NR 324 Week 1 EDAPT_Altered Fluid and Electrolyte Balance and Altered Acid-Base Balance

• Fluid volume imbalances = electrolyte abnormalities which cause: o Altered LOC o Confusion o Seizures o Others… • Nursing Interventions: o Monitor LOC- imbalance can cause seizures o Monitor vital signs, labs, s&s o Take seizure precautions- protect client from further injury related to seizure o Admin anti seizure meds prn Cardiovascular Effects: • Heart failure and arrhythmias can reduce the cardiac output of the heart. When this occurs, fluid can back up into the lungs and peripheral circulation. • Nursing Interventions: o Monitor bp, HR, CO- helps to determine if pt has volume loss or overload complications o Check 12 lead ECG- determine if there are dysrhythmias present & poss electrolyte imbalance o Check B-type natriuretic peptide (BNP) levels- det. If pt is developing heart failure o Admin diuretics & monitor electrolytes before, during, & after admin o Admin IV fluids if blood/ fluid is lost from intravascular compart- fluid restores volume in the intravascular compart. & expands remaining blood volume Vascular Effects: • Vascular system can move fluid into interstitial area causing EDEMA • Monitoring & treating edema helps restore fluid balance • Nursing Interventions: o Assess pitting & non pitting edema o Assess extremity using 6 P’s ▪ pulselessness, pain, poikilothermic, paresthesia, paralysis, & pallor ▪ this assesses for peripheral circulation o Elevate extremity w/ 2 + pillows – reduces fluid volume in extremity o Apply anti embolic stockings & sequential compression devices- improves circulation o Admin diuretics prn- helps get rid of excess fluid volume Edema • Protein (albumin) in the ICF & ECF compartments create oncotic pressure in tissue to keep water inside the vascular system o Shift in albumin = fluid shift from vascular to interstitial fluid compart • Assess “third spacing” by measuring pitting edema • TX for edema= diuretics, stockings, elevation above heart, lower sodium in diet • TX for edema for client w/ renal insufficiency= ACE inhibitor or temp. dialysis • Monitor kidney function w/ treatment (BUN & creatinine levels are CRITICAL) o 0+ -- No pitting edema o 1+ -- Mild pitting edema (depression disappears) o 2+ -- Moderate pitting edema (depression disappears 10-15 sec) o 3+ -- Moderately severe pitting edema (depression last longer than 1 min) o 4+ -- Severe pitting edema (depression last longer than 2 min) IV Fluid Types: • isotonic solutions- equal concentration on both sides of cell membrane, raise intravascular volume w/out changing electrolyte concentrations o Used for extreme fluid loss (trauma, burns, dehydration) o 0.9% NaCl and Lactated Ringer’s. o Too much isotonic= heart or respiratory failure • hypotonic solutions- expand intravascular volume o Used for dehydration due to diabetic ketoacidosis & DI o Use caution when administering to pt’s @ risk of developing cerebral edema (head injury pt) o 0.45% NaCl, can cause rehydration of a dehydrated cell o Too much hypotonic= cerebral edema • hypertonic solutions- when ECF has more solutes than fluid in cells, water flows out of cells o 3% NaCl, D5 LR & D5 0.9% NaCl, can