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Fluid, Electrolyte and Fluid, Electrolyte and Acid-Base BalanceAcid-Base Balance
ByBy
M,ABD ELMOTAALM,ABD ELMOTAAL
Fluid BalanceFluid Balance
General ConceptsGeneral Concepts Intake = Output = Fluid BalanceIntake = Output = Fluid Balance Sensible lossesSensible losses
UrinationUrination DefecationDefecation Wound drainageWound drainage
Insensible lossesInsensible losses Evaporation from skinEvaporation from skin Respiratory loss from lungsRespiratory loss from lungs
Fluid CompartmentsFluid Compartments
Intracellular Intracellular 40% of body weight40% of body weight
ExtracellularExtracellular 20% of body weight20% of body weight Two typesTwo types
INTERSTITIALINTERSTITIAL (between) (between) INTRAVASCULARINTRAVASCULAR (inside) (inside)
Age-Related Fluid ChangesAge-Related Fluid Changes
Full-term baby - 80%Full-term baby - 80% Lean Adult Male - 60%Lean Adult Male - 60% Aged client - 40%Aged client - 40%
Fluid and Electrolyte TransportFluid and Electrolyte Transport
PASSIVE PASSIVE TRANSPORT TRANSPORT SYSTEMSSYSTEMS DiffusionDiffusion FiltrationFiltration OsmosisOsmosis
ACTIVE ACTIVE TRANSPORT TRANSPORT SYSTEMSYSTEM PumpingPumping Requires Requires
energy energy expenditureexpenditure
DiffusionDiffusion Molecules move across a biological Molecules move across a biological
membrane from an area of higher membrane from an area of higher to an area of lower concentrationto an area of lower concentration
Membrane typesMembrane types PermeablePermeable Semi-permeableSemi-permeable ImpermeableImpermeable
FiltrationFiltration Movement of solute and solvent Movement of solute and solvent
across a membrane caused by across a membrane caused by hydrostatic (water pushing) pressurehydrostatic (water pushing) pressure
Occurs at the capillary levelOccurs at the capillary level If normal pressure gradient changes If normal pressure gradient changes
(as occurs with right-sided heart (as occurs with right-sided heart failure) edema results from “third failure) edema results from “third spacing”spacing”
OsmosisOsmosis
Movement of solvent from an area Movement of solvent from an area of lower solute concentration to of lower solute concentration to one of higher concentrationone of higher concentration
Occurs through a semipermeable Occurs through a semipermeable membrane using osmotic (water membrane using osmotic (water pulling) pressurepulling) pressure
Active Transport SystemActive Transport System
Solutes can be moved against a Solutes can be moved against a
concentration gradientconcentration gradient Also called “pumping”Also called “pumping” Dependent on the presence of ATPDependent on the presence of ATP
Fluid TypesFluid Types
IsotonicIsotonic
HypotonicHypotonic
HypertonicHypertonic
Isotonic SolutionIsotonic Solution
No fluid shift because solutions No fluid shift because solutions
are equally concentratedare equally concentrated Normal saline solution (0.9% NaCl)Normal saline solution (0.9% NaCl)
Hypotonic SolutionHypotonic Solution
Lower solute concentrationLower solute concentration Fluid shifts from hypotonic solution Fluid shifts from hypotonic solution
into the more concentrated into the more concentrated
solution to create a balance (cells solution to create a balance (cells
swell)swell) Half-normal saline solution (0.45% Half-normal saline solution (0.45%
NaCl)NaCl)
Hypertonic SolutionHypertonic Solution
Higher solute concentrationHigher solute concentration
Fluid is drawn into the hypertonic Fluid is drawn into the hypertonic
solution to create a balance (cells solution to create a balance (cells
shrink)shrink)
5% dextrose in normal saline 5% dextrose in normal saline
(D5/0.9% NaCl)(D5/0.9% NaCl)
Regulatory MechanismsRegulatory Mechanisms
Baroreceptor reflexBaroreceptor reflex
Volume receptorsVolume receptors
Renin-angiotensin-aldosterone Renin-angiotensin-aldosterone
mechanismmechanism
Antidiuretic hormoneAntidiuretic hormone
Baroreceptor ReflexBaroreceptor Reflex
Respond to a fall in arterial blood Respond to a fall in arterial blood pressurepressure
Located in the atrial walls, vena Located in the atrial walls, vena cava, aortic arch and carotid sinuscava, aortic arch and carotid sinus
Constricts afferent arterioles of the Constricts afferent arterioles of the kidney resulting in retention of fluidkidney resulting in retention of fluid
Volume ReceptorsVolume Receptors
Respond to fluid excess in the atria Respond to fluid excess in the atria and great vesselsand great vessels
Stimulation of these receptors Stimulation of these receptors creates a strong renal response creates a strong renal response that increases urine outputthat increases urine output
Renin-Angiotensin-AldosteroneRenin-Angiotensin-Aldosterone
ReninRenin Enzyme secreted by kidneys when Enzyme secreted by kidneys when
arterial pressure or volume dropsarterial pressure or volume drops Interacts with angiotensinogen to Interacts with angiotensinogen to
form angiotensin I form angiotensin I (vasoconstrictor)(vasoconstrictor)
Renin-Angiotensin-AldosteroneRenin-Angiotensin-Aldosterone
AngiotensinAngiotensin Angiotensin I is converted in Angiotensin I is converted in
lungs to angiotensin II using ACE lungs to angiotensin II using ACE (angiotensin converting enzyme)(angiotensin converting enzyme)
Produces vasoconstriction to Produces vasoconstriction to elevate blood pressureelevate blood pressure
Stimulates adrenal cortex to Stimulates adrenal cortex to secrete aldosteronesecrete aldosterone
Renin-Angiotensin-AldosteroneRenin-Angiotensin-Aldosterone
AldosteroneAldosterone Mineralocorticoid that controls Na+ Mineralocorticoid that controls Na+
and K+ blood levelsand K+ blood levels Increases Cl- and HCO3- Increases Cl- and HCO3-
concentrations and fluid volumeconcentrations and fluid volume
Aldosterone Negative Feedback Aldosterone Negative Feedback MechanismMechanism
ECF & Na+ levels drop ECF & Na+ levels drop secretion secretion
of ACTH by the anterior pituitary of ACTH by the anterior pituitary
release of aldosterone by the release of aldosterone by the
adrenal cortex adrenal cortex fluid and Na+ fluid and Na+
retentionretention
Antidiuretic HormoneAntidiuretic Hormone
Also called vasopressinAlso called vasopressin Released by posterior pituitary when Released by posterior pituitary when
there is a need to restore intravascular there is a need to restore intravascular fluid volume fluid volume
Release is triggered by osmoreceptors Release is triggered by osmoreceptors in the thirst center of the hypothalamusin the thirst center of the hypothalamus
Fluid volume excess Fluid volume excess decreased ADH decreased ADH Fluid volume deficit Fluid volume deficit increased ADH increased ADH
Fluid ImbalancesFluid Imbalances
DehydrationDehydration HypovolemiaHypovolemia HypervolemiaHypervolemia Water intoxicationWater intoxication
DehydrationDehydration
Loss of body fluids Loss of body fluids increased increased concentration of solutes in the concentration of solutes in the blood and a rise in serum Na+ blood and a rise in serum Na+ levelslevels
Fluid shifts out of cells into the Fluid shifts out of cells into the blood to restore balanceblood to restore balance
Cells shrink from fluid loss and can Cells shrink from fluid loss and can no longer function properlyno longer function properly
Clients at RiskClients at Risk
ConfusedConfused ComatoseComatose BedriddenBedridden InfantsInfants ElderlyElderly Enterally fedEnterally fed
What Do You See?What Do You See?
IrritabilityIrritability ConfusionConfusion DizzinessDizziness WeaknessWeakness Extreme thirstExtreme thirst urine outputurine output
FeverFever Dry Dry
skin/mucous skin/mucous membranesmembranes
Sunken eyesSunken eyes Poor skin turgorPoor skin turgor TachycardiaTachycardia
What Do We Do?What Do We Do?
Fluid Replacement - oral or IV over Fluid Replacement - oral or IV over 48 hrs.48 hrs.
Monitor symptoms and vital signsMonitor symptoms and vital signs Maintain I&OMaintain I&O Maintain IV accessMaintain IV access Daily weightsDaily weights Skin and mouth careSkin and mouth care
HypovolemiaHypovolemia
Isotonic fluid Isotonic fluid loss from the loss from the extracellular extracellular spacespace
Can progress to Can progress to hypovolemic hypovolemic shockshock
Caused by:Caused by: Excessive Excessive
fluid loss fluid loss (hemorrhage)(hemorrhage)
Decreased Decreased fluid intakefluid intake
Third space Third space fluid shiftingfluid shifting
What Do You See?What Do You See?
Mental status Mental status deteriorationdeterioration
ThirstThirst TachycardiaTachycardia Delayed Delayed
capillary refillcapillary refill
Orthostatic Orthostatic hypotensionhypotension
Urine output < Urine output < 30 ml/hr30 ml/hr
Cool, pale Cool, pale extremitiesextremities
Weight lossWeight loss
What Do We Do?What Do We Do?
Fluid Fluid replacementreplacement
Albumin Albumin replacementreplacement
Blood Blood transfusions for transfusions for hemorrhagehemorrhage
Dopamine to Dopamine to maintain BPmaintain BP
MAST trousers MAST trousers for severe for severe shockshock
Assess for fluid Assess for fluid overload with overload with treatmenttreatment
HypervolemiaHypervolemia
Excess fluid in the extracellular Excess fluid in the extracellular compartment as a result of fluid or compartment as a result of fluid or sodium retention, excessive intake, sodium retention, excessive intake, or renal failureor renal failure
Occurs when compensatory Occurs when compensatory mechanisms fail to restore fluid mechanisms fail to restore fluid balancebalance
Leads to CHF and pulmonary edemaLeads to CHF and pulmonary edema
What Do You See?What Do You See?
TachypneaTachypnea DyspneaDyspnea CracklesCrackles Rapid, bounding Rapid, bounding
pulsepulse HypertensionHypertension S3 gallopS3 gallop
Increased CVP, Increased CVP, pulmonary artery pulmonary artery pressure and pressure and pulmonary artery pulmonary artery wedge pressure wedge pressure (Swan-Ganz)(Swan-Ganz)
JVDJVD Acute weight gainAcute weight gain EdemaEdema
EdemaEdema
Fluid is forced into tissues by the Fluid is forced into tissues by the hydrostatic pressurehydrostatic pressure
First seen in dependent areasFirst seen in dependent areas Anasarca - severe generalized edemaAnasarca - severe generalized edema Pitting edemaPitting edema Pulmonary edemaPulmonary edema
What Do We Do?What Do We Do?
Fluid and Na+ Fluid and Na+ restrictionrestriction
DiureticsDiuretics Monitor vital signsMonitor vital signs Hourly I&OHourly I&O Breath soundsBreath sounds
Monitor ABGs and Monitor ABGs and labslabs
Elevate HOB and Elevate HOB and give O2 as orderedgive O2 as ordered
Maintain IV accessMaintain IV access Skin & mouth careSkin & mouth care Daily weightsDaily weights
Water IntoxicationWater Intoxication
Hypotonic Hypotonic extracellular extracellular fluid shifts into fluid shifts into cells to attempt cells to attempt to restore to restore balancebalance
Cells swellCells swell
Causes:Causes: SIADHSIADH Rapid infusion of Rapid infusion of
hypotonic solutionhypotonic solution Excessive tap Excessive tap
water NG irrigation water NG irrigation or enemasor enemas
Psychogenic Psychogenic polydipsiapolydipsia
What Do You See?What Do You See?
Signs and symptoms of increased Signs and symptoms of increased
intracranial pressureintracranial pressure Early: change in LOC, N/V, muscle Early: change in LOC, N/V, muscle
weakness, twitching, crampingweakness, twitching, cramping
Late: bradycardia, widened pulse Late: bradycardia, widened pulse
pressure, seizures, comapressure, seizures, coma
What Do We Do?What Do We Do?
Prevention is the Prevention is the
best treatmentbest treatment Assess neuro Assess neuro
statusstatus Monitor I&O and Monitor I&O and
vital signsvital signs Fluid restrictionsFluid restrictions
IV accessIV access
Daily weightsDaily weights
Monitor serum Na+Monitor serum Na+
Seizure Seizure
precautionsprecautions
ElectrolytesElectrolytes
ElectrolytesElectrolytes
Charged particles in solutionCharged particles in solution Cations (+)Cations (+) Anions (-)Anions (-) Integral part of metabolic and Integral part of metabolic and
cellular processescellular processes
Positive or Negative?Positive or Negative?
Cations (+)Cations (+) SodiumSodium PotassiumPotassium CalciumCalcium MagnesiumMagnesium
Anions (-)Anions (-) ChlorideChloride BicarbonateBicarbonate PhosphatePhosphate SulfateSulfate
Major CationsMajor Cations
EXTRACELLULAR EXTRACELLULAR SODIUM (Na+)SODIUM (Na+)
INTRACELLULARINTRACELLULAR POTASSIUM POTASSIUM
(K+)(K+)
Electrolyte ImbalancesElectrolyte Imbalances
Hyponatremia/ Hyponatremia/
hypernatremiahypernatremia
Hypokalemia/ Hypokalemia/
HyperkalemiaHyperkalemia
Hypomagnesemia/ Hypomagnesemia/
HypermagnesemiaHypermagnesemia
Hypocalcemia/ Hypocalcemia/
HypercalcemiaHypercalcemia
Hypophosphatemia/ Hypophosphatemia/
HyperphosphatemiaHyperphosphatemia
Hypochloremia/ Hypochloremia/
HyperchloremiaHyperchloremia
SodiumSodium
Major extracellular cationMajor extracellular cation
Attracts fluid and helps preserve fluid Attracts fluid and helps preserve fluid
volumevolume
Combines with chloride and bicarbonate to Combines with chloride and bicarbonate to
help regulate acid-base balancehelp regulate acid-base balance
Normal range of serum sodium 135 - 145 Normal range of serum sodium 135 - 145
mEq/LmEq/L
Sodium and WaterSodium and Water
If sodium intake suddenly increases, If sodium intake suddenly increases, extracellular fluid concentration also extracellular fluid concentration also risesrises
Increased serum Na+ increases thirst Increased serum Na+ increases thirst and the release of ADH, which and the release of ADH, which triggers kidneys to retain watertriggers kidneys to retain water
Aldosterone also has a function in Aldosterone also has a function in water and sodium conservation when water and sodium conservation when serum Na+ levels are lowserum Na+ levels are low
Sodium-Potassium PumpSodium-Potassium Pump
Sodium (abundant Sodium (abundant outside cells) tries to outside cells) tries to get into cellsget into cells
Potassium (abundant Potassium (abundant inside cells) tries to inside cells) tries to get out of cellsget out of cells
Sodium-potassium Sodium-potassium pump maintains pump maintains normal normal concentrationsconcentrations
Pump uses ATP, Pump uses ATP, magnesium and an magnesium and an enzyme to maintain enzyme to maintain sodium-potassium sodium-potassium concentrationsconcentrations
Pump prevents cell Pump prevents cell swelling and swelling and creates an creates an electrical charge electrical charge allowing allowing neuromuscular neuromuscular impulse impulse transmissiontransmission
HyponatremiaHyponatremia Serum Na+ level < 135 mEq/LSerum Na+ level < 135 mEq/L Deficiency in Na+ related to amount of Deficiency in Na+ related to amount of
body fluidbody fluid Several typesSeveral types
DilutionalDilutional DepletionalDepletional HypovolemicHypovolemic HypervolemicHypervolemic IsovolemicIsovolemic
Types of HyponatremiaTypes of Hyponatremia Dilutional - results from Na+ loss, water Dilutional - results from Na+ loss, water
gaingain Depletional - insufficient Na+ intakeDepletional - insufficient Na+ intake Hypovolemic - Na+ loss is greater than Hypovolemic - Na+ loss is greater than
water loss; can be renal (diuretic use) water loss; can be renal (diuretic use) or non-renal (vomiting)or non-renal (vomiting)
Hypervolemic - water gain is greater Hypervolemic - water gain is greater than Na+ gain; edema occursthan Na+ gain; edema occurs
Isovolumic - normal Na+ level, too Isovolumic - normal Na+ level, too much fluidmuch fluid
What Do You See?What Do You See? Primarily neurologic symptomsPrimarily neurologic symptoms
Headache, N/V, muscle twitching, Headache, N/V, muscle twitching, altered mental status, stupor, altered mental status, stupor, seizures, comaseizures, coma
Hypovolemia - poor skin turgor, Hypovolemia - poor skin turgor, tachycardia, decreased BP, tachycardia, decreased BP, orthostatic hypotensionorthostatic hypotension
Hypervolemia - edema, hypertension, Hypervolemia - edema, hypertension, weight gain, bounding tachycardiaweight gain, bounding tachycardia
What Do We Do?What Do We Do?
MILD CASEMILD CASE Restrict fluid intake Restrict fluid intake
for for hyper/isovolemic hyper/isovolemic hyponatremiahyponatremia
IV fluids and/or IV fluids and/or increased po Na+ increased po Na+ intake for intake for hypovolemic hypovolemic hyponatremiahyponatremia
SEVERE CASESEVERE CASE Infuse hypertonic Infuse hypertonic
NaCl solution (3% NaCl solution (3% or 5% NaCl)or 5% NaCl)
Furosemide to Furosemide to remove excess fluidremove excess fluid
Monitor client in Monitor client in ICUICU
HypernatremiaHypernatremia
Excess Na+ relative to body waterExcess Na+ relative to body water Occurs less often than hyponatremiaOccurs less often than hyponatremia Thirst is the body’s main defenseThirst is the body’s main defense When hypernatremia occurs, fluid shifts When hypernatremia occurs, fluid shifts
outside the cellsoutside the cells May be caused by water deficit or over-May be caused by water deficit or over-
ingestion of Na+ingestion of Na+ Also may result from diabetes insipidusAlso may result from diabetes insipidus
What Do You See?What Do You See?
Think Think S-A-L-TS-A-L-T SSkin flushedkin flushed AAgitationgitation LLow grade feverow grade fever TThirsthirst
Neurological symptomsNeurological symptoms Signs of hypovolemiaSigns of hypovolemia
What Do We Do?What Do We Do?
Correct underlying Correct underlying disorderdisorder
Gradual fluid Gradual fluid replacementreplacement
Monitor for s/s of Monitor for s/s of cerebral edemacerebral edema
Monitor serum Na+ Monitor serum Na+ levellevel
Seizure Seizure precautionsprecautions
PotassiumPotassium
Major intracellular cationMajor intracellular cation Untreated changes in K+ levels can Untreated changes in K+ levels can
lead to serious neuromuscular and lead to serious neuromuscular and
cardiac problemscardiac problems Normal K+ levels = 3.5 - 5 mEq/LNormal K+ levels = 3.5 - 5 mEq/L
Balancing PotassiumBalancing Potassium
Most K+ ingested is excreted by the Most K+ ingested is excreted by the kidneyskidneys
Three other influential factors in K+ Three other influential factors in K+ balance :balance : Na+/K+ pumpNa+/K+ pump Renal regulationRenal regulation pH levelpH level
Sodium/Potassium PumpSodium/Potassium Pump
Uses ATP to pump potassium into Uses ATP to pump potassium into cellscells
Pumps sodium out of cellsPumps sodium out of cells Creates a balanceCreates a balance
Renal RegulationRenal Regulation
Increased K+ levels Increased K+ levels increased K+ increased K+ loss in urineloss in urine
Aldosterone secretion causes Na+ Aldosterone secretion causes Na+ reabsorption and K+ excretionreabsorption and K+ excretion
pHpH
Potassium ions and hydrogen ions Potassium ions and hydrogen ions exchange freely across cell exchange freely across cell membranesmembranes
Acidosis Acidosis hyperkalemia (K+ moves hyperkalemia (K+ moves out of cells)out of cells)
Alkalosis Alkalosis hypokalemia (K+ moves hypokalemia (K+ moves into cells)into cells)
HypokalemiaHypokalemia
Serum K+ < 3.5 mEq/LSerum K+ < 3.5 mEq/L Can be caused by GI losses, diarrhea, Can be caused by GI losses, diarrhea,
insufficient intake, non-K+ sparing insufficient intake, non-K+ sparing
diuretics (thiazide, furosemide)diuretics (thiazide, furosemide)
What Do You See?What Do You See?
Think Think S-U-C-T-I-O-NS-U-C-T-I-O-N SSkeletal muscle weaknesskeletal muscle weakness UU wave (EKG changes) wave (EKG changes) CConstipation, ileusonstipation, ileus TToxicity of digitalis glycosidesoxicity of digitalis glycosides IIrregular, weak pulserregular, weak pulse OOrthostatic hypotensionrthostatic hypotension NNumbness (paresthesias)umbness (paresthesias)
What Do We Do?What Do We Do?
Increase dietary K+Increase dietary K+ Oral KCl supplementsOral KCl supplements IV K+ replacement( infusion)IV K+ replacement( infusion) Change to K+-sparing diureticChange to K+-sparing diuretic Monitor EKG changesMonitor EKG changes
IV K+ ReplacementIV K+ Replacement Mix well when Mix well when
adding to an IV adding to an IV solution bagsolution bag
Concentrations Concentrations should not should not exceed 40-60 exceed 40-60 mEq/LmEq/L
Rates usually Rates usually 10-20 mEq/hr10-20 mEq/hr
NEVER GIVE IV NEVER GIVE IV PUSH PUSH
POTASSIUMPOTASSIUM
HyperkalemiaHyperkalemia
Serum K+ > 5 Serum K+ > 5
mEq/LmEq/L
Less common than Less common than
hypokalemiahypokalemia
Caused by altered Caused by altered
kidney function, kidney function,
increased intake increased intake
(salt substitutes), (salt substitutes),
blood transfusions, blood transfusions,
meds (K+-sparing meds (K+-sparing
diuretics), cell diuretics), cell
death (trauma)death (trauma)
What Do You See?What Do You See? IrritabilityIrritability ParesthesiaParesthesia Muscle weakness (especially legs)Muscle weakness (especially legs) EKG changes (tented T wave)EKG changes (tented T wave) Irregular pulseIrregular pulse HypotensionHypotension Nausea, abdominal cramps, diarrheaNausea, abdominal cramps, diarrhea
What Do We Do?What Do We Do?
MildMild Loop diuretics Loop diuretics
(Lasix)(Lasix) Dietary restrictionDietary restriction
ModerateModerate KayexalateKayexalate
EmergencyEmergency 10% calcium 10% calcium
gluconate for gluconate for
cardiac effectscardiac effects Sodium bicarbonate Sodium bicarbonate
for acidosisfor acidosis
CalciumCalcium
99% in bones, 1% in serum and soft 99% in bones, 1% in serum and soft tissue (measured by serum Ca++)tissue (measured by serum Ca++)
Works with phosphorus to form bones Works with phosphorus to form bones and teethand teeth
Role in cell membrane permeabilityRole in cell membrane permeability Affects cardiac muscle contractionAffects cardiac muscle contraction Participates in blood clottingParticipates in blood clotting
Calcium RegulationCalcium Regulation Affected by body stores of Ca++ and Affected by body stores of Ca++ and
by dietary intake & Vitamin D intakeby dietary intake & Vitamin D intake Parathyroid hormone draws Ca++ Parathyroid hormone draws Ca++
from bones increasing low serum from bones increasing low serum levels levels (Parathyroid pulls)(Parathyroid pulls)
With high Ca++ levels, calcitonin is With high Ca++ levels, calcitonin is released by the thyroid to inhibit released by the thyroid to inhibit calcium loss from bone calcium loss from bone (Calcitonin (Calcitonin keeps)keeps)
HypocalcemiaHypocalcemia
Serum calcium < 8.9 mg/dlSerum calcium < 8.9 mg/dl Ionized calcium level < 4.5 mg/DlIonized calcium level < 4.5 mg/Dl Caused by inadequate intake, Caused by inadequate intake,
malabsorption, pancreatitis, thyroid malabsorption, pancreatitis, thyroid or parathyroid surgery, loop or parathyroid surgery, loop diuretics, low magnesium levelsdiuretics, low magnesium levels
What Do You See?What Do You See?
NeuromuscularNeuromuscular Anxiety, confusion, irritability, muscle Anxiety, confusion, irritability, muscle
twitching, paresthesias (mouth, twitching, paresthesias (mouth, fingers, toes), tetanyfingers, toes), tetany
FracturesFractures DiarrheaDiarrhea Diminished response to digoxinDiminished response to digoxin EKG changes EKG changes
What Do We Do?What Do We Do?
Calcium gluconate for postop thyroid Calcium gluconate for postop thyroid
or parathyroid clientor parathyroid client
Cardiac monitoringCardiac monitoring
Oral or IV calcium replacementOral or IV calcium replacement
HypercalcemiaHypercalcemia
Serum calcium > 10.1 mg/dlSerum calcium > 10.1 mg/dl Ionized calcium > 5.1 mg/dlIonized calcium > 5.1 mg/dl Two major causesTwo major causes
CancerCancer HyperparathyroidismHyperparathyroidism
What Do You See?What Do You See?
Fatigue, confusion, lethargy, comaFatigue, confusion, lethargy, coma Muscle weakness, hyporeflexiaMuscle weakness, hyporeflexia Bradycardia Bradycardia cardiac arrest cardiac arrest Anorexia, nausea/vomiting, Anorexia, nausea/vomiting,
decreased bowel sounds, decreased bowel sounds, constipationconstipation
Polyuria, renal calculi, renal failurePolyuria, renal calculi, renal failure
What Do We Do?What Do We Do?
If asymptomatic, treat underlying If asymptomatic, treat underlying
causecause Hydrate the patient to encourage Hydrate the patient to encourage
diuresisdiuresis Loop diureticsLoop diuretics CorticosteroidsCorticosteroids
PhosphorusPhosphorus
The primary anion in the intracellular The primary anion in the intracellular fluidfluid
Crucial to cell membrane integrity, Crucial to cell membrane integrity, muscle function, neurologic function and muscle function, neurologic function and metabolism of carbs, fats and proteinmetabolism of carbs, fats and protein
Functions in ATP formation, Functions in ATP formation, phagocytosis, platelet function and phagocytosis, platelet function and formation of bones and teethformation of bones and teeth
HypophosphatemiaHypophosphatemia
Serum phosphorus < 2.5 mg/dlSerum phosphorus < 2.5 mg/dl Can lead to organ system failureCan lead to organ system failure Caused by respiratory alkalosis Caused by respiratory alkalosis
(hyperventilation), insulin release, (hyperventilation), insulin release, malabsorption, diuretics, DKA, malabsorption, diuretics, DKA, elevated parathyroid hormone levels, elevated parathyroid hormone levels, extensive burnsextensive burns
What Do You See?What Do You See? MusculoskeletalMusculoskeletal
muscle weaknessmuscle weakness respiratory muscle respiratory muscle
failurefailure osteomalaciaosteomalacia pathological pathological
fracturesfractures CNSCNS
confusion, confusion, anxiety, seizures, anxiety, seizures, comacoma
CardiacCardiac hypotensionhypotension decreased cardiac decreased cardiac
outputoutput HematologicHematologic
hemolytic anemiahemolytic anemia easy bruisingeasy bruising infection riskinfection risk
What Do We Do?What Do We Do?
MILD/MODERATEMILD/MODERATE Dietary Dietary
interventionsinterventions
Oral supplementsOral supplements
SEVERESEVERE IV replacement IV replacement
using potassium using potassium
phosphate or phosphate or
sodium phosphatesodium phosphate
HyperphosphatemiaHyperphosphatemia
Serum phosphorus > 4.5 mg/dlSerum phosphorus > 4.5 mg/dl
Caused by impaired kidney function, Caused by impaired kidney function,
cell damage, hypoparathyroidism, cell damage, hypoparathyroidism,
respiratory acidosis, DKA, increased respiratory acidosis, DKA, increased
dietary intakedietary intake
What Do You See?What Do You See?
Think Think C-H-E-M-OC-H-E-M-O CCardiac irregularitiesardiac irregularities HHyperreflexiayperreflexia EEating poorlyating poorly MMuscle weaknessuscle weakness OOligurialiguria
What Do We Do?What Do We Do?
Low-phosphorus dietLow-phosphorus diet Decrease absorption with antacids Decrease absorption with antacids
that bind phosphorusthat bind phosphorus Treat underlying cause of Treat underlying cause of
respiratory acidosis or DKArespiratory acidosis or DKA IV saline for severe IV saline for severe
hyperphosphatemia in patients hyperphosphatemia in patients with good kidney functionwith good kidney function
Acid-Base BalanceAcid-Base Balance
Food Sources of Food Sources of PotassiumPotassium
Sweet Potatoes
Beet GreensBeet Greens
PotatoesPotatoes
White BeansWhite Beans
DatesDates
YogurtYogurt
TomatoesTomatoes
RaisinsRaisins
ClamsClams
AvocadosAvocados
Cocoa Powder and Cocoa Powder and ChocolateChocolate
Pistachios and Other Pistachios and Other NutsNuts
dietary‑magnesium‑sources.jpg
ancient-minerals.comancient-minerals.com- - Magnesium food Magnesium food sourcessources were once were once
commonlycommonly
SourcesSources of of MagnesiumMagnesium in in FoodFood: The Top 5: The Top 5
Acid-Base BasicsAcid-Base Basics
Balance depends on regulation of Balance depends on regulation of free hydrogen ionsfree hydrogen ions
Concentration of hydrogen ions is Concentration of hydrogen ions is measured in pHmeasured in pH
Arterial blood gases are the Arterial blood gases are the major diagnostic tool for major diagnostic tool for evaluating acid-base balanceevaluating acid-base balance
Arterial Blood GasesArterial Blood Gases
pHpH 7.35 - 7.457.35 - 7.45
PaCO2PaCO2 35 - 45 mmHg35 - 45 mmHg
HCO3HCO3 22-26 mEq/L22-26 mEq/L
AcidosisAcidosis
pH < 7.35pH < 7.35
Caused by accumulation of acids or Caused by accumulation of acids or by a loss of basesby a loss of bases
AlkalosisAlkalosis
pH > 7.45pH > 7.45
Occurs when bases accumulate or Occurs when bases accumulate or acids are lostacids are lost
Regulatory SystemsRegulatory Systems
Three systems come into play when Three systems come into play when pH rises or fallspH rises or falls
Chemical buffersChemical buffers Respiratory systemRespiratory system KidneysKidneys
Chemical BuffersChemical Buffers
Immediate actingImmediate acting
Combine with Combine with
offending acid or offending acid or
base to neutralize base to neutralize
harmful effects harmful effects
until another until another
system takes oversystem takes over
Bicarb buffer - Bicarb buffer - mainly responsible mainly responsible for buffering blood for buffering blood and interstitial fluidand interstitial fluid
Phosphate buffer - Phosphate buffer - effective in renal effective in renal tubulestubules
Protein buffers - Protein buffers - most plentiful - most plentiful - hemoglobinhemoglobin
Respiratory SystemRespiratory System Lungs regulate blood levels of CO2Lungs regulate blood levels of CO2 CO2 + H2O = Carbonic acidCO2 + H2O = Carbonic acid High CO2 = slower breathing (hold High CO2 = slower breathing (hold
on to carbonic acid and lower pH)on to carbonic acid and lower pH) Low CO2 = faster breathing (blow Low CO2 = faster breathing (blow
off carbonic acid and raise pH)off carbonic acid and raise pH) Twice as effective as chemical Twice as effective as chemical
buffers, but effects are temporarybuffers, but effects are temporary
KidneysKidneys
Reabsorb or Reabsorb or
excrete excess excrete excess
acids or bases acids or bases
into urineinto urine
Produce Produce
bicarbonatebicarbonate
Adjustments by Adjustments by
the kidneys take the kidneys take
hours to days to hours to days to
accomplishaccomplish Bicarbonate Bicarbonate
levels and pH levels and pH
levels increase or levels increase or
decrease togetherdecrease together
Arterial Blood Gases (ABG)Arterial Blood Gases (ABG)
Uses blood from an arterial punctureUses blood from an arterial puncture Three test results relate to acid-base Three test results relate to acid-base
balancebalance pHpH PaCO2PaCO2 HCO3HCO3
Interpreting ABGsInterpreting ABGs
Step 1 - check the pHStep 1 - check the pH Step 2 - What is the CO2?Step 2 - What is the CO2? Step 3 - Watch the bicarbStep 3 - Watch the bicarb Step 4 - Look for compensationStep 4 - Look for compensation Step 5 - What is the PaO2 and SaO2?Step 5 - What is the PaO2 and SaO2?
Step 1 - Check the pHStep 1 - Check the pH
pH < 7.35 = acidosispH < 7.35 = acidosis
pH > 7.45 = alkalosispH > 7.45 = alkalosis
Move on to Step 2Move on to Step 2
Step 2 - What is the CO2?Step 2 - What is the CO2?
PaCO2 gives info about the PaCO2 gives info about the respiratory component of acid-respiratory component of acid-base balancebase balance
If abnormal, does the change If abnormal, does the change correspond with change in pH?correspond with change in pH? High pH expects low PaCO2 High pH expects low PaCO2
(hypocapnia)(hypocapnia) Low pH expects high PaCO2 Low pH expects high PaCO2
(hypercapnia)(hypercapnia)
Step 3 – Watch the BicarbStep 3 – Watch the Bicarb
Provides info regarding metabolic Provides info regarding metabolic
aspect of acid-base balanceaspect of acid-base balance If pH is high, bicarb expected to be If pH is high, bicarb expected to be
high (metabolic alkalosis)high (metabolic alkalosis) If pH is low, bicarb expected to be If pH is low, bicarb expected to be
low (metabolic acidosis)low (metabolic acidosis)
Step 4 – Look for CompensationStep 4 – Look for Compensation
If a change is seen in If a change is seen in BOTHBOTH PaCO2 PaCO2 andand bicarbonate, the body is trying bicarbonate, the body is trying to compensateto compensate
Compensation occurs as opposites, Compensation occurs as opposites, (Example: for metabolic acidosis, (Example: for metabolic acidosis, compensation shows respiratory compensation shows respiratory alkalosis)alkalosis)
Step 5 – What is the PaO2 and Step 5 – What is the PaO2 and SaO2SaO2
PaO2 reflects ability to pickup O2 PaO2 reflects ability to pickup O2
from lungsfrom lungs
SaO2 less than 95% is inadequate SaO2 less than 95% is inadequate
oxygenationoxygenation
Low PaO2 indicates hypoxemiaLow PaO2 indicates hypoxemia
Acid-Base ImbalancesAcid-Base Imbalances
Respiratory AcidosisRespiratory Acidosis
Respiratory AlkalosisRespiratory Alkalosis
Metabolic AcidosisMetabolic Acidosis
Metabolic AlkalosisMetabolic Alkalosis
Respiratory AcidosisRespiratory Acidosis
Any compromise in breathing can Any compromise in breathing can result in respiratory acidosisresult in respiratory acidosis
Hypoventilation Hypoventilation carbon dioxide carbon dioxide buildup and drop in pHbuildup and drop in pH
Can result from neuromuscular Can result from neuromuscular trouble, depression of the brain’s trouble, depression of the brain’s respiratory center, lung disease or respiratory center, lung disease or airway obstructionairway obstruction
ABG ResultsABG Results
UncompensatedUncompensated pH < 7.35pH < 7.35
PaCO2 >45PaCO2 >45
HCO3 NormalHCO3 Normal
CompensatedCompensated pH NormalpH Normal
PaCO2 >45PaCO2 >45
HCO3 > 26HCO3 > 26
What Do We Do?What Do We Do?
Correct underlying causeCorrect underlying cause BronchodilatorsBronchodilators Supplemental oxygenSupplemental oxygen Treat hyperkalemiaTreat hyperkalemia Antibiotics for infectionAntibiotics for infection Chest PT to remove secretionsChest PT to remove secretions Remove foreign body obstructionRemove foreign body obstruction
Respiratory AlkalosisRespiratory Alkalosis
Most commonly results from Most commonly results from hyperventilation caused by pain, hyperventilation caused by pain, salicylate poisoning, use of nicotine salicylate poisoning, use of nicotine or aminophylline, hypermetabolic or aminophylline, hypermetabolic states or acute hypoxia states or acute hypoxia (overstimulates the respiratory (overstimulates the respiratory center)center)
What Do You See?What Do You See?
Anxiety, restlessnessAnxiety, restlessness DiaphoresisDiaphoresis Dyspnea (Dyspnea ( rate and depth) rate and depth) EKG changesEKG changes Hyperreflexia, paresthesiasHyperreflexia, paresthesias TachycardiaTachycardia TetanyTetany
ABG ResultsABG Results
UncompensatedUncompensated pH > 7.45pH > 7.45
PaCO2 < 35PaCO2 < 35
HCO3 NormalHCO3 Normal
CompensatedCompensated pH NormalpH Normal
PaCO2 < 35PaCO2 < 35
HCO3 < 22HCO3 < 22
What Do We Do?What Do We Do?
Correct underlying disorderCorrect underlying disorder
Oxygen therapy for hypoxemiaOxygen therapy for hypoxemia
Sedatives or antianxiety agentsSedatives or antianxiety agents
Paper bag breathing for Paper bag breathing for
hyperventilationhyperventilation
Metabolic AcidosisMetabolic Acidosis Characterized by gain of acid or Characterized by gain of acid or
loss of bicarb loss of bicarb Associated with ketone bodiesAssociated with ketone bodies
Diabetes mellitus, alcoholism, Diabetes mellitus, alcoholism, starvation, hyperthyroidismstarvation, hyperthyroidism
Other causesOther causes Lactic acidosis secondary to shock, Lactic acidosis secondary to shock,
heart failure, pulmonary disease, heart failure, pulmonary disease, hepatic disease, seizures, strenuous hepatic disease, seizures, strenuous exerciseexercise
What Do You See?What Do You See?
Confusion, dull headacheConfusion, dull headache Decreased DTRsDecreased DTRs S/S hyperkalemia (abdominal S/S hyperkalemia (abdominal
cramps, diarrhea, muscle cramps, diarrhea, muscle weakness, EKG changes)weakness, EKG changes)
Hypotension, Kussmaul’s Hypotension, Kussmaul’s respirationsrespirations
Lethargy, warm & dry skinLethargy, warm & dry skin
ABG ResultsABG Results
UncompensatedUncompensated pH < 7.35pH < 7.35
PaCO2 NormalPaCO2 Normal
HCO3 < 22HCO3 < 22
CompensatedCompensated pH NormalpH Normal
PaCO2 < 35PaCO2 < 35
HCO3 < 22HCO3 < 22
What Do We Do?What Do We Do?
Regular insulin to reverse DKARegular insulin to reverse DKA
IV bicarb to correct acidosisIV bicarb to correct acidosis
Fluid replacementFluid replacement
Dialysis for drug toxicityDialysis for drug toxicity
AntidiarrhealsAntidiarrheals
Metabolic AlkalosisMetabolic Alkalosis
Commonly associated with Commonly associated with hypokalemia from diuretic use, hypokalemia from diuretic use, hypochloremia and hypocalcemiahypochloremia and hypocalcemia
Also caused by excessive vomiting, Also caused by excessive vomiting, NG suction, Cushing’s disease, NG suction, Cushing’s disease, kidney disease or drugs containing kidney disease or drugs containing baking sodabaking soda
What Do You See?What Do You See?
AnorexiaAnorexia ApathyApathy ConfusionConfusion CyanosisCyanosis HypotensionHypotension Loss of reflexesLoss of reflexes
Muscle twitchingMuscle twitching NauseaNausea ParesthesiaParesthesia PolyuriaPolyuria VomitingVomiting WeaknessWeakness
ABG ResultsABG Results
UncompensatedUncompensated pH > 7.45pH > 7.45
PaCO2 NormalPaCO2 Normal
HCO3 >26HCO3 >26
CompensatedCompensated pH NormalpH Normal
PaCO2 > 45PaCO2 > 45
HCO3 > 26HCO3 > 26
What Do We Do?What Do We Do?
IV ammonium chlorideIV ammonium chloride
D/C thiazide diuretics and NG D/C thiazide diuretics and NG
suctioningsuctioning
AntiemeticsAntiemetics
IV TherapyIV Therapy
CrystalloidsCrystalloids – – volume expandervolume expander Isotonic (D5W, 0.9% Isotonic (D5W, 0.9%
NaCl or Lactated NaCl or Lactated Ringers)Ringers)
Hypotonic (0.45% Hypotonic (0.45% NaCl)NaCl)
Hypertonic Hypertonic (D5/0.9% NaCl, (D5/0.9% NaCl, D5/0.45% NaCl)D5/0.45% NaCl)
ColloidsColloids – plasma – plasma expander (draw expander (draw fluid into the fluid into the bloodstream)bloodstream) AlbuminAlbumin Plasma proteinPlasma protein DextranDextran
The EndThe End
(Whew!!!!!!)(Whew!!!!!!)