're going to have a low ph meaning less than 7.35 and you're going to have a pco2 or carbon dioxide level above 45. that means you have more acid in your body so it makes you more acidic that's how you're going to tell if it's respiratory acidosis or not when you think about somebody respiratory acidosis um it's very likely they might have hyperkalemia meaning it's too high so your patient might have signs and symptoms of um you know we we a weak decreased pulse right because we already said when when you start thinking about hyperkalemia we worry about some some weakness in and some dysrhythmias that might occur as well like i said just make sure you're looking at your patient make sure you're thinking about their vital signs if your patient's not breathing adequately enough because they're a little depressed or they're asleep or they're unconscious or whatever the case may be if they're not breathing in adequate enough respirations they're going to retain co2 which is going to lead to respiratory acidosis a patient with respiratory alkalosis this is somebody who's probably breathing too fast so if you are having um you know you're hyperventilating because you're having a panic attack or something like that and you're breathing out all your co2 too fast as the co2 levels go down your ph will go up so on the patient rush for alkalosis you would see a ph of higher than 7.45 meaning alkalitic and you would see a co2 level less than 35 meaning there's less acid in the body a metabolic acidosis is something that's caused as you lose too much of your base so when i think about metabolic acidosis it's an excess fluid body a body fluid loss typically if you had diarrhea think about acidosis coming out of your rectum on the bottom part so anytime you have diarrhea think about your metabolic acidosis right acidosis is associated with diarrhea or that loss of fluid from the gi tract you can kind of see some of the other things going on here a patient who is in renal failure right who can't who can't uh who has the inability to pee this also could you know cause your patient to have um metabolic acidosis we have to worry about that as well renal failure lends itself to metabolic acidosis as well make sure you're able to identify what that looks like and what the causes may be metabolic alkalosis is the last one we talk about and this is when you have too much acid loss if you think about what causes this i think about a patient who is vomiting excess vomiting if you're throwing up the acid in your stomach that acid leaves your body so it leaves too much of a base so this is one where um the patient that's that's usually what i look at what i think about is this patient here why does this matter metabolic alkalosis can cause weakness of the muscles right so if i'm thinking about these patients i i just kind of curious about what what go wrong with my patient so nursing management monitoring for that acid-base imbalance like irritability muscle weakness muscle twitching muscle cramps muscle spasms these are patients who have a lot of muscle weakness itself [Music] all right so make sure as you're going through your studies for unit 4 you a memorize what the lab values are make sure you know that range and then understand some conditions that might lend themselves to this imbalance and then be able to identify on your abg's what your patient is presenting with what some of the likely causes might be as well that's all i have i hope you have a great day