Fluids and Electrolytes

NCM202B_A Fluids and Electrolytes – Ms. Deborah F. Tejam, RN MN

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Fluids and Electrolytes

Miss Debbie F. Tejam, RN MN

50-60% (40L) in adults is composed of Body fluids

75% in children

50% in females because women have more fat cells; fluids cannot occupy fat cells

60% in males because men are more vascular

10% of fluid loss is serious (dehydration, diarrhea, excessive vomiting, more severe in children

20% of fluid loss is fatal; person may die (extensive burns, hypovolemia, hemorrhage, dec fluids in intravascular

space

Body Fluid Compartments

1. Intracellular Fluid Compartments

- Fluids inside the cells

- 35-40% or 2/3 or 25L

2. Extracellular Fluid Compartments

- Fluids outside the cell; more complex

- 15-20%

- ***must be in respective fluid compartments

- Further classified into

- E.g. CSF, fluids in the joints (synovial fluids), GI Fluids

a. Intravascular Fluid Compartments

o Fluid in the blood stream

o 5%

b. Interstitial Fluid Compartments

o Fluids between the cells and in the body tissues

o 10-15%

c. Transcellular Fluid

o Outside the ICF

Manifestation of Shifting

Edema

- Excess accumulation of fluid in the interstitial space

Localized Edema

- Occurs as a result of traumatic injury (E.g. accident, injury or surgery)

ANASARCA/Brawny Edema

- Generalized edema

- Excessive accumulation of fluid in the interstitial spaces all throughout the body (may be caused by

CHF, Renal Failure, Hepatic Failure

Nursing Responsibilities

Detect signs and symptoms of fluid imbalance

IV Fluid – source of fluid directly intravascular space; excess in fluid – may be caused by improper regulation

Renal failure – excess fluid – imbalance in fluid ad electrolytes


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Functions of Fluids

1. Maintain Blood Volume

- Direct relationship between volume of fluid blood volume and BP

2. Transport System

- Fluid as a vehicle to transport nutrients to nourish cell and get rid of waste materials away from cell

3. Maintenance of Normal Body temperature. (independent nursing intervention in cases of hyperthermia:

increase oral fluid intake)

4. Elimination of Waste Products

Standard Fluid Requirement

- Depends on the weight of the patient: 100mL/kg for the first 10 kg if BW + 50mL/kg for the next 10kg of

BW + 15mL/kg for remaining weight

- E.g. Weight of the patient is 60kg – 10kg = 50 kg

100mL/kg x 10kg = 1000mL

50kg – 10kg = 40 kg; 50mL/kg x 10kg = 500mL

15mL/kg x 40kg = 600mL

For a 60 kg patient 1000mL + 500mL = 600mL = 2100mL for that day

- Contraindication : CHF, RF

Mechanisms of Fluid Balance

o Kidneys: Control fluid and electrolytes; secrete renin (when there is decrease urine output); renin convert

angiotensin 1 angiotensin 2 via ACE stimulate adrenal gland to secrete aldosterone(hormone that

retains Na and water)

o Lungs: Control CO2 levels and H2O vapor insensible loss (we are not aware of)

o Skin: Fluid losses insensible loss (we are not aware of)

o Hormonal Control

o ADH (water retainer; inhibits dieresis or production of urine)

o Aldosterone (Na and water retainer hormone)

Average Fluid Losses and Gains in 24 Hours

Intake Output

Oral Liquid 1300mL Urine 1500mL

Water in Stool 1000mL Stool 200mL

Water from metabolism 300mL Insensible Losses

Lungs 300mL

Skin 600mL

Total 2600mL Total 2600mL

Electrolytes

- Substances that carries electrical charge (+ cation or - anion); like fluids located in certain compartments;

they are suppose to occupy that environment; minor shift will lead to serious problem esp K person may

die

- Amount of cations and anions must be equal to maintain homeostasis

o Sodium (Na )

o + charge cation

o Major ECF Cation

o Most abundant in ECF


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o Regulate Fluid volume b/c it can retain water

o Maintain neuromuscular excitability

o Control H2O distribution between ECF and ICF

o Potassium (K)

o Cation

o Located inside the cell

o Major ICF cation; most abundant in ICF

o Necessary for transmission and conduction of nerve impulses

o Contraction of skeletal, cardiac, and smooth muscles

o Excreted in kidneys and GIT. Kidneys does not have a mechanism to retain potassium

o Chloride (CI)

o Main ECF anion

o Affect body pH

o Vital Role in maintaining acid base balance

o Calcium

o Occupies same space as Na and Cl ECF

o Necessary for none and teeth formation, blood coagulation, nerve impulses transmission and N

muscle contraction

o Mg

o Main ICF same with K

o Transmit nerve impulses

o Stimulate parathyroid hormone section

o P (-)

o Main ICF anion

o Promotes energy storage and CHO, CHON and fat metabolism

o HCO3

o Present in ECF

o Regulates acid-base balance

o anion

Normal Lab Values (308-314 – Daniels)

o Na (135-145mEq/L)

o K (3.5-5mEq/L)

o Ca (4.5-5.5mEq/L)

o P (1.7-2.6 mEq/L)

o Cl (98-108 mEq/L)

o Mg (1.5-2.5 mEq/L)

o HCO3(22-26 mEq/L)

Fluid Imbalance (fluid volume deficit or dehydration – hypovolemia (there is a low volume in the ECF); and fluid

volume excess

o Hypovolemia

o Definition – a low volume of ECF; especially in the intravascular space relate to decrease in blood

volume

o fluid volume deficit/dehydration (not only Intravascular Volume is only depleted but all fluid

compartments are decreased)


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o Etiology

o inadequate fluid intake

o Fluid loss/inadequate fluid replacement

o Inc urinary output

o Diuretics

o Types of DHN

1. Isotonic: H2O and dissolved electrolytes are lost in equal proportions, most common(see book for

IV fluids for replacement

2. Hypertonic: H2O loss exceeds electrolyte loss causing cellular DHN and shrinkage;

3. Hypotonic: electrolyte loss exceeds water loss, causing a plasma volume deficit and causing cells to

swell

o Manifestation/Assessment

o Thirst – earliest sign

o Postural hypotension (dec BP when there is a change in position 20mmHG drop causing lingin

ang ulo

o Weight loss (relate weight loss to volume; 1kg=1L)

o Poor skin turgor

o Inc HR inc RR

o Dry mucous membranes

o Urine: dec in volume, dark, odorous, inc specific gravity (reflects hydration status of patient,

and ability of kidney to either concentrate or dilute urine)

o Interventions/Implementations

o Correct cause, prevent further loss

o Replace fluid (PO or IV)

o Weigh client daily

o MIO, serum electrolytes

o Measure urine Sp. Gravity

o NDx: Deficient fluid volume r/t fluid loss greater than intake AEB vomiting, diarrhea, weight loss

o Hypervolemia inc in ECF compartment especially the Intravascular compartment

o Definition:

1. High volume of water in the intravascular fluid compartment

2. Fluid volume excess, overhydration or fluid overload

o Etiology

o Excessive fluid intake

o Excess or rapid IV infusion

o Inadequate fluid elimination RF

o Hypernatremia

o Heart failure

o Manifestations

o Weight gain

o Inc BP, pulse CVP (N = 4-10cmH2O)

o Edema, dyspnea

o Dec Hct, Dec Sp Gr

o Neck Vein Distention


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o Implementation

o Diuretics

o Restrict fluids

o MIO, weigh daily

o Semi-fowler’s (for DOB)

o Low Na diet

o Monitor serum electrolytes

o Third Spacing (can be related to hypovolemia)

- Movement/translocation of fluids from vascular space to other space such as abdominal cavity

(abdominal third spacing – Ascites)

o 3 Common Sites

1. Peritoneal cavity

2. Pleural cavity

3. Pericardial sac

o Manifestations

o Hypovolemia (no weight loss because of shifting to different compartment)

o Ascites

o Generalized (anasarca) edema in all interstitial spaces

o Pallor

o Implementation

o Restore circulatory volume

o Restore colloidal osmotic pressure

o Diuretic IV

o Nursing Management

o Assess to detect hypovolemia and Hypervolemia

Electrolyte Imbalance

o Imbalance whenever there is excess or deficit of electrolytes

o Hyper- or Hypo- to help describe deficit or excess

o –emia – presence of which in the blood

Potassium (K)

o NV=3.5-5mEq/L

o Deficit or excess may lead to cardiac failure

o Hyperkalemia is more deadly (7mEq/L) than the common hypokalemia

o Causes: over ingestion if K+, rapid infusion of K+; K+ sparing diuretics, RF; Addison’s disease; Burns

o Assessment

Nausea

Irregular HR, slow weak pulse rate, dec BP

Muscle cramps, paresthesias, weakness

o Nursing Interventions

Cardiac monitor

D/C IV K+ and hold oral K+

Diuretics

Monitor renal function

Avoid food high in K+


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o Hypokalemia (Serum K < 3.5mEq/L) – loop diuretics (potassium wasting)

May be caused by: diuretics [loop diuretics (potassium wasting)], vomiting and diarrhea

(GI fluids contain a lot of K), if patient has renal disease

Assessment

Weakness

Disorientation, coma

N and V, abdominal distention

Cardiac dysrhythmias

ECG changes: ST depression, flat or inverted T wave, prominent U wave

Nursing Interventions (inc serum K)

MIO, serum electrolytes

K+ supplements

Check renal function (potassium may not be excreted in cases of renal failure causing

Hyperkalemia); check if patient can void freely; Started KCl drip after patient voided

freely, never give K IV push or IV bolus

Dilute before administration (20-40mEq of K dilute in 1000mL in solu set); if PO dilute

the potassium in 4-8oz of water or juice

Maximum recommended infusion rate 5-10 mEq/h, never to exceed 20mEq/hr

Cardiac monitor

Sodium (Na+)

o NV: 135-145mEq/L

o Hyponatremia

Causes

Diuretics, wound, drainage

Dec secretion of aldosterone, renal disease

Prolonged vomiting

Assessment (HypoNa)

Lethargy, cramps, vomiting, confusions

Muscular weakness

Anorexia

Convulsion in severe deficit

Nursing Interventions

Administer IVF with Na+ (3% or 5% saline)

Restrict water intake, MIO

o Hypernatremia

Causes

Excessive Na+ intake

Dec h20 intake

Sever GI losses

Assessment

Delirium, convulsion, coma

Dry, flaky skin

Edema



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Restrict Na

Oral/Parenteral Fluids

Safety Measures

Calcium (Ca+)

o NV: 4.5-5.5mEq/L)

o Hypocalcemia:

Causes

Inadequate oral intake of Ca

Lactose intolerance

Vit. D deficiency

Removal or destruction of the parathyroid glands

Assessment

Circumoral paresthesia

Muscle cramps, Tetany

(+) Trousseau’s (carpopedal spasm/carpal spasm) – use BP cuff, parameter is systolic

blood pressure – inflate for 4 minutes a little higher than systolic BP, assess for carpal

spasms and Chvostek’s Sign – tap facial nerve and check for facial spasm

Implementation

Administer Ca supplements PO or IV

Warm IV Ca before administration

Observe for infiltration; monitor for hypercalcemia

10% Ca Gluconate

Monitor sign of fracture

Diet: High in Ca+

o Hypercalcemia

Causes:

Excessive intake of ca, Vit. D

RF

Hyperparathyroidism

Hyperthyroidism

Immobility (may cause urinary stasis)

Assessment

Muscles weakness

Renal Calculi

Anorexia, nausea, constipation


Ambulation, avoid large doses of Vit. D

Adequate Hydration (at least 3L)

Strain Urine – to be able to collect stones and send to Lab for analysis for the

management of the patient using the different diets

Acid-ash fluids – helps acidify the urine, alkaline stone such as Ca may not form


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Acid-Base Balance

A. Hydrogen Ion, Acids and Bases

o H ions (H+)

o Vital to life

o Expressed as pH – N pH range is 1-14

o Neutral pH is 7

o The more hydrogen ion a compound has the more acidic it is

B. Acids

o Produces as end produces of metabolism

o Contains H ions; if acid gives out H, the concentration of the acidity of that compound weakens

o H+ ions

C. Bases

o Contains no H+

o May accept H+ from acid to neutralize or dec the strength of a base, therefore becoming a weaker acid

Mechanism for Maintaining Acid-Base Balance – 3regulatory mechanisms

A. Buffer Mechanism

- the fastest acting regulatory system

- provide immediate protection against changes in H+ concentration in the ECF (by adding (made acidic)

or removing H (becomes basic)

- absorb or release H+ as needed

- major chemical regulator of plasma pH is….HCO3-H2CO3 buffer system

B. Respiratory Mechanism

- 2nd fastest

- CO2 is one of the component of H2CO3

- CO2 + H2O = H2CO3

- Lungs regulate H2CO3 levels by releasing or conserving CO2 by in or dec RR

- In acidosis, RR and depth go up to blow up acids

- In alkalosis, RR and depth, go down; the CO2 is retained, and the carbonic acid builds to neutralize and

dec the strength of excess HCO3

-

C. Renal or Urinary Mechanisms

- The ultimate correction if acid base disturbances

- Kidney restore HCO3 by the release of H- by holding the HCO3 ions

- In acidosis, pH goes down

- In alkalosis, pH goes up

3 Important Assessment to determine acid base imbalance

- Obtained through ABG radial artery, ideal site for ABG, heparinized syringed

- pH of blood –7.35 (<acidosis)-7.45(>alkalosis)

- PaCO2 – 35 (<alkalosis)-45mmHg(>acidosis)

- HCO3 – 22(<acidosis)-26mEq/L(>alkalosis)

- PO2 – N value is 80-100%

- O2Sat – N value is 97-100%

- ROME – respi opposite metabolic equal


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Acid-Base Imbalance

1. Alkalosis – excessive accumulation of base and excessive loss of acid in body fluids

2. Acidosis – this is an excessive accumulation of acid and excessive loss if base in body fluids

4 General Classes of Acid-Base Imbalance

1. Metabolic – indicator is HCO3

Metabolic Acidosis – most severe

- Decrease HCO3

- Decreased plasma pH

Causes

- Starvation

- Malnutrition

- Ketogenic Diet

- Systemic Infection

- Diarrhea (base goes out, patient becomes acidic; excessive loss of HCO3)

- RF, DM

Manifestations

- Kussmaul’s respirations, confusion, stupor, disorientation

- Ketone breath, Hyperkalemia

- N and V


- Treat underlying cause

- Promote food air exchange

- Give NaHCO3

- Monitor K Level

Metabolic Alkalosis

- HCO3 excess

Causes

- Vomiting

- Alkali ingestion

- Gastric suction

- Long term diuretic therapy

Manifestations

- Shallow respirations

- Confusion, irritability, agitation, coma

- Hypokalemia, hypocalcemia

- Dysrhythmias

- Muscle tremors


- Restore fluid volumes, monitory serum L- and CA++ levels, institutes safety measure

2. Respiratory – indicator is PaCO2

Respiratory Acidosis

- Excess PaCO2, dec pH

- Retention of PaCO2 , hypoventilation


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Causes

- Acute: respiratory suppression or obstruction duets pulmonary edema, over sedation, pneumonia

- Chronic: chronic airflow limitation or COPD

Manifestations

- Hypoventilation

- Respi insufficiency

- pH <7.35, PaCO2 > 45

- Tachycardia

- Confusion, lethargy, coma


- Administer NaHCO3

- Monitor ABG, O2

- Promote good air exchange

- Semi-fowler’s

- Encourage patient to turn to sides and deep breathing (q2h)

- bronchodilators

Respiratory Alkalosis – most common

- PaCO2 deficit

Causes

- Hyperventilation

- Hypoxia

- Anxiety

- Fever, pain

- Pneumonia, ARDS

- CHF

Manifestations

- Inc RR (early manifestation)

- PaCO2: <35; pH increase

- Numbness, tingling of fingers and toes

- Chest pain

- Convulsion


- Breathe into paper nag or cupped hands

- Provide emotional support

- Monitor electrolyte levels

Guidelines

1. Check if acidosis or alkalosis

2. Determine if metabolic or respiratory

3. Determine if fully or partially compensated

Compensated if both are abnormal; if compensated, ID if fully or partially compensated; parameter is pH; if

pH normal it is fully compensated, if abnormal-partially compensated

Uncompensated if one is normal and the other is abnormal


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Ex. 1

pH – 7.58 alkalosis

PaCO2 – 21 alkalosis

HCO3 – 20 acid

Respiratory alkalosis, partially compensated

Ex. 2

pH – 7.37 (N), change the reference point to 7.4 :. < 7.4 acidosis ~ acidosis; >7.4 ~ alkalosis

PaCO2 – 56 acidosis

HCO3 – 29 alkalosis

Respiratory acidosis, fully compensated

Ex. 3

pH – 7.26 acid

PaCo2 – 39N

HCO3 – 19 acid

Metabolic acidosis, uncompensated

Blood Gases (See Book)

ABG’s

o Most accurate means of assessing respi function

Care of Patient with Burns

Burns

- Injury from heat, electric current, chemical, friction, or excessive sunlight exposure

- Classified according to depth (1st, 2nd, 3rd, 4th)

Characteristics of 1st Degree Burn (Superficial)

a. Superficial tissue destruction

b. Painful and Erythema

c. Without blister (never break blisters to prevent excessive fluid loss and risk of infection)

d. Discomfort 48-72 hours

e. Desquamation in 3-7 days

2nd Degree Burn/Partial Thickness (Could be superficial partial thickness or deep partial thickness)

Second degree superficial partial thickness burns:

A. Tissue destruction (entire epidermis and some of the epidermis)

B. Form wet, thin walled blisters after surgery

C. Painful

D. Healing less than 21 days

Second degree deep partial thickness burns:

A. Tissue destruction involving possibly the entire dermis

B. Mottled appearance with large area of waxy white injury


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C. Very sensitive to touch, air currents

D. Healing takes more than 21 days

E. Presence or absence of infection

Third degree full thickness burns

o Damage throughout the dermis, subcutaneous, muscles

o Tissue appears charred or lifeless

o Color variable (deep red, black, brown)

o Extensive scarring and contractures

o Painless to touch

o Autografting require for healing

Fourth Degree full thickness burns

o Involves skin, fat, muscles, and bones

o Color variable

o Charring visible in deepest areas

o Limited extremity movement

o Insensate

o Amputation of extremity

o Autograft required for healing

1. Minor Burns

a. Partial thickness burns of <15% TBSA

b. Full thickness burns are <2% TBSA

c. Burned areas do not involved the eyes, ears, hands, face, feet or perineum

*1% = palm of the hand

Eyes associated with corneal abrasions losing sight without normal functioning

Hands and feet require physical therapy; to prevent contractures

Face and chest associated with respiratory dysfunction; face compromises respiration

Perineum associated with infection with autocontamination from urine/feces

Ears – balanced and equilibrium are affected

2. Moderate Burns

a. Partial thickness burns are deep and 15-25% of TBSA

b. Full thickness burns of <10% TBSA

c. Burn areas do not involve eyes, hands, ears, face, feet, perineum

d. No electrical burns or inhalation injuries

3. Major/Severe Burns

a. Partial thickness burns of >25%of TBSA

b. Full thickness burns of 10% TBSA or greater

c. Burn areas involve eyes, ears, hands, face, feet or perineum

d. Burn injuries was an electrical burns or inhalation injuries


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Estimating the Extent of Injury

Rule of Nine

- quick assessment tool to identify burn injury; all in all is a 100%; the exact amount of fluid resuscitation

is dependent on the extent of burn injury;

Lund and Browder Method

- modifies the percentages for body segments according to age; has diagram according to age;

- provides more accurate estimate of burn size

- uses a diagram of the body divided into section, with the representative % of the TBSA throughout the

lifespan

- should be reevaluated after initial wound debridement; time consuming

Types of Burns

A. Thermal Burns: caused by exposure to flames, hot liquids, steam or hot objects; most common type of

burn; e.g. residential fire, explosive automobile accident

B. Chemical Burns

a. Caused by tissue contact with strong alkali, or organic compounds; e.g. household cleaning agents –

muriatic acid

C. Electrical Burns

a. Caused by heat generated by electrical energy; e.g. lightning strike, high voltage power line

b. Results in internal tissue damage; cardiac failure

D. Radiation Burns: caused by exposure to UV light, x-rays or radioactive source; e.g. sunburn

Pathophysiology of Burns

Burn

Inc Vascular Permeability

Edema Inc Hct

Dec IV Volume Inc Viscosity

Inc Peripheral Resistance

Dec CO

Hypovolemia

Hemodynamic/Systemic Changes see book

Oliguria – 100-400cc/day

Anuria – 0-100cc/day


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Patients with burns are put in reverse isolation room

40xgreater evaporative fluid losses and continue until complete wound complete wound closure occurs

Nursing Diagnosis

1. Ineffective airway clearance r/t secretions, tracheobronchial edema, and obstruction

2. Acute pain r/t exposed nerve ending and associated trauma (may be caused by physical therapy, wound

dressing, debridement)

3. Deficient in fluid volume r/t IV fluid shift and evaporation

4. Risk for infection r/t impaired skin integrity (break in the skin)

5. Impaired tissue integrity r/t impaired perfusion and burn injured skin

6. Impaired physical mobility r/t pain, contractures

7. Disturbed body image r/t altered body functions or appearance

8. Imbalance nutrition: less than body requirements r/t decrease appetite

Planning and Implementation in Burns

1. Eliminate the source of the burn, depending on cause:

A. Flame: Stop, Drag and Roll, wet blanket, splash cold water, remove clothing and cover person

B. Scald: cold water as much as possible, remove clothing

C. Chemicals: dilute the chemical with a copious amount of water, eyes-flush with running water for 20

minutes; PNSS for flushing

D. Electric Current: turn off the main switch first

2. Ensure a patent airway

3. Assess and treat associated injuries.

4. Asses and treat CO inhalation: 100% oxygen until ABG demonstrate adequate oxygenation (80-100%)

5. Take special action for clients who had electrical burns:

A. Apply a cervical collar and place patient on a spinal board ASAP (flat, hard surface)

B. Monitor cardiac arrest

C. Discuss potential late complications

6. Monitor and treat burn shock, occurs in major burn: massive fluid shift of plasma, electrolytes and proteins

into burn wound. Usually occurs in major burn

7. Estimate the burn size

8. Estimate the adequacy of fluid resuscitation (basis is the urine output); if urine output is within N 30-

60cc/h:.px is hemodynamically stable

9. Promote optimum recovery

A. Ensure optimum nutrition – high protein, high carb, high fat, Vit. C

B. Provide meticulous wound management – to prevent infection and promote wound healing

C. Initiate physical therapy to prevent contractures

D. Provide psychosocial support to promote mental health of client

E. Provide family centered care – rehab may take several years

Phases of Management of the Burn Injury

Emergent

- Time of injury until fluid resuscitation is complete, (36-48 hours)

- Goal: prevent hypovolemic shock, preserve vital organ functioning


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Resuscitative

- Initiation of fluid and ends when capillary integrity returns to near normal levels

- Exact amount of fluid (LR) administered is based in the client’s weight and extent of injury: Parkland

formula = 2-4mL of LR x BW in kg x % burn

Example: What is the fluid requirement of patient weighing 75 kg has 70% TBSA burn

4mL LR x 75kg x 70% = 21000mL in 24h

*One half needed for the first 8 hours

*1/2(21000) = 10500mL in 8hr 1312mL/h

*one half is needed in the next 16h

*1/2(21000) = 10500mL in 16h or 656mL/h

- Goal: prevent shock, maintain vital organ function

Acute Phase

- 46-72h after injury

- Emphasis: restorative therapy until wound closure

- Focus: infection control, wound care, wound closure, nutritional support, pain management, and physical

therapy

Rehabilitative Phase

- Final phase

- Wound closure to discharge

- Overlaps acute care phase

- Goal: gain independence

Fluid Shifting in Burns

Oliguric Phase – intravascular to interstitial

Hct increased, renal output decreased, hyperK, HypoNa, metabolic acidosis

Diuretic Phase – interstitial to intravascular

Hct dec, renal output inc, hypoK, HypoNa, metabolic acidosis

Fluid Resuscitation

Indications:

- Adults with burns (>15%-20% TBSA)

- Electrical injury, elderly, cardiac or pulmonary disease and compromised response to burn injury

Successful fluid resuscitation is evidenced by:

- Stable vital signs

- Palpable peripheral pulse

- Adequate urine output

- Clear sensorium

Urinary output is the most common and most sensitive assessment parameter for cardiac output and tissue

perfusion

Pain Management in Burns – administer premedication before any procedure

Background Pain – continuous and of low intensity;


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Procedural Pain – acute and of high intensity; whenever there is performance of any therapeutic procedures to the

client – dressing, physical therapy, medication, debridement

DOC:

- MoSO4 92-24mg) or meperidine (Demerol)

- Avoid IM or SC routes-the muscle and fats is affected in extensive burns

- Avoid administering medication PO

- Medicate prior to painful procedures

Nutrition

- Promote wound healing and prevent infection

- Maintain NPO status if the px is on NPO (administer TPN if ordered)

- Enteral tube feeding, peripheral parenteral nutrition, or TPN

- 5-35 bowel sounds per minute in 4 quadrants

- High CHON, CHO, fats and vitamins

Surgical Management for Burn Clients

Escharotomy

- A lengthwise incision is made through the burn eschar (scab)

- Apply topical antimicrobial agent as prescribed

Fasciotomy

- if there is no adequate tissue perfusion, the surgeon considers Fasciotomy

- an incision is made, extending through the subcutaneous tissue and fascia.

- Performed in OR under GA

Wound Care – considered in the acute phase

- Daily wound care

1. Cleansing, debridement, and dressing of the burn wounds

2. Debridement (surgical debridement and mechanical debridement)

a. Removal of eschar

b. Deep partial or full thickness burn

3. Hydrotherapy

a. Wounds are cleansed by immersion, showering or spraying

b. Occurs for 30 minutes to the procedure

c. Pre-medicated prior to the procedure

d. Not used for hemodynamically unstable or those with new skin graft

Topical Antimicrobial Agents for Burns

Silver sulfadiazine (Silvadene)

- most widely used agent; has lesser side effects than others; can be administered through close method

(impregnated in a gauze) and the open method (do not cover wound after application of medication)

- Use open treatment, light or occlusive dressings

- Apply OD or BID

Mafenide acetate 10% cream or 5% solution (Sulfamylon)


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- Painful during and after application

- Reapply q12h

- Close method or open method

Silver Nitrate (0.5% solution)

- Stains everything

Wound Closure

- Prevents infection and loss of fluid

- Promotes healing

- Prevent contracture

- Performed on the 5th to 21st day

- Can be permanent or temporary

Permanent

Autografting

- Permanent wound coverage

- Surgical removal of a thin layer of the client’s own unburned skin

- Monitor for bleeding

- Immobilize after surgery (3-7 days)

- Care of graft site – immobilize, elevate, keeps site free from pressure, keep it dry, avoid weight bearing

- Care of donor site – keep site clean and dry, sterile dressing, avoid scratching

Temporary Wound Coverings

Biological

- Amniotic membranes from human placenta

- Change dressing q48h

Allograft (Homograft)

- Donated human cadaver skin is harvested within 24h after death

- Rejection occur within 24h – pruritus, fever, sign of allergies

Xenograft (Heterograft)

- From other species pigs

- Porcine skin is harvested after slaughter and preserved

- Rejection occur within 24-72h

- Replaced q2-5 days until wound heals naturally

Urinary and Renal Diseases

Kidney T12-L3 – location of the kidney

1. Renal cortex

2. Renal medulla

3. Renal pelvis

1 million nephrons in each kidney

The Nephron

2 important structures

1. Glomerulus – filters the blood; remove metabolic waste is blood

Glomerular Filtration Rate – rate the kidney filters blood 180L of blood/day; 125mL of blood/min


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2 liters of urine is formed as waste product

2. Tubules

Proximal Convoluted Tubules

A. Functions of the Kidney

1. Urine formation

2. Regulate acid base balance

3. Excrete waste products

4. Secrete renin and erythropoietin

5. Maintain homeostasis of blood

6. Control of FE balance

7. Control of BP

B. Bladder – storage of urine

1. Ureterovesical sphincter

2. Capacity: 300-500mL (half full); may reach more than 1000mL

C. Urethra

1. Conduit during urination

2. Male 24 cm female 4cm

D. Urine Production

1. As fluid flows through the proximal tubules, H2O and solutes are reabsorbed

2. H2O and solute that are not reabsorbed become urine

Urine Formation

1. Glomerular Filtration – involves filtration of plasma by glomerulus; filtered substances include water,

electrolytes, creatinine, glucose, uric acid.

2. Tubular Reabsorption – filtered substances will enter BOMeN? Capsule will now move to the tubular

system, either this filtered substances will be reabsorbed or excreted

3. Tubular Secretion – the formed urine in the tubular section will now be drained from the collecting tubules

Laboratory and Diagnostic Test

Urine Studies

1. Urinalysis

o Assess the nature of urine produce

a. Evaluates color, pH, and specific gravity

Color: Yellow

Volume: 30-60cc/hour

Appearance: Clear

Odor: aromatic then strong ammoniacal odor

Specific Gravity: 1.015-1.025 (24hour urine collection) for creatinine clearance

Random specimen is 1.003-1.030 (random specimen)

pH: 4-8.0


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b. Determines the presence of glucose should be absent unless DM, protein AGN or Nephrotic

syndrome if present, ketones absent unless having Diabetic Ketone Acidosis and blood may

imply calculi if present.

c. Analyzes sediment for cells – presence of WBC, casts bacteria RBC casts-presence would imply

glomerular bleeding WBC casts-glomerular nephritis, Fatty cast-nephrotic syndrome, crystals

2. Urine Culture and Sensitivity

o Diagnose bacterial infection of the UT

o Confirm the causative microorganism

o Sterile specimen bottle

3. Residual Urine

o Amount of urine left in the bladder after voiding measure via catheter un the bladder

o Normal residual urine is less than 100cc.

4. Creatinine Clearance

o Specimen is the urine of the patient; 24 hour collection for clearance

o Determine amount of creatinine in the urine

o Measures overall renal function; measure GFR

24 hour Urine Specimen

o Preferred method for creatinine clearance test

Have client void first and discard specimen; note time. That is the time started for 24 hour

collection.

Collect all subsequent urine specimens for 24 hours.

If specimen is accidentally discarded, the test must be restarted.

Record the exact start and end of collection; include date and time; and document in the

nurses notes.

5. BUN (blood) 10 is to

o Measures renal ability to excrete urea nitrogen (end product of protein metabolism)

o NV: 7-18mg/dL

o Kidneys are capable of excreting urea nitrogen, result may be affected by protein intake of client

6. Serum Creatinine (blood) 1

o Specific test for renal disorders

o Not affected by dietary intake nor hydration status

o Reflects the ability of kidneys to excrete creatinine

o NV: M: 0.7-1.3mg/dL F: 0.6-1.1mg/dL

KUB

- X-ray of the abdominal body; to detect calculi

IVP (Intravenous Pyelogram)

- Fluoroscopic visualization of the urinary tract after injection with a radiopaque dye.

- Injection of contrast media; radiopaque dye, in the form of iodine preparation

Nursing Care (Pre-test)

o Assess for iodine sensitivity (allergy to seafood)

o Obtain consent

o Cathartic or enema

o NPO for 8 hours


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Post-test

o Force fluids

o Assess venipuncture signs for bleeding

o V/S MIO

Cystoscopy

- Use of a lighted scope (cystoscope to inspect the bladder)

Nursing Care (Pre-test)

o Explain that procedure will be under GA/local anesthesia

o Obtain consent

o Sedatives 1 h before the test as ordered

o GA: NPO 4-8 h

o If local anesthesia, liquid may be given at breakfast

Post-test

o Monitor for urinary obstruction (e.g. blood clots)

o MIO (pink tinged/tea colored urine is expected); report gross hematuria, dysuria, excessive pain,

fever, or chills

o Administer meds, antibiotics

Disorders of the Genitourinary System

Cystitis

- Inflammation of the urinary bladder that is caused by invasion of bacteria esp E. Coli; lower urinary tract

infection

- More common in females

Predisposing Factors

o Stagnation of urine

o Obstruction

o Sexual intercourse

Clinical Findings

o Abdominal or flank pain (to where the kidneys are)/tenderness

o Frequency or urgency to void

o Pain on voiding

o Nocturia, hematuria

o Fever

Diagnostic Tests

o Urine C&S

Presence of E. Coli (80-90% of the time is causative agents) – Bactrin is DOC

Nursing Care

o Force fluids

o Asses urine for odor, hematuria, and sediment

o Strict aseptic technique in FC

o Administer medications, antibiotics, antipyretic, analgesic

o Client teaching

Void when there is urge to urinate


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Inc oral fluid intake up to 3L daily

Personal hygiene

Void and drink water after intercourse

Acidify the urine – acid ash diet (cranberry juice, plum juice, citrus, calamansi) to prevent

UTI or cystitis, environment is made acidic

Nephrolithiasis/Urolithiasis

General Information

- Presence of stones anywhere in the urinary tract

- Problem is obstruction; men is of high risk than females

- Compositions of stone

o 90% is made of calcium; uric acid and cystine stones

o Incidence: Men age 20-55 years

Predisposing Factors

o Diet: large amount of Ca, oxalate

o Inc uric acid levels

o Immobility – urine stagnates, forms sediments, obstruction

o Family history of gout or calculi

Clinical Findings

o Sudden sharp pain or severe flank pain

o Hematuria, frequency , urgency or urination, N&V

o Diaphoresis

o Pallor

o Pyuria

Medical Management

1. Surgery

A. Percutaneous Nephrostomy

o Tube is inserted through the skin and underlying tissues into renal pelvis

B. Percutaneous Nephrolithotomy

o Delivers U/S waves through a probe placed on the calculus

2. Extracorporeal Shock-Wave Lithotripsy (ESWL)

o Client is placed in water and exposed to shock waves that disintegrate the stones

Nursing Care

o Strain all urine with layered gauze

o Force fluids

o Encourage ambulation to prevent urinary stasis

o Relieve pain – analgesics as ordered

o MIO

o Provide modified diet – according to the stones in the patient

Diet Modified According to Stone

Alkali Stones

o Calcium Stones

Provide acid-ash diet

Cheese, whole grains, egg, poultry, meat, cranberry, prune juice, plums, Vit A, C, E,

folic acid supplements and Riboflavin


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o Oxalate Stones

Avoid excess intake of foods/fluids high in oxalates – avoid tea, chocolates, rhubarb,

spinach

Acid-ash diet

Acidic Stones

o Uric Acid Stones – uric acid is a metabolic product of purines – legumes, organ meats,

Reduce foods high in purine

Maintain alkaline urine

Alkali-ash diet – all fruits except those in acid ash diet

o Cystine Stones

Common in young men, rarely seen in adults

Low methionine – essential amino acid in which the non essential amino acid cystine is

formed

Limit CHON foods

Maintain alkaline ash diet

Nursing Care

o Administer Allopurinol (Zyloprim) – inc fluid intake

o Client teaching and discharge planning

Prevent urinary stasis – ambulate, inc oral fluid intake, void if urge comes

Adhere to prescribed diet

Routine U/A, quarterly.

Recognize and report recurrence (hematuria, flank pain)

Pyelonephritis

- Upper urinary tract infection

Acute Infection

o Ascends from the UT or an invasive procedure

o Can progress to chronic Pyelonephritis

Assessment

o Fever and chills, N/V

o Tenderness, flank pain

o Dysuria, nocturia

o Frequency an urgency

Chronic Infection

o Obstruction and reflux

o Recurrent infections

Assessment

o patient is usually unaware of disease

o bladder irritability

o slight dull ache over the kidneys

o Develops HPN atrophy of the kidneys

o Azotemia/Uremia – excessive accumulation of metabolic wastes in the blood (BUN)

Nursing Care

o MIO


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o Rest

o Administer antibiotics, analgesics

o Support client and SO and explain possibility of dialysis, transplant options

o Provide client teaching and discharge planning:

Medication regimen

Diet: high calorie, low protein

Renal Failure

- Kidney has lost its functions already

Acute Renal Failure – a sudden and potentially reversible loss of kidney function

3 Causes

o Prerenal Causes – condition that diminishes the flow of blood to the kidneys

Hypotension

Cardiogenic Shock – when contraction of heart is infection

Acute vasoconstriction

Hemorrhage

Burns

Septicemia

CHF

o Intrarenal Causes – conditions that damages the kidneys

Acute Tubular Necrosis (ATN)

DM and HPN – 2 most important contributing factor to renal failure

Malignant HPN

Acute Glomerulonephritis

Tumors

BT reactions

Nephrotoxins

o Postrenal Causes – obstruction of urine outflow

Calculi

Tumors

Blood Clots

BPH

Strictures – narrowing

Trauma

Anatomic Malformations

Stages and Clinical Findings

o Oliguric Phase (1-2 weeks) – edema, HPN, HyperNa, HypoCa, HyperK, Hyperphosphatemia,

Hypermagnesemia, metabolic acidosis

Dec fluid intake, inc BUN d/t nitrogenous waste accumulation

o Diuretic Phase (last for 2 weeks) – 5-17 liters/day, patient is at risk for DHN, inc fluid intake and IV,

electrolyte imbalances like HypoNa, HypoK, Hypovolemia is problem

o Convalescent Phase – Normal Urine Volume, Inc LOC, BUN stable and normal, May develop CRF if

does not improve


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Nursing Care

o Monitor FE balance

o Promote optimal nutritional status – low salt and low protein

o Prevent complication from impaired mobility

o Prevent fever and infection

Chronic Renal Failure –a progressive irreversible deterioration of renal function that ends in fatal uremia or

ESRD

Stages

o Stage 1 (Diminished Renal Reserve) – GFR is only at 40-50%, nocturia, polyuria, little accumulation

of metabolic wastes

o Stage 2 (Renal Insufficiency) – accumulation of the metabolic wastes in our blood, GFR is olnly at

20-40%, Oliguria and edema

o Stage 3 (End Stage) – GFR is less than 10%, uremia, most distinctive manifestation is Uremic Frost-

cardinal sign (white crystals)- precipitates of urea crystals; SpGr Fixed at 1.010 may mean

isosthenuria

Clinical Findings

o N&V, Dec Urinary output, Azotemia, HPN (later), Uremic frost, dyspnea, Hypotension (early),

lethargy, memory impairment, pericardial friction rub, congestive heart failure

Nursing Care

o Prevent neurologic complications

o Promote optimal GI function

o Monitor/prevent alteration in FE

o Promote maintenance of skin integrity

o Monitor bleeding complication, and prevent injury

o Asses for Hyperphosphatemia

Paresthesia

Muscle cramps

Seizures

Abnormal reflexes

o Administer Al(OH)3 gels as orders – Amphogel, AltemaGEL

o Promote/maintain maximal CV function

o Provide care for client receiving dialysis

Dialysis

- an artificial means by removing metabolic wastes in the blood along with excess fluid and electrolytes for

those who have renal failure

Diffusion

Osmosis

Ultrafiltration – makes use of positive pressure to cause the fluid across the medium or semi permeable

membrane, faster than osmosis

Types

1. Hemodialysis

General Information


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o Shunting of blood form the client’s vascular system through an artificial dialyzing system and return

of dialyzed blood to the client’s circulation.

o Dialysis coils acts as a semi-permeable membrane

o Dialysate is a specially prepared solution

o

2. Peritoneal dialysis – amount of exchanges dependent on the amount of metabolic waste is the blood. See

book. Incision is 2cm below the umbilicus

i. Continuous Ambulatory Peritoneal Dialysis (CAPD) – a continuous type of peritoneal dialysis at

home; Dialysate is delivered from flexible plastic container through a permanent peritoneal

catheter.

ii. Continuous Cycling Peritoneal Dialysis (CCPD)

iii. Intermittent Peritoneal Dialysis (IPD)

Nursing Care

o Chart client’s weight

o Assess V/S

o Assemble specially prepared Dialysate solution

o Have the client void.

Inflow: Allow Dialysate to flow unrestricted into the peritoneal cavity 10-20 minutes

Dwell Period: allow fluid to remain in peritoneal cavity for prescribed period

Drain: Unclamp outflow tube and allow to flow by gravity, change position to facilitate drainage of Dialysate

solution

o Observe characteristics of Dialysate outflow.

Normal is clear, pale, yellow

Cloudy – implies peritonitis

Brownish – may be caused by bowel imperforation

Bloody – normal during the first few exchanges, abnormal if continuous

o MIO and maintain records

o Assess for complications (page 295 procedure manual)

Respi insufficiency

Leakage

Abdominal pain

Disequilibrium syndrome

Types of Venous Access

1. External Arteriovenous Shunt or Graft – can be used for several years, Nsg Resp – check for the patency of

conduit, assess for thrill (vibration) – palpated and bruit – auscultated; No BP, IM, Skin test, No drawing of

blood, no constrictive clothing, no hyperextension , no weight bearing, shower instead of tub bath

Can be used 14 days or more after creation.

-

2. Internal Arteriovenous Fistula – side to side anastomosis; more preferred than EAS. Lesser risk for

infection b/c it is internally located. Both require sterile dressing. Can be used 6 weeks after creation, can

be used up to 5 years. Nsg Resp is the same with shunt

o Large artery/vein are anastomosed below the surface

Advantages of AV Fistula:

i. No danger of dislodgement


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ii. Less infection

Disadvantages of AV Fistula

o 2 venipuncture with each dialysis

o Requires 4-6 weeks healing time

Nursing Management

i. Monitor weight, V/S, Se Electrolytes, and waste products

ii. Access for (thrill and bruit)

iii. Avoid constrictive clothing

iv. Avoid venipuncture

v. Assess for complication

Complications During Dialysis

i. Disequilibrium syndrome – because of rapid removal of metabolic wastes

ii. Hypotension

iii. Hypertension

iv. Transfusion reaction

v. Psychological problem

Nursing Care: before and during Hemodialysis

o Have client void

o Weigh client before and after

o Assess V/S

o Withhold antihypertensive, sedatives, and vasodilators

o Bed rest

o Headache and nausea may occur

o Monitor signs of bleeding (hematoma etc), avoid trauma and injur

Nursing Care Post Dialysis

o Chart client’s weight (usually decrease in weight)

o Assess for complication (bleeding, hypovolemic shock, disequilibrium syndrome)

A. Hypovolemic Shock

B. Dialysis Disequilibrium Syndrome

Assess for N&V, elevated BP, disorientation, leg cramps and peripheral paresthesias

3. Femoral Vein catheterization

4. Subclavian Catheterization

Kidney Transplantation – see the book

Benign Prostatic Hypertrophy (BPH)

General Information

- Most common problem of the male reproductive system

- 50% of men over age 50

- 75% of men over age 75

Etiology

- Unknown

Clinical Findings


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- Nocturia

o Frequency of urination

o Decreased force and amount of urinary stream

o Urinary Hesitancy – caused by obstruction

o Hematuria

o Enlargement of prostate gland upon palpation by DRE

Diagnostic Tests

- Urinalysis

o Alkalinity is increased

o SpGr is inc

- BUN and Creatinine – inc

- Prostate Specific Antigen (PSA)

o NV: <4ng/mL

- Cystoscopy to visualize enlargement of the prostate

Nursing Care

- Administer antibiotics

- Provide teaching concerning medications

o Terazocin (Hytrin) – relax the bladder sphincter to make it easier to urinate

o Finasteride (Proscar) – shrinks the prostates

- Force fluids

- Provide catheter care

- Provide care for prostatic surgeries

Prostatic Surgery

- Indicate for BPH and Prostatic CA

Types

1. Transurethral Resection of the Prostate (TURP) – no abdominal incision

2. Transurethral Prostatectomy

3. Suprapubic Prostatectomy – lower midline incision in the abdomen

Retropubic Prostatectomy

4. Radical Perineal Prostatectomy – done in the perineal area; highest risk for autocontamination and

impotence, only considered for prostate CA

Nursing Care: Pre-op

- Provide routine pre-op care

- Information about the procedure and the expected post-op care

- Bowel prep

- For fluids, administer antibiotics, acid ash diet

Nursing Care: Post-Op

- Provide routine post-op care

- Maintain patency of catheter

- Prevent infection: antibiotics

- Relieve pain: analgesics

- Reduce anxiety

- Health education and health maintenance

Documents

Fluids and Electrolytes