NCM 112 Lesson2
NCM 112 Lesson2
NCM 112 Lesson2
A. Body Fluids
1. Adults
a. Women: 50-55% body weight is water
b. Men: 60-70% body weight is water
c. Infant: 75-80% body weight is water
d. Elderly: 47% body weight is water
2. Intracellular: 80% of total body water
3. Extracellular: 20% of total body water
a. Interstitial
b. Intravascular (plasma)
c. Other: cerebrospinal fluid, intraocular fluid, bone water, gastrointestinal secretions
B. Electrolytes (normal values may vary slightly between institutions and laboratories)
1. Extracellular
a. Na+ 135-145 mEq/1
b. Ca++ 8-10mg/dl
c. Cl- 85-115 mEq/1
d. HCO3- 22-29 mEq/1
2. Intracellular
a. K+ 3.5-5.5 mEq/1
b. PO4 2.5-4.5 mg/dl
c. Mg+ 1.3-2.0 mEq/l
3. Electrolytes Functions
a. Promote neuromuscular excitability
b. Maintain fluid volume
c. Distribute water between fluid compartments
d. Regulate acid-base balance
Assessment of Fluids
a. Daily Weight
b. Skin Turgor
c. Intake and Output
d. Fontanel
e. Orbits of Eyes
f. Urine Specific Gravity
1. Fluid volume deficit: water and electrolytes lost in same proportion (blood and urine become
concentrated)
a. Causes
1. Fever
2. Vomiting
3. Diarrhea or ostomy losses
4. Increased urine output
5. Increased respirations
6. Use of diuretics
7. Insufficient IV fluid replacement
8. Draining fistulas
9. Third spacing (burns, ascites)
b. Manifestations
1. Weight loss
2. Poor skin turgor
3. Urine: decrease in volume, dark, odorous, increased specific gravity
4. Increased respirations
5. Dry mucous membrane
6. Increased heart rate
7. Increased hematocrit (hemoconcentration)
8. Decreased central venous pressure (CVP)
c. Nursing Interventions
1. Weigh client daily
2. Monitor intake and output
3. Replace fluid-P.O. or IV (Lactated Ringers, 0.9% NS) per order
4. Measure urine specific gravity
5. Correct underlying cause
c. Nursing Interventions
1. Administer diuretics - furosemide (Lasix) as per order
2. Restrict fluids, monitor intake and output
3. Weigh client daily
4. Provide skin care
5. Use Semi-Fowler's position
6. Maintain low-sodium diet
Regulation of Body pH
Perfusion Incentive
A. Acid-Base Imbalance
1. Metabolic acidosis
a. Definition: Base Bicarbonate Deficit - increase in hydrogen ion concentration
b. Causes
1. Long-Term Diarrhea
2. Renal failure
3. Systemic infections
4. Diabetic acidosis
5. Starvation, malnutrition, ketogenic (high-fat) diet
c. Manifestations
1. Headache
2. Confusion, stupor
3. Loss of consciousness
4. pH below 7.35
5. HCO3-below 22
6. Tachypnea (increased respirations) or Kussmaul's respirations
d. Nursing Interventions
1. Promote good air exchange
a. Semi-Fowler's Position
b. Incentive Spirometer
c. Coughing and Deep Breathing
2. Monitor K+ level
3. Give sodium bicarbonate, as ordered
2. Metabolic alkalosis
a. Definition: Base Bicarbonate Excess - decrease in hydrogen ion concentration
b. Causes
1. Vomiting (excessive loss of chloride)
2. Gastric suction
3. Alkali ingestion (excessive bicarbonate)
4. Long-term diuretic therapy
c. Manifestations
1. CNS symptoms:
a. confusion
b. irritability
c. agitation
d. coma
2. Shallow Respiration
3. Tetany
4. pH below 7.45
5. HCO3- above 26
d. Nursing Interventions
1. Restore fluid volume
2. Prevent metabolic alkalosis
a. Monitor K+ level
b. Evaluate need for intravenous K+ replacement for clients on gastric
suction
c. Promote intake of K+ rich foods or oral replacement for clients on
long term diuretic therapy
3. Respiratory acidosis
a. Definition: Excess Carbonic Acid - increase in hydrogen ion concentration
b. Causes
1. Acute: respiratory suppression or obstruction due to pulmonary edema,
over-sedation, pneumonia
2. Chronic: chronic airflow limitation (CAL) Or COPD
c. Manifestations
1. Acute
a. Confusion
b. Restlessness
c. Weakness
d. Headache
e. Coma
f. pH below 7.35
g. pCO2 above 45 mm Hg
2. Chronic (These symptoms are classic signs of COPD)
a. pCO2 above 45 mm Hg
b. Tachypnea
c. Dyspnea
d. Weight loss
d. Nursing Interventions
1. Administer sodium bicarbonate per order
2. Promote good respiratory exchange
3. Administer bronchodilators per order
4. Monitor arterial blood gases (ABGs)
4. Respiratory alkalosis
a. Definition: carbonic acid deficit; decrease in hydrogen ion concentration
b. Causes
1. Hyperventilation - secondary to pain, anxiety, thyroid toxicosis
2. Decreased O 2 (pneumonia, pulmonary edema)
3. Elevated body temperature
4. Salicylate intoxication
c. Nursing Interventions
1. Have client breathe into paper bag
2. Have client breathe into cupped hands
3. Provide oxygen, if hypoxic
d. Manifestations
1. Unconsciousness
2. Circumoral numbness
3. pCO2 below 35 mm Hg
B. Blood Gases
1. Arterial Blood Gases (ABG)s
a. Most accurate means of assessing respiratory function
b. Must be sterile, anaerobic
c. Drawn into heparinized syringe
d. Keep on ice and transport to lab immediately
e. Document amount of oxygen delivered
f. Document client's body temperature
g. Apply pressure to site for 5-10 minutes
2. Components
POINTS TO REMEMBER:
1. Clients with low sodium will present with acute on set of confusion.
2. Never give K+ to a client who is not voiding: no "P," no "K"
3. When a client has a high calcium level, phosphorus levels will be low and vice versa; works like a
see-saw