NU 373 - Week 2

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Common causes of fluid volume excess

Common causes include malfunction of the kidneys, causing an inability to excrete the excesses, and failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body.

Discharge planning for patients with DKA

Discharge planning with the Diabetic Nurse Specialist will involve meal planning, insulin administration, signs and symptoms of hypo/hyperglycemia, and when adjusting the insulin dose is appropriate because of things like exercise and stress levels. This is an important time for the bedside nurse to communicate with the interdisciplinary team if the patient needs further teaching or adjustments in medication orders.

Metabolic alkalosis - manifestations

Dizziness, tingling, hypertonicity, depressed respirations (compensatory)

Steps for interpreting ABGs

(1) Determine whether the pH is alkalotic or acidic. (2) Look at the PaCO2. Changes in the PaCO2 reflect lung function. (3) Check the HCO3- levels. Changes in the HCO3- reflect kidney function. (4) Look at the PaCO2 or the HCO3- levels and match either with the pH. If the pH is low and the PaCO2 is high, the patient has respiratory acidosis. If the pH is high and the PaCO2 is low, the patient has respiratory alkalosis. If the pH and HCO3- are high but the PaCO2 is normal, the patient has metabolic alkalosis. The patient has metabolic acidosis if the pH and HCO3- are low and the PaCO2 is normal. (5) Look at the total picture and determine whether compensation has occurred. (6) Look at the PaO2 and SaO2. The PaO2 and SaO2 provide information about the patient's oxygenation status. If the PaO2 is less than 80, or the SaO2 is less than 95%, the patient has hypoxemia.

Edema - causes

(1) Increased capillary pressure due to increased vascular volume (e.g. heart failure, kidney disease, premenstrual sodium retention, pregnancy, environmental heat stress, thiazolidinedione therapy), venous obstruction (e.g. liver disease with portal vein obstruction, acute pulmonary edema, venous thrombosis), and decreased arteriolar resistance (e.g.calcium channel-blocking drug responses). (2) Decreased colloidal osmotic pressure due to increased loss of plasma proteins (e.g. protein-losing kidney diseases, extensive burns, etc.) or decreased production of plasma proteins (e.g. liver disease, starvation, malnutrition). (3) Increased capillary permeability (e.g. inflammation, allergic reactions (hives, etc.), malignancy (ascites, pleural effusion, etc.), tissue injury, burns, etc.). (4) Obstruction of lymphatic flow (e.g. malignant obstruction of lymphatic structures, surgical removal of lymph nodes).

What are the functions of the kidneys in relation to acid-base balance? (overview)

(1) Regulate (ECF) volume by selective retention and excretion of body fluids. (2) Regulate electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded substances. (3) Regulate pH of ECF by excretion or retention of hydrogen ions. (4) Excrete metabolic wastes. The kidneys normally filter 180 Liters of plasma daily in the adult, while excreting only 1.5 Liters of urine.

What are the functions of the lungs in relation to acid-base balance? (overview)

(1) Remove approximately 300 mL of water daily through exhalation (insensible water loss) in the normal adult. (2) Eliminate about 13,000 mEq of hydrogen ions (H+) daily, as opposed to only 40 to 80 mEq excreted daily by the kidneys. (3) Act promptly to correct metabolic acid-base disturbances; regulate H+ concentration (pH) by controlling the level of carbon dioxide (CO2) in the extracellular fluid.

Diabetic ketoacidosis - manifestations

(1) The hyperglycemia of DKA leads to polyuria, polydipsia (increased thirst), and marked fatigue. In addition, the patient may experience blurred vision, weakness, and headache. Patients with marked intravascular volume depletion may have orthostatic hypotension (which is a drop in systolic blood pressure of 20 mm Hg or more on changing from a reclining to a standing position). (2) The acidosis of DKA leads to GI symptoms, such as anorexia, nausea, vomiting, and abdominal pain. The patient may have acetone breath (a fruity odor), which occurs with elevated ketone levels. In addition, Kussmaul respirations represent the body's attempt to decrease the acidosis. Mental status in DKA varies widely from alert, lethargic, or even comatose.

What are the functions of water in the body?

(1) Transport nutrients to cells and wastes from cells. (2) Transport hormones, enzymes, blood platelets, and red and white blood cells. (3) Facilitate cellular metabolism and proper cellular chemical functioning. (4) Act as a solvent for electrolytes and nonelectrolytes. (5) Help maintain normal body temperature. (6) Facilitate digestion and promote elimination. (7) Act as a tissue lubricant.

ABGs - PO2- normal levels

>80 mm Hg

Buffer

A buffer is a substance that prevents body fluids from becoming overly acidic or alkaline. Buffers combine with excess acids or bases to prevent major changes in pH, keeping the pH of body fluids as close as possible to normal (7.35 to 7.45). Buffers work in one of two ways. A buffer can function like a base and bind or soak up free hydrogen ions. Alternately, it may function like an acid and release hydrogen ions when too few are present in a solution. The body has three buffer systems: (1) the carbonic acid-sodium bicarbonate buffer system, (2) the phosphate buffer system, and (3) the protein buffer system.

Homeostasis of pH - chemical buffer systems

Nursing responsibilities when administering IV fluids

A relatively common form of therapy for handling fluid disturbances is the use of infused IV solutions. The nurse is responsible for initiating, monitoring, and discontinuing the therapy. The nurse is also responsible for critically evaluating all patient orders prior to administration. Any concerns regarding the type or amount of therapy prescribed should be immediately and clearly communicated to the prescribing practitioner. For example, if a patient's potassium level is noted to be elevated and the patient is prescribed a potassium-containing IV solution such as Lactated Ringer's, the nurse should notify the prescribing practitioner of the laboratory result and request a revision of the patient order.

Arterial blood gases (ABGs)

ABGs are laboratory tests commonly used to determine the adequacy of oxygenation and ventilation, as well as in the assessment and treatment of acid-base imbalance. The ABG findings are obtained through analysis of an arterial blood sample. The pH of the plasma or blood indicates balance or impending acidosis or alkalosis. The blood's oxygen and carbon dioxide gas values are also reported, providing information regarding the effectiveness of the respiratory system.

Calcium - Sources and losses

Absorbed from foods in the presence of normal gastric acidity and vitamin D. Lost via feces and urine. Sources include milk and milk products; dried beans; green, leafy vegetables; small fish with bones; and dried peas and beans.

Gastrointestinal tract - functions in relation to fluid and electrolyte balance

Absorbs water and nutrients that enter the body through this route.

Acid-base balance

Acidity or alkalinity of a solution is determined by its concentration of hydrogen ions (H+). The unit of measure used to describe acid-base balance is pH, which is an expression of H+ ion concentration and the resulting acidity or alkalinity of a substance.

Acidosis

Acidosis is the condition characterized by an excess of H ions or loss of base ions (bicarbonate) in ECF in which the pH falls below 7.35.

Cross-matching

Act of determining the compatibility of two blood specimens

Active transport

Active transport is a process that requires energy for the movement of substances through a cell membrane, against the concentration gradient, from an area of lesser solute concentration to an area of higher solute concentration. Adenosine triphosphate (ATP), which is stored in all cells, supplies energy for solute movement in and out of the cell. Although this process is not entirely understood, the energy requirements for active transport are affected by characteristics of the cell membrane, specific enzymes, and concentrations of ions. This process explains the so-called pump mechanism. If diffusion can be called "coasting downhill," active transport can be called "pumping uphill." Substances believed to use active transport include amino acids, glucose (in certain places only, such as in the kidneys and intestines), and ions of sodium, potassium, hydrogen, and calcium.

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.

Ans: 50 gtts/min.

Lactic acidosis

Acute lactic acidosis is a common type of metabolic acidosis in people who are hospitalized and develops when there is excess production or diminished removal of lactic acid from the blood. Lactic acid is produced by the anaerobic metabolism of glucose. Most cases of lactic acidosis are caused by inadequate oxygen delivery, or hypoxia, as in shock or cardiac arrest. Such conditions not only increase lactic acid production but also impair lactic acid clearance because of poor liver and kidney perfusion. Mortality rates are high because of shock and tissue hypoxia. Severe sepsis is commonly associated with lactic acidosis, and hyperlactatemia can be a strong predictor of mortality for people with sepsis. Lactic acidosis can occur during intense exercise in which the metabolic needs of the muscles outpace their aerobic capacity for production of ATP, causing them to revert to anaerobic metabolism and produce lactic acid. Lactic acidosis is associated with disorders in which tissue hypoxia does not appear to be present. It has been reported in people with leukemia, lymphomas, and other cancers; those with poorly controlled diabetes; and in people with severe liver failure. Mechanisms causing lactic acidosis in these conditions are poorly understood.

Respiratory acidosis - risk factors

Acute respiratory disease, Pulmonary edema, Aspiration, Atelectasis, Overdose, Cardiac arrest, Chronic respiratory disease, Emphysema, Asthma, Cystic fibrosis, CNS depression, Neuromuscular disease.

Potassium - Sources and losses

Adequate quantities via a well-balanced diet. Leading food sources: fruits and vegetables, dried peas and beans, whole grains, milk, meats. Lost via kidneys, stool, sweat, emesis.

Personal factors that impact body water content

Age, body fat, and biological sex. For example: Infants have more ECF (which is more easily lost) and so they are more at risk for fluid volume deficits. Fat cells contain less water than lean tissue and so obese people actually have smaller % total body water compared to their weight. Older people tend to lose muscle mass as a part of aging and so after the age of 60, total body water is about 45% of a person's body weight.

Alkalosis

Alkalosis occurs when there is a lack of H ions or a gain of base (bicarbonate) and the pH exceeds 7.45

Potential causes of insulin deficiency that can lead to DKA

An insulin deficiency may result from an insufficient dosage of insulin prescribed or from insufficient insulin being given by the patient. Errors in insulin dosage may be made by patients who are ill and who ASSUME that if they are eating less or if they are vomiting, they must decrease their insulin doses. (Because illness, especially infections, can cause increased blood glucose levels, the patient does not need to decrease the insulin dose to compensate for decreased food intake when ill and may even need to increase the insulin dose.) Other potential causes of decreased insulin include patient error in drawing up or injecting insulin (especially in patients with visual impairments), intentional skipping of insulin doses (especially in adolescents with diabetes who are having difficulty coping with diabetes or other aspects of their lives), or equipment problems (e.g., occlusion of insulin pump tubing).

Bicarbonate - General description, functions

Bicarbonate (HCO3−): an anion that is the major chemical base buffer within the body; found in both ECF and ICF; normal serum bicarbonate level: 25-29 mEq/L. Functions: Regulates acid-base balance.

Bicarbonate - Regulation

Bicarbonate levels regulated primarily by the kidneys. Bicarbonate readily available as a result of carbon dioxide formation during metabolism.

Labs in patients with diabetic ketoacidosis

Blood glucose levels may vary between 300 and 800 in the patient presentation. The severity of DKA is not necessarily related to the blood glucose level. Evidence of ketoacidosis is reflected in low serum bicarbonate (0 to 15 mEq/L) and low pH (6.8 to 7.3) values. A low partial pressure of carbon dioxide (PCO2 10 to 30 mm Hg) reflects respiratory compensation (Kussmaul respirations) for the metabolic acidosis. Accumulation of ketone bodies (which precipitates the acidosis) is reflected in blood gases and urine ketone measurements.

What is the importance of acid-base balance in the body?

Body fluids must maintain an acid-base balance to sustain health, homeostasis, and life. Specific chemical reactions are constantly occurring within the body that influence metabolism and the functions of various bodily systems. These chemical reactions are dependent on a balance of acids and bases. Conditions such as infection may alter acid-base balance.

Calcium - General description, functions

Calcium (Ca2+): most abundant electrolyte in the body; normal total serum calcium level: 8.6-10.2 mg/dL; normal ionized serum calcium level: 4.5-5.1 mg/dL. Functions: Role in blood coagulation and in transmission of nerve impulses. Helps regulate muscle contraction and relaxation. Major component of bones and teeth.

Chloride - General description, functions

Chloride (Cl−): major ECF anion; normal serum level of chloride: 97-107 mEq/L. Functions: Major component of interstitial and lymph fluid; gastric and pancreatic juices, sweat, bile, and saliva. Acts with sodium to maintain the osmotic pressure. Combines with hydrogen ions to produce hydrochloric acid.

Interpreting ABGs - signs of compensation

Complete compensation occurs when the body's ability to compensate is so effective that the pH falls within the normal range. Partial compensation occurs when the pH remains outside the normal range. Compensation involves opposites: for example, in primary metabolic acidosis, compensation involves respiratory alkalosis; in primary respiratory acidosis, compensation involves metabolic alkalosis. Determine which level more closely corresponds with the pH, indicating the primary cause of the problem. The other level reflects the compensation.

Osmolarity

Concentration of particles in a solution, or a solution's pulling power.

Lactated ringer's solution

Contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+). Used in the treatment of hypovolemia, burns, and fluid lost from GI sources.

Nursing responsibilities during treatment of patients with DKA

Continuous HR/ cardiac rhythm/ RR monitoring with Q1hr BP and Q4hr temp. Q1hr and PRN neurological checks to watch for Increased intracranial pressure. Q1hr lab draws- BS, ABG and chemistry. QVoid urinalysis and dip for ketones/ Strict Ins and Outs. Fluid management with frequent IVF composition changes. Identify educational needs of patient and family. Connect patient and family with Diabetic Educator/ Dietician for meal planning. Support patient and family in this lifestyle change for better health outcomes. Calculate Correction factor (or sliding scale) and Carb ratio with Insulin administration. Provide Medications including Insulin SubQ when appropriate. Discharge planning. Interdisciplinary communication to create a multi-focal plan of care.

A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean? · A. Respiratory Alkalosis, Uncompensated · B. Respiratory Acidosis, Partially Compensated · C. Metabolic Alkalosis, Uncompensated · D. Metabolic Alkalosis, Partially Compensated

Correct Answer: A. Respiratory Alkalosis, Uncompensated The primary disorder is acute respiratory alkalosis (low CO2) due to the pain and anxiety causing her to hyperventilate. There has not been time for metabolic compensation.

Mr. Wales, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment? • A. Metabolic Acidosis, Uncompensated · B. Metabolic Alkalosis, Uncompensated · C. Respiratory Alkalosis, Uncompensated · D. Metabolic Alkalosis, Partially Compensated

Correct Answer: B. Metabolic Alkalosis, Uncompensated · The postoperative client's ABG results show that he has metabolic alkalosis because of an increased pH and HCO3. It is uncompensated due to the normal PaCO2 which is within 35 to 45 mmHg.

Three-year-old Adrian is admitted to the hospital with a diagnosis of asthma and respiratory distress syndrome. The mother of the child reports to the nurse on duty that she has witnessed slight tremors and behavioral changes in her child over the past four days. The attending physician orders routine ABGs following an assessment of the ABCs. The ABG results are pH 7.35, PaCO2 72 mmHg, and HCO3 38 mEq/L. What acid-base disorder is shown? · A. Respiratory Acidosis, Uncompensated · B. Respiratory Acidosis, Fully Compensated · C. Respiratory Alkalosis, Fully Compensated · D. Metabolic Alkalosis, Partially Compensated

Correct Answer: B. Respiratory Acidosis, Fully Compensated · The patient has respiratory acidosis (raised carbon dioxide) resulting from asthma and respiratory distress syndrome, with compensation having normal pH value within 7.35to 7.45, increased PaCO2 which is acidic and increased HCO3 which is basic.

George Kent is a 54-year-old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this? A. Respiratory Acidosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Acidosis, Partially Compensated

Correct Answer: B. Respiratory Acidosis, Partially Compensated The patient has respiratory acidosis (raised carbon dioxide) resulting from an acute exacerbation of chronic obstructive pulmonary disease, with partial compensation.

Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain. The client's respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli. The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg, and HCO3 24 mEq/L. What does this mean? · A. Respiratory Alkalosis, Partially Compensated · B. Respiratory Acidosis, Uncompensated · C. Metabolic Alkalosis, Partially Compensated · D. Metabolic Acidosis, Uncompensated

Correct Answer: B. Respiratory Acidosis, Uncompensated The results show that Mrs. Johansson has respiratory acidosis because of decreased pH and increased PaCO2 which means acidic in nature. Meanwhile, it is uncompensated because HCO3 is within the normal range.

Baby Angela was rushed to the Emergency Room following her mother's complaint that the infant has been irritable, difficult to breastfeed, and has had diarrhea for the past 3 days. The infant's respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg, and HCO3 19 mEq/L. What does this mean? A. Respiratory Alkalosis, Fully Compensated B. Metabolic Acidosis, Uncompensated C. Metabolic Acidosis, Fully Compensated D. Respiratory Acidosis, Uncompensated

Correct Answer: C. Metabolic Acidosis, Fully Compensated Baby Angela has metabolic acidosis due to decreased HCO3 and slightly acidic pH. Her pH value is within the normal range which made the result fully compensated.

Ricky's grandmother has been suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown? · A. Respiratory Alkalosis, Uncompensated · B. Respiratory Acidosis, Partially Compensated · C. Metabolic Alkalosis, Uncompensated · D. Metabolic Alkalosis, Partially Compensated

Correct Answer: C. Metabolic Alkalosis, Uncompensated · The primary disorder is uncompensated metabolic alkalosis (high HCO3 -). As CO2 is the strongest driver of respiration, it generally will not allow hypoventilation as compensation for metabolic alkalosis.

Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials "911" because Anne is unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided? · A. Metabolic Acidosis · B. Metabolic Alkalosis · C. Respiratory Acidosis · D. Respiratory Alkalosis

Correct Answer: C. Respiratory Acidosis · One of the risk factors of having respiratory acidosis is hypoventilation which may be due to brain trauma, coma, and hypothyroidism or myxedema. Other risk factors include COPD, Respiratory conditions such as pneumothorax, pneumonia, and status asthmaticus. Drugs such as Morphine and MgSO4 toxicity are also risk factors of respiratory acidosis.

Client Z is admitted to the hospital and is to undergo brain surgery. The client is very anxious and scared of the upcoming surgery. He begins to hyperventilate and becomes very dizzy. The client loses consciousness and the STAT ABGs reveal pH 7.61, PaCO2 22 mmHg, and HCO3 25 mEq/L. What is the ABG interpretation based on the findings? A. Metabolic Acidosis, Uncompensated B. Respiratory Alkalosis, Partially Compensated C. Respiratory Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated

Correct Answer: C. Respiratory Alkalosis, Uncompensated · The results show that client Z has respiratory alkalosis since there is an increase in the pH value and a decrease in PaCO2 which are both basic. It is uncompensated due to the normal HCO3 which is within 22-26 mEq/L.

Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and mucous membranes are dry—and he has a two-week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment? · A. Respiratory Acidosis, Uncompensated · B. Respiratory Acidosis, Partially Compensated · C. Metabolic Alkalosis, Uncompensated · D. Metabolic Acidosis, Partially Compensated

Correct Answer: D. Metabolic Acidosis, Partially Compensated · The student was diagnosed with diabetes mellitus. The results show that he has metabolic acidosis (low HCO3 -) with respiratory compensation (low CO2).

A nurse is caring for a client admitted to the ER with DKA. In the acute phase the priority nursing action is to prepare to: A. Administer regular insulin intravenously B. Administer 5% dextrose intravenously C. Correct the acidosis D. Apply an electrocardiogram monitor

Correct answer: A. Administer regular insulin intravenously Option A: Lack (absolute or relative) of insulin is the primary cause of DK1. Options B and C: Treatment consists of insulin administration (regular insulin), IV fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Option D: Applying an electrocardiogram monitor is not a priority action.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the ER. Which finding would a nurse expect to note as confirming this diagnosis? A. Elevated blood glucose level and a low plasma bicarbonate B. Decreased urine output C. Increased respiration and an increase in pH D. Comatose state

Correct answer: A. Elevated blood glucose level and a low plasma bicarbonate Option A: In diabetic acidosis, the arterial pH is less than 7.35. plasma bicarbonate is less than 15mEq/L, and the blood glucose level is higher than 250mg/dl and ketones are present in the blood and urine. Options B and C: The client would be experiencing polyuria, and Kussmaul's respirations would be present. Option D: A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis

12. Glucose is an important molecule in a cell because this molecule is primarily used for: · A. Extraction of energy · B. Synthesis of protein · C. Building of genetic material · D. Formation of cell membranes

Correct answer: A. Extraction of energy Glucose catabolism is the main pathway for cellular energy production.

The nurse is admitting a patient diagnosed with type 2 diabetes mellitus. The nurse should expect the following symptoms during an assessment, except: A. Hypoglycemia B. Frequent bruising C. Ketonuria D. Dry mouth

Correct answer: A. Hypoglycemia Option A: Hypoglycemia does not occur in type 2 diabetes unless the patient is on insulin therapy or taking other diabetes medication. Option B: Type 2 diabetes can affect blood circulation which makes it easier for the skin to bruise. Option C: The presence of ketones in the urine happens due to a lack of available insulin. Option D: Losing a lot of fluids caused by frequent urination can lead to dehydration hence patients can develop dry mouth.

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercise. Which statement by the client indicated an inadequate understanding of the peak action of NPH insulin and exercise? A. "The best time for me to exercise is every afternoon." B. "The best time for me to exercise is right after I eat." C. "The best time for me to exercise is after breakfast." D. " "The best time for me to exercise is every afternoon."

Correct answer: A. Option A: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 6-14 hours; therefore afternoon exercise will occur during the peak of the medication. Options B, C, and D do not address peak action times.

Albert, a 35-year-old insulin-dependent diabetic, is admitted to the hospital with a diagnosis of pneumonia. He has been febrile since admission. His daily insulin requirement is 24 units of NPH. Every morning Albert is given NPH insulin at 0730. Meals are served at 0830, 1230, and 1830. The nurse expects that the NPH insulin will reach its maximum effect (peak) between the hours of: A. 1130 and 1330 B. 1330 and 1930 C. 1530 and 2130 D. 1730 and 2330

Correct answer: B. 1330 and 1930 The peak time of insulin is the time it is working the hardest to lower the blood glucose. NPH insulin is an intermediate-acting insulin that has an onset of 1 to 3 hours after injection, peaks 4 to 12 hours later, and is effective for about 12 to 16 hours.

Glycosylated hemoglobin (HbA1C) test measures the average blood glucose control of an individual over the previous three months. Which of the following values is considered a diagnosis of pre-diabetes? A. 6.5-7% · B. 5.7-6.4% · C. 5-5.6% · D. >5.6%

Correct answer: B. 5.7-6.4% Option B: Glycosylated hemoglobin levels between 5.7%-6.4% is considered as pre-diabetes. Option A: Glycosylated hemoglobin levels over 6.5 % are considered diagnostic of diabetes. Options C and D: Glycosylated hemoglobin levels less than 5.6 % are normal.

A client is taking NPH insulin daily every morning. The nurse instructs the client that the most likely time for a hypoglycemic reaction to occur is: A. 2-4 hours after administration B. 6-14 hours after administration C. 16-18 hours after administration D. 18-24 hours after administration

Correct answer: B. 6-14 hours after administration The peak time of insulin is the time it is working the hardest to lower the blood glucose. NPH insulin is an intermediate-acting insulin that has an onset of 1 to 3 hours after injection, peaks 4 to 12 hours later, and is effective for about 12 to 16 hours.

A clinical feature that distinguishes a hypoglycemic reaction from a ketoacidosis reaction is: · A. Blurred vision · B. Diaphoresis · C. Nausea · D. Weakness

Correct answer: B. Diaphoresis A hypoglycemic reaction activates a fight-or-flight response in the body which then triggers the release of epinephrine and norepinephrine resulting in diaphoresis.

A nurse went to a patient's room to do routine vital signs monitoring and found out that the patient's bedtime snack was not eaten. This should alert the nurse to check and assess for: A. Elevated serum bicarbonate and decreased blood pH B. Signs of hypoglycemia earlier than expected C. Symptoms of hyperglycemia during the peak time of NPH insulin D. Sugar in the urine

Correct answer: B. Signs of hypoglycemia earlier than expected. Eating a bedtime snack can prevent blood glucose levels from dropping very low during the night and lessen the Somogyi effect where glucose levels drop significantly between 2:00 a.m. and 3:00 a.m.

A male nurse is providing a bedtime snack for his patient. This is based on the knowledge that intermediate-acting insulins are effective for an approximate duration of: · A. 6-8 hours · B. 10-14 hours · C. 14-18 hours · D. 24-28 hours

Correct answer: C. 14-18 hours Option C: Intermediate-acting insulins include Humulin N and Novolin N. They have an onset of two to four hours, peak of 4 to 12 hours, and a duration of 14 to 18 hours. Option A: Regular or short-acting insulins include Humulin R and Novolin R. They have an onset of half an hour, a peak of two to three hours, and a duration of six to eight hours. Option D: Long-acting insulins include Levemir and Lantus. They have an onset of several hours, minimal or no peak, and a duration of 24 hours or more.

A nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include fasting blood glucose of 120mg/dl, temperature of 101ºF, pulse of 88 bpm, respirations of 22 bpm, and a BP of 140/84 mmHg. Which finding would be of most concern to the nurse? A. Pulse B. Blood pressure C. Respiration D. Temperature

Correct answer: D. Temperature An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis.

Cause of diabetic ketoacidosis

DKA is caused by an absence or markedly inadequate amount of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein, and fat.

Dehydration

Decreased water volume in body tissue

Hypovolemia

Deficiency of blood plasma. Fluid volume deficit (FVD) is caused by a loss of both water and solutes in the same proportion from the ECF space. This state is commonly known as hypovolemia or isotonic fluid loss. Both osmotic and hydrostatic pressure changes force the interstitial fluid into the intravascular space in an effort to compensate for the loss of volume in the blood vessels. As the interstitial space is depleted, its fluid becomes hypertonic, and cellular fluid is then drawn into the interstitial space, leaving cells without adequate fluid to function properly. Fluid volume deficits result from the loss of body fluids, especially if fluid intake is decreased simultaneously. (For example, when a patient has a GI infection with vomiting and diarrhea, they often don't feel well to then replace that loss with oral intake.) Young children, older adults, and people who are ill are especially at risk for hypovolemia. The losses don't always occur through vomiting and diarrhea, and can also occur from third-space fluid shifts. The fluid is not necessarily lost but trapped in another body space for a period of time and essentially unavailable, for example in ascites or during sepsis when the osmotic pressure of the vessels is disrupted and the fluid shifts to the interstitial space (causing edema).

Metabolic acidosis

Defined as a decrease in pH because of a decrease in the HCO3− level. Caused by an increased production of metabolic acids such as lactic acid or ketoacids (as in diabetic ketoacidosis), decreased acid excretion by the kidney, excessive loss of HCO3− as in diarrhea, or an increase in Cl−. Shown by measuring the HCO3− level of an arterial blood gas (ABG). Both the lungs and the kidneys attempt to compensate for this disorder by either excreting or retaining PaCO2 (the lungs) and/or HCO3− and H+ ions (the kidneys). The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate. The lungs attempt to increase carbon dioxide excretion by increasing the rate and depth of respirations, which occurs within a short time. However, respiratory compensation is generally not adequate, and the kidneys attempt to compensate by retaining bicarbonate and by excreting more hydrogen. In summary: Metabolic acidosis = low pH (increased hydrogen ion concentration) and a low plasma bicarbonate concentration due to a gain of hydrogen or loss of bicarbonate.

Metabolic acidosis - risk factors

Diarrhea, Intestinal fistulas, Parenteral nutrition; Excessive intake of acids, such as salicylates; Diabetic ketoacidosis, Renal failure, Starvational ketoacidosis

Insulin calculations

Difference between actual and target blood glucose ÷ correction factor = # units of rapid acting insulin. Ex. 170(actual)- 120(target) ÷ 50 (CF) = 1 unit. // Carb Ratio = 1 unit: x grams. Ex. 1 unit of insulin for every 8 grams of carbs (add total grams of Carbohydrates the patient is about to consume)

Diffusion

Diffusion is the tendency of solutes to move freely throughout a solvent. The solute moves from an area of higher concentration to an area of lower concentration (i.e., "downhill") until equilibrium is established. Gases also move by diffusion. Oxygen and carbon dioxide exchange in the lung's alveoli and capillaries occurs by diffusion.

Respiratory regulation of hydrogen ions

Due to the huge surface area from which CO2 can readily diffuse, the lungs can bring about rapid changes in H+ when needed. Carbon dioxide, constantly produced by cellular metabolism (carbonic acid [H2CO3] yields CO2 and H2O), is excreted by exhalation. When the amount of CO2 in the blood increases, the sensitive chemoreceptors in the respiratory center in the medulla are stimulated to increase the rate and depth of respirations to eliminate more CO2. As more CO2 is exhaled, the H2CO3 level in the blood decreases, and the pH of the blood becomes more alkaline. When the blood level of CO2 decreases, the respiratory center decreases the rate and depth of respirations to retain the CO2 so that carbonic acid can be formed, thereby maintaining the delicate balance.

Respiratory regulation of hydrogen ions

Electrolytes

Electrolytes are substances that are capable of breaking into particles called ions. An ion is an atom or molecule carrying an electrical charge. Some ions develop a positive charge and are called cations. Other ions develop a negative charge and are called anions. These charged particles are the basis of chemical interactions in the body necessary for metabolism and other functions. The electrolyte content of the fluids in various compartments of the body differs significantly. Maintaining homeostasis of fluid volume and electrolytes is essential to healthy body functioning. The body produces balance by shifting fluids and solutes between the ECF and the ICF. Electrolyte imbalances commonly involve a deficit or excess of one or more electrolytes. Abnormalities in electrolyte levels can point towards fluid or acid-base imbalances.

Magnesium - Regulation

Eliminated by kidneys. Regulated by parathyroid hormone.

Phosphate - Regulation

Eliminated by kidneys. Regulation by parathyroid hormone and by activated vitamin D. Phosphate and calcium are inversely proportional; an increase in one results in a decrease in the other.

Chloride - Sources and losses

Enters body via gastrointestinal tract. Almost all chloride in diet comes from salt. Found in foods high in sodium, processed foods.

Phosphate - Sources and losses

Enters body via gastrointestinal tract. Sources include all animal products (meat, poultry, eggs, milk, bread, ready-to-eat cereal). Absorption is diminished by concurrent ingestion of calcium, magnesium, and aluminum.

Magnesium - Sources and losses

Enters the body via gastrointestinal tract. Sources include green, leafy vegetables; nuts; seafood; whole grains; dried peas and beans; cocoa. Lost via urine with use of loop diuretics.

Renal regulation of hydrogen ions

Essentially, the kidneys excrete or retain hydrogen ions and form or excrete bicarbonate ions in response to the pH of the blood. In the presence of acidosis, the kidneys excrete hydrogen ions and form and conserve bicarbonate ions, thus raising the pH to the normal range. If alkalosis is present, the kidneys retain hydrogen ions and excrete bicarbonate ions in an effort to return to a balanced state. As a result, the concentration of bicarbonate in the plasma is regulated by the kidneys. Acid-base regulation by the kidneys occurs more slowly than that which occurs by the carbonic acid-sodium bicarbonate system or by respiratory regulation. It may take as long as 3 days for a normal fluid pH to be restored by the kidneys. The pH of urine varies, depending on the ions that are being excreted, but it is generally between 4.5 and 8.2.

Hypervolemia

Excess of plasma.

Fluid volume excess

Excessive retention of water and sodium in ECF in near-equal proportions results in a condition termed fluid volume excess (FVE). FVE may be a result of fluid overload (excess water and sodium intake) or due to impairment of the mechanisms that maintain homeostasis. Due to the increased extracellular osmotic pressure from the retained sodium and water, fluid is pulled from the cells to equalize the tonicity. By the time the intracellular and extracellular spaces are isotonic to each other, an excess of both water and sodium is in the ECF, whereas the cells are nearly depleted. The excessive ECF may accumulate in either the intravascular compartments (hypervolemia) or interstitial spaces.

Expression of hydrogen ion concentration and resulting acidity of a substance

Extracellular fluid (ECF)

Extracellular fluid (ECF) is all the fluid outside the cells, accounting for about 30% of the total body water or 20% of the adult's body weight. ECF includes two major areas, the intravascular and interstitial compartments. A third, usually minor, compartment is the transcellular fluid. Intravascular fluid, or plasma, is the liquid component of the blood (i.e., fluid found within the vascular system). Interstitial fluid is the fluid that surrounds tissue cells and includes lymph. Transcellular fluids include cerebrospinal, pericardial, synovial, intraocular, and pleural fluids, as well as sweat and digestive secretions. The capillary walls and cell membranes separate the intracellular and extracellular compartments.

Fluid loss - sensible vs insensible

Fluid intake and fluid loss is ideally balanced in a healthy person. Fluid is lost from the body through sensible and insensible losses. Sensible losses can be measured and include fluid lost during urination, defecation, and wounds. Insensible losses cannot be measured or seen and include fluid lost from evaporation through the skin and as water vapor from the lungs during respiration. Water losses vary according to the person and the circumstances. Fluid output averages 2,500 to 2,900 mL per day (average 2,600 mL), with approximately 1,500 mL as urine from the kidneys, 600 mL fluid loss from the skin, 300 mL from the lungs, and 200 mL in feces via the GI tract.

Hypovolemia - severity of fluid losses by percentage of weight lost

Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit (which for a 130lb person, 5% is 6.5 lbs); an 8% weight loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening.

Hydrostatic pressure

Force exerted by a fluid against the container wall. When the hydrostatic pressure inside the capillary exceeds the surrounding interstitial space, fluids and solutes are forced out of the capillary wall into the interstitial space. In contrast, when the pressure inside the capillary is less than the pressure in the interstitial space, the fluids and solutes will move back into the capillary.

Metabolic acidosis - manifestations

Headache, confusion, drowsiness, increased respiratory rate and depth (Kussmaul), nausea and vomiting. Peripheral vasodilation and decreased cardiac output occur when the pH drops to less than 7. Additional physical assessment findings include decreased blood pressure, cold and clammy skin, dysrhythmias, and shock. Chronic metabolic acidosis is usually seen with chronic kidney disease.

High anion gap acidosis - causes

High anion gap acidosis results from excessive accumulation of fixed acid. If increased to 30 mEq/L (30 mmol/L) or more, then a high anion gap metabolic acidosis is present regardless of the values of pH and HCO3−. High anion gap occurs in ketoacidosis, lactic acidosis, the late phase of salicylate poisoning, uremia, methanol or ethylene glycol toxicity, and ketoacidosis with starvation. The hydrogen is buffered by HCO3−, causing the bicarbonate concentration to fall. In all of these instances, abnormally high levels of anions flood the system, increasing the anion gap above normal limits.

Three main clinical features of diabetic ketoacidosis (DKA)

Hyperglycemia, dehydration / electrolyte loss, metabolic acidosis

Hyperkalemia

Hyperkalemia refers to an excess of potassium in ECF (serum potassium >5 mEq/L). Excess potassium may result from renal failure, hypoaldosteronism, or the use of certain medications such as potassium chloride, heparin, angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), and potassium-sparing diuretics. Nerve conduction as well as muscle contractility can be affected. Skeletal muscle weakness and paralysis may occur. A variety of cardiac irregularities may result, including cardiac arrest.

Hypernatremia

Hypernatremia refers to a surplus of sodium in ECF (serum sodium >145 mEq/L) caused by excess water loss or an overall excess of sodium. Fluid deprivation, lack of fluid consumption (such as in patients who cannot perceive, respond to, or communicate thirst, diarrhea, and excess insensible water loss (hyperventilation, burns) lead to excess sodium. Fluids move from the cells because of the increased extracellular osmotic pressure, causing them to shrink and leaving them without sufficient fluid. The cells of the central nervous system are especially affected, resulting in signs of neurologic impairment, including restlessness, weakness, disorientation, delusion, and hallucinations. Permanent brain damage (especially in children) can occur.

Hypertonic solutions

Hypertonic solutions have higher solute concentrations (osmolality) to that of intracellular fluid therefore the fluid from within the cell is drawn out of the cell and into the extracellular fluid. Cells shrink. Hypertonic example: NaCl 3%.

Respiratory alkalosis - risk factors

Hyperventilation: Extreme anxiety (most common), Hypoxemia, High fever, Early sepsis, Excessive ventilation by mechanical ventilator, CNS lesion involving the respiratory center.

Metabolic vs respiratory acidosis and alkalosis

In metabolic acid-base imbalances, a metabolic disturbance alters the bicarbonate levels in the ECF. In respiratory acid-base imbalances, a respiratory disturbance alters the carbonic acid level in the ECF.

Phosphate - General description, functions

Phosphate (PO4−): major ICF anion; a buffer anion in both ICF and ECF; normal serum phosphate level: 2.5-4.5 mg/dL. Functions: Role in acid-base balance as a hydrogen buffer. Promotes energy storage; carbohydrate, protein, and fat metabolism. Bone and teeth formation. Role in muscle and red blood cell function.

Hypokalemia

Hypokalemia refers to a potassium deficit in ECF (serum potassium <3.5 mEq/L) and is a common electrolyte abnormality. Potassium may be lost through vomiting, gastric suction, or diarrhea, or as the result of the use of diuretics. When the extracellular potassium level falls, potassium moves from the cell, creating an intracellular potassium deficiency. Sodium and hydrogen ions are then retained by the cells to maintain isotonic fluids. These electrolyte shifts influence normal cellular functioning, the pH of ECF, and the functions of most body systems, including the cardiovascular system. Skeletal muscles are generally the first to demonstrate a potassium deficiency. Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias (tingling sensation), and dysrhythmias.

Hypotonic solutions

Hypotonic solutions have lower solute concentrations (osmolality) to that of intracellular fluid therefore the fluid from the solution moves into the cell by process of osmosis. Cells swell. Hypotonic example: NaCl 0.45% (1/2 normal saline) or D5W. Never give hypotonic fluids to a client with increased intracranial pressure because it increases swelling of cells in the brain which further increases intracranial pressure.

Respiratory alkalosis - intervention

If anxiety is the cause, encourage the patient to breathe slower (in order to accumulate and retain more CO2) or into a closed system (paper bag). Sedative may also be necessary in extreme anxiety. Treatment of other causes is directed at correcting the underlying problem.

Insulin resistance associated with DKA

Illness and infections are associated with insulin resistance. In response to physical (and emotional) stressors, there is an increase in the level of "stress" hormones—glucagon, epinephrine, norepinephrine, cortisol, and growth hormone. Think fight or flight hormones. These hormones promote glucose production by the liver and interfere with glucose utilization by muscle and fat tissue, counteracting the effect of insulin. If insulin levels are not increased during times of illness and infection, hyperglycemia may then progress to DKA.

Nursing care with diuretics

In some situations Diuretics may be used to treat certain fluid, electrolyte, and acid-base imbalances. They are drugs that increase renal excretion of water, sodium, and other electrolytes. Although helpful in treating patients with Fluid volume excess, they can increase the risk for fluid volume deficit and serious electrolyte deficiencies. Careful monitoring of fluid intake, urine output, and serum electrolytes is essential for patient safety. The nurse will want to Direct particular attention toward the patient's serum potassium level.

Risk factors for "risk for deficient fluid volume"

Inability to access fluids, extremes of age, insufficient knowledge about fluid needs

Risk factors for deficient fluid volume

Inability to obtain or swallow fluids (debilitation, oral pain), extremes of age, vomiting, diarrhea, burns, excessive use of laxative, excessive diaphoresis, fever

Thyroid gland - functions in relation to fluid and electrolyte balance

Increases blood flow in the body by releasing thyroxine, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output.

Nervous system - functions in relation to fluid and electrolyte balance

Inhibits and stimulates mechanisms influencing fluid balance; acts chiefly to regulate sodium and water intake and excretion. Regulates oral intake by sensing intracellular dehydration, which triggers thirst (thirst center located in the hypothalamus). Neurons, called osmoreceptors, are sensitive to changes in the concentration of ECF, sending appropriate impulses to the pituitary gland to release ADH or inhibit its release to maintain ECF volume concentration.

Bicarbonate - Sources and losses

Losses possible via diarrhea, diuretics, and early renal insufficiency. Excess possible via over-ingestion of acid neutralizers, such as sodium bicarbonate.

Insulin to address DKA - nursing administration

Insulin is usually infused IV at a slow, continuous rate. Hourly blood glucose values must be measured. Regular insulin is the only type of insulin approved for IV use. Insulin replaces the endogenous hormone when the body does not produce enough insulin or when there are not enough insulin receptor sites to provide adequate glucose control. Even if blood glucose levels are decreasing and returning to normal, the insulin drip must not be stopped until subcutaneous insulin therapy has been started. Rather, the rate or concentration of the dextrose infusion may be increased to prevent hypoglycemia. Blood glucose levels are usually corrected before the acidosis is corrected. Therefore, IV insulin may be continued for 12 to 24 hours, until the serum bicarbonate level increases (to at least 15 to 18 mEq/L) and until the patient can eat. Monitoring serial arterial blood gases will allow for calculation of the Anion Gap, and once that closes (meaning the electrolyte levels are in appropriate proportions and acidosis is fixed), the patient is "corrected" and they will be able to be "converted" which is when they can be able to eat and take subQ insulin as ordered. The sequence of events for converting the patient is that the patient will be able to order a meal (ideally breakfast), calculate the carbs in the meal to figure out the carb ratio, account for the blood glucose level (either by correction factor or sliding scale), eat the mean, and then take the subQ insulin dose.

Intracellular fluid (ICF)

Intracellular fluid (ICF) is the fluid within cells, constituting about 70% of the total body water or 40% of the adult's body weight.

Anions

Ions that carry a negative electric charge

Isotonic solutions

Isotonic solutions have similar solute concentrations (osmolality) to that of intracellular fluid. These types of solutions do not impact the size of the cell. Isotonic example: NaCl 0.9% (normal saline).

How does insulin administration affect ketone bodies?

Ketone bodies (acids) accumulate as a result of fat breakdown. The acidosis that occurs in DKA is reversed with insulin, which inhibits fat breakdown, thereby ending ketone production and acid buildup.

Respiratory alkalosis - manifestations

Lightheadedness, Can't concentrate. Hyperventilation syndrome: Tinnitus, Palpitations, Sweating, Dry mouth, Tremulousness, Convulsions and unconscious.

Solvents

Liquid holding a substance in solution

Respiratory acidosis

Low pH and high PaCO2 due to alveolar hypoventilation. Caused by conditions that impair alveolar ventilation. Respiratory Acidosis is a primary excess of carbonic acid in the ECF. It is produced by inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 and increased levels of carbonic acid. Any decrease in alveolar ventilation that results in retention of carbon dioxide can cause respiratory acidosis. Initially, the increased amounts of CO2 stimulate the medulla in the respiratory center to increase the respiratory rate. Due to the increase in respiratory rate, CO2 is expelled and the CO2 level of the blood is reduced. If the respiratory response is not effective, the increasing CO2 levels will stimulate the kidneys to eliminate H+ ions (acids) and conserve bicarbonate and sodium ions. It can occur as an acute disorder in which there is a rapid rise in PCO2, a minimal increase in plasma HCO3−, and a large decrease in pH.

Magnesium - General description, functions

Magnesium (Mg2+): second most abundant ICF cation after potassium; normal serum concentration of magnesium: 1.3-2.3 mEq/L. Functions: Metabolism of carbohydrates and proteins. Role in neuromuscular function. Acts on cardiovascular system, producing vasodilation.

Major electrolytes in extracellular fluid (ECF)

Major electrolytes in the ECF include sodium, chloride, calcium, and bicarbonate.

Major electrolytes in intracellular fluid (ICF)

Major electrolytes in the ICF include potassium, phosphorus, and magnesium.

Management of patients with diabetic ketoacidosis

Management of these patients requires ICU level care. Treatment involves correcting the dehydration, electrolyte loss, and the acidosis along with the hyperglycemia. Rehydrating the patient may take 6-10 liters of fluid because of the polyuria, diarrhea, vomiting, and the insensible losses from compensatory hyperventilation. Aggressive fluid replacement usually starts with normal saline, changes to a hypotonic solution with less needs for sodium replacement, and then as an insulin drip is started, the IVF may then add dextrose in order to not drop the blood sugar too quickly. Monitoring of fluid volume status involves frequent measurements of vital signs, lung assessment, and monitoring of intake and output. Initial urine output lags behind IV fluid intake as dehydration is corrected. Plasma expanders may be necessary to correct severe hypotension that does not respond to IV fluid treatment. Monitoring for signs of fluid overload is especially important for patients who are older, have renal impairment, or are at risk for heart failure.

Anion gap - calculation

Measuring the anion gap is essential in analyzing acid-base disorders. The anion gap can be calculated by either of the following equations: (1) Anion gap = Na+ + K+ - (Cl- + HCO3-) or (2) Anion gap = Na+ - (Cl- + HCO3-). Potassium is often omitted from the equation because of its low level in the plasma; therefore, the second equation is used more often than the first.

Respiratory acidosis - manifestations

Mental cloudiness, dizziness, muscular twitching, unconsciousness, weakness, dull headache

Metabolic acidosis - high anion gap vs normal anion gap acidosis

Metabolic acidosis can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. The anion gap refers to the difference between the sum of all measured positively charged electrolytes (cations) and the sum of all negatively charged electrolytes (anions) in blood. Because the sum of measured cations is typically greater than the sum of measured anions, there normally exists a gap referred to as the anion gap. Because blood does not carry an electrical charge, the anion gap reflects normally unmeasured anions (phosphates, sulfates, and proteins) in plasma that increase the anion gap by replacing bicarbonate. Measuring the anion gap is essential in analyzing acid-base disorders.

Metabolic alkalosis

Metabolic alkalosis is an excess of bicarbonate HCO3, a decrease in H+ ions, or both, in the ECF, resulting in an increase in pH. This may be the result of excessive acid losses or increased base ingestion or retention. The body attempts to compensate by retaining carbon dioxide. The respirations become slow and shallow, and periods of no breathing may occur. The kidneys attempt to excrete excess H2O and Na ions with the excessive bicarbonate and retain H+ ions. In summary: Metabolic alkalosis = high pH and a high plasma bicarbonate concentration due to a gain of bicarbonate or a loss of hydrogen.

Nursing assessment of patients with fluid, electrolyte, and acid-base imbalances - laboratory tests

Might include urinalysis for pH (low can occur in metabolic acidotic states like DKA, diarrhea) and Specific gravity (urine's concentration or dilution level). Arterial Blood Gas Analysis. A chem 10 panel, which will identify the patient's plasma electrolyte balance.

Mineral and electrolyte preparations - nursing responsibilities

Mineral and electrolyte preparations are frequently prescribed to correct electrolyte imbalances. Nursing responsibilities include: (1) Accurate administration of the medications, (2) Understanding the intended therapeutic effect and evaluating the effectiveness of the therapy through patient assessment, (3) Understanding and appreciating the risks associated with administration and the appropriate precautions to avoid adverse outcomes, (4) Assessing for drug interactions (5) and teaching patients about their prescribed mineral and electrolyte preparations and associated self-care behaviors.

Normal anion gap acidosis - causes

Normal anion gap acidosis results from the direct loss of bicarbonate, as in diarrhea, lower intestinal fistulas, ureterostomies, and the use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Normal anion gap acidosis is also referred to as hyperchloremic acidosis.

What is the normal pH of blood plasma?

Normal blood plasma is slightly alkaline and has a normal pH range of 7.35 to 7.45, with 7.4 being the optimal blood pH. When the blood plasma pH exceeds the normal pH range in either direction, signs and symptoms of illness develop, and if the condition goes on unabated, death results.

ABGs - HCO3- levels

Normal: 22-26 mEq/L. Acid <22. Base >26.

ABGs - PaCO2 levels

Normal: 35-45 mm Hg. Acid >45. Base <35.

Sodium - Sources and losses

Normally enters the body through the gastrointestinal tract from dietary sources, such as salt added to processed foods, sodium preservatives added to processed foods. Lost from gastrointestinal tract, kidneys, and skin.

Chloride - Regulation

Normally paired with sodium; excreted and conserved with sodium by the kidneys. Regulated by aldosterone. Low potassium level leads to low chloride level.

Autologous transfusion

Occurs when a patient donates one's own blood for a transfusion

Osmosis

Passage of a solvent through a semipermeable membrane from an area of lesser concentration to an area of greater concentration until equilibrium is established. Through the process of osmosis, water (the solvent) passes from an area of lesser solute concentration and more water to an area of greater solute concentration and less water until equilibrium is established. As a result, the volume of the more concentrated solution increases, and the volume of the weaker solution decreases. The process of osmosis stops when the concentration of solutes has been equalized on both sides of the cell membrane. The greater the difference in the concentration of the two solutions on each side of a semipermeable membrane, the greater the osmotic pressure or drawing power of water.

Capillary filtration

Passage of fluid across the wall of the capillary; results from the force of blood "pushing" against the walls of the capillaries

Mixed acid-base disorders

Patients can simultaneously experience two or more independent acid-base disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3− concentration immediately suggests a mixed disorder. An example of a mixed disorder is the simultaneous occurrence of metabolic acidosis and respiratory acidosis during respiratory and cardiac arrest. The only mixed disorder that cannot occur is a mixed respiratory acidosis and alkalosis, because it is impossible to have alveolar hypoventilation and hyperventilation at the same time.

Patients at higher risk of fluid, electrolyte, and acid-based imbalances

Patients with: Acute and chronic illnesses (e.g., diabetes mellitus, congestive heart failure, renal failure); Abnormal losses of body fluids (e.g., prolonged or severe vomiting or diarrhea, draining wounds, fistulas); Burns, Trauma, Surgery; patients receiving therapies that may disrupt fluid and electrolyte balance (e.g., medications such as diuretics and steroids) and treatments such as IV therapy and PN. Identifying the nature of the imbalances should include their severity, etiology, and your assessment findings.

Pitting vs nonpitting edema

Pitting vs nonpitting edema `Pitting edema occurs when the accumulation of interstitial fluid exceeds the absorptive capacity of the tissue gel. In this form of edema, tissue water becomes mobile and can be translocated with pressure exerted by a finger. Nonpitting edema usually reflects a condition in which plasma proteins have accumulated in the tissue spaces and coagulated. It is seen most commonly in areas of localized infection or trauma. The area often is firm and discolored.

Potassium - General description, functions

Potassium (K+): major cation of ICF; normal serum concentration of potassium: 3.5-5.0 mEq/L. Functions: Controls intracellular osmolality. Regulator of cellular enzyme activity. Role in the transmission of electrical impulses in nerve, heart, skeletal, intestinal, and lung tissue; Regulation of acid-base balance by cellular exchange with H+.

Colloid osmotic pressure

Pressure exerted by plasma proteins on permeable membranes in the body; synonym for oncotic pressure. Reabsorption is the process that acts to prevent too much fluid from leaving the capillaries no matter how high the hydrostatic pressure. Plasma proteins, particularly albumin, concentrated in the intravascular space or plasma facilitate this reabsorption process by "pulling" the fluid back into the capillaries.

Calcium - Regulation

Primarily excreted by gastrointestinal tract; lesser extent by kidneys. Regulated by parathyroid hormone and calcitonin. High serum phosphate results in decreased serum calcium; low serum phosphate leads to increased serum calcium.

Adrenal glands - functions in relation to fluid and electrolyte balance

Regulate blood volume and sodium and potassium balance by secreting aldosterone, a mineral corticoid secreted by the adrenal cortex, causing sodium retention (and thus water retention) and potassium loss. Decreased secretion of aldosterone causes sodium and water loss and potassium retention. Cortisol, another adrenocortical hormone, has only a fraction of the potency of aldosterone. However, secretion of cortisol in large quantities can produce sodium and water retention and potassium deficit.

How is homeostasis of pH in the body maintained?

The narrow range of normal pH is achieved through three major homeostatic regulators of hydrogen ions: (1) chemical buffer systems, (2) respiratory mechanisms, and (3) renal mechanisms.

Parathyroid glands - functions in relation to fluid and electrolyte balance

Regulate calcium (Ca2+) and phosphate (HPO42−) balance by means of parathyroid hormone (PTH); PTH influences bone reabsorption, calcium absorption from the intestines, and calcium reabsorption from the renal tubules. Increased secretion of PTH causes elevated serum calcium concentration and lowered serum phosphate concentration. Decreased secretion of PTH causes lowered serum calcium concentration and elevated serum phosphate concentration.

Potassium - Regulation

Regulated by aldosterone. Eliminated by the kidneys (no effective method of conserving potassium). Additional regulation via transcellular shift between the ICF and ECF compartments.

Risk factors for excess fluid volume

Renal failure, decreased cardiac output, excessive IV infusion/fluid intake, excessive sodium intake

Respiratory alkalosis

Respiratory Alkalosis is a primary deficit of carbonic acid in the ECF. It is the result of alveolar hyperventilation, breathing that is faster and deeper, and the consequent increase in the elimination of CO2. This loss of CO2 leads to a decrease in the carbonic acid level in the plasma and an increase in the pH. The chemoreceptors in the medulla sense the increase in pH and the presence of less carbonic acid and stimulate the body to breathe either more slowly or less deeply. If this condition lasts for about 6 hours or longer, the kidneys attempt to alleviate the imbalance by increasing the bicarbonate excretion and by retaining more hydrogen to correct the imbalance. Because respiratory alkalosis often occurs suddenly, a compensatory decrease in HCO3− levels may not occur before corrections have been accomplished meaning the person may resolve their hyperventilation before the body needs to further compensate.

Nursing physical assessment of patients with fluid, electrolyte, and acid-base imbalances

Skin Turgor (elasticity). Moisture of the oral cavity. Tears and Salivation (a concerning sign in children especially). Appearance of skin/temp (metabolic acidosis can cause peripheral vasodilation and therefore warm, flushed skin). Presence of edema? (The nurse should take a measurement of an extremity or body part with a millimeter tape, in the same area each day, as a more exact method of measurement of edema). An excess of interstitial fluid may accumulate predominantly in the lower extremities of ambulatory patients and in the presacral region of bedridden patients. Clinically, edema is not usually apparent in the adult until there is retention of 5-10 lb of excess fluid. Formation of edema may be localized (as in thrombophlebitis of an arm) or generalized (as in heart failure, cirrhosis of the liver, or nephrotic syndrome).

Sodium - General description, functions

Sodium (Na+): chief electrolyte of ECF; normal serum concentration of sodium: 135-145 mEq/L. Functions: Regulates extracellular fluid volume; Na+ loss or gain accompanied by a loss or gain of water. Affects serum osmolality. Role in muscle contraction and transmission of nerve impulses. Regulation of acid-base balance as sodium bicarbonate.

Hyponatremia

Sodium is the most abundant electrolyte in the ECF. Hyponatremia refers to a sodium deficit in ECF (serum sodium <135 mEq/L) caused by a loss of sodium or a gain of water. Sodium may be lost through vomiting, diarrhea, fistulas, sweating, or as the result of the use of diuretics. The decrease in sodium causes fluid to move by osmosis from the less concentrated ECF compartment to the ICF space. This shift of fluid leads to swelling of the cells, with resulting confusion, hypotension, edema, muscle cramps and weakness, and dry skin. Severe hyponatremia (serum sodium <115 mEq/L) is manifested by signs of increasing intracranial pressure, which may include lethargy, muscle twitching, focal weakness, hemiparesis, and seizures; death may occur.

Specific gravity

Specific gravity is a measure of the urine's concentration. The range depends on the patient's state of hydration and varies with urine volume and the load of solutes to be excreted. Normal values range from 1.005 to 1.030 (concentrated urine, ≥1.025; dilute urine, ≤1.001 to 1.010). Increased urine specific gravity can occur with dehydration, vomiting, diarrhea, and heart failure. Decreased urine specific gravity can occur with renal damage.

Pituitary gland - functions in relation to fluid and electrolyte balance

Stores and releases the antidiuretic hormone (ADH) (manufactured in the hypothalamus), which acts to allow the body to retain water. It acts chiefly to regulate sodium and water intake and excretion. When osmotic pressure of the ECF is greater than that of the cells (as in hypernatremia—excess sodium—or hyperglycemia), ADH secretion is increased, causing renal retention of water. When osmotic pressure of the ECF is less than that of the cells (as in hyponatremia), ADH secretion is decreased, causing renal excretion of water. When blood volume is decreased, an increased secretion of ADH results in water conservation. When blood volume is increased, a decreased secretion of ADH results in water loss.

Nursing assessment of patients with fluid, electrolyte, and acid-base imbalances - I&Os, weights

Strict I and Os can identify where the losses are originating from (vomit, diarrhea, excessive urination). Daily weights will provide a trend to see the body fluid shifts, 1kg of weight gain roughly equals a 1L gain in fluid.

Electrolytes

Substance capable of breaking into ions and developing an electric charge when dissolved in solution

Acid

Substance containing a hydrogen ion that can be liberated or released

Solutes

Substance dissolved in a solution

Base

Substance that can accept or trap a hydrogen ion; synonym for alkali

Nursing assessment of patients with fluid, electrolyte, and acid-base imbalances - vital signs

Temp (a fever increases loss of fluids). A temp of 103F can increase daily fluid requirement by 1L. Pulse (tachycardia is an early sign of fluid deficit and quality/amplitude can be decreased). Irregular HR can occur with potassium imbalance. Respirations (Metabolic ACIDosis like DKA can have deep, rapid respirations to compensate, Metabolic Alkalosis can have slow, shallow respirations as compensation) and moist crackles can indicate fluid volume excess. Blood Pressure measured in supine, sitting and standing position whenever concern for fluid imbalance to look for orthostatic changes. A decrease in BP can indicate fluid volume deficit.

Anion gap

The AG describes the difference between the plasma concentration of the major measured cation (Na+ and K+) and the sum of the measured anions (Cl− and HCO3−). The AG is used in diagnosing causes of metabolic acidosis. An increased level is found in conditions such as lactic acidosis, alcoholic acidosis, poisoning by substances such as salicylate and antifreeze, and diabetic ketoacidosis that results from elevated levels of metabolic acids. A low AG is found in conditions like hyperkalemia, hypercalcemia, hypermagnesemia, lithium intoxication, or multiple myeloma (when an abnormal immunoglobulin is produced).

Healthy fluid input and output amounts

The desirable amount of fluid intake and loss in adults ranges from 1,500 to 3,500 mL each 24 hours, with most people averaging 2,500 to 2,600 mL per day. Although these figures are helpful guidelines, the person's health state as well as balance between actual intake and loss must be considered when assessing nursing needs. A person's intake should normally be approximately balanced by output or fluid loss. A general rule is that in healthy adults, the output of urine normally approximates the ingestion of liquids, and the water from food and oxidation is balanced by the water loss through the feces, the skin, and the respiratory process.

Goal of treatment for patients with fluid, electrolyte, and acid-base imbalances

The goal for implementing a plan of care is to maintain or restore optimum function related to fluid, electrolyte, and acid-base balance, alleviate symptoms or side effects of disease or treatment, and prevent complications. Ideally the healthy adult patient will: (1) Maintain an approximate balance between fluid intake and fluid output (average about 2,500 mL fluid intake and output over 3 days). (2) Maintain a urine specific gravity within normal range (1.005 to 1.030). (3) Practice self-care behaviors to promote fluid, electrolyte, and acid-base balance; maintain adequate intake of fluid and electrolytes; and respond appropriately to the body's signals of impending fluid, electrolyte, or acid-base imbalance.

What are the functions of the kidneys in relation to acid-base balance? (detailed)

The kidneys are the third line of defense in acid-base disturbances and play three major roles in regulating acid-base balance. The first is through the excretion of H+ from fixed acids that result from protein and lipid metabolism. The second is accomplished through the reabsorption of the HCO3− that is filtered in the glomerulus, so this important buffer is not lost in the urine. The third is the production of new HCO3− that is released back into the blood. The kidneys also play a role in controlling pH: in conditions of acid load, ammonium (NH4+) production and excretion allow for acid secretion and pH normalization. The renal mechanisms for regulating acid-base balance begin to adjust the pH in hours and continue to function for days until the pH has returned to normal or near-normal range.

Homeostasis of pH - renal mechanisms

The kidneys assist the bicarbonate system by regulating the production of bicarbonate. They also regulate excretion or retention of hydrogen ions.

Major anions in body fluids

The major anions in body fluid are chloride, bicarbonate, and phosphate.

Major cations in body fluids

The major cations in body fluid are sodium, potassium, calcium, hydrogen, and magnesium.

What is the major electrolyte that is of concern during treatment of diabetic ketoacidosis?

The major electrolyte of concern during treatment of DKA is potassium. The initial plasma concentration of potassium may be low, normal, or high, but more often than not, tends to be high (hyperkalemia) from disruption of the cellular sodium-potassium pump (in the face of acidosis). Therefore, the serum potassium level must be monitored frequently. Some of the factors related to treating DKA that affect potassium concentration include rehydration, which leads to increased plasma volume and subsequent decreases in the concentration of serum potassium. Rehydration also leads to increased urinary excretion of potassium. Insulin administration enhances the movement of potassium from the extracellular fluid into the cells. Cautious but timely potassium replacement is vital to avoid dysrhythmias that may occur with hypokalemia. Potassium replacement is withheld only if hyperkalemia is present or if the patient is not urinating.

Anion gap - values

The normal value for an anion gap is 8 to 12 mEq/L (8 to 12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12 to 16 mEq/L (12 to 16 mmol/L). The unmeasured anions in the serum normally account for less than 16 mEq/L of the anion production. A person diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) suggests excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.

What should the nursing care plan include when treating fluid, electrolyte, and acid-base imbalances?

The nursing care plan should include the appropriate nursing diagnoses or collaborative problems, followed by the identification of specific outcomes and associated interventions and then the ability to Evaluate the effectiveness of that care plan.

Phosphate buffer system

The phosphate buffer system is active in ICFs, especially in the renal tubules. It converts alkaline sodium phosphate (Na2HPO4), a weak base, to acid-sodium phosphate (NaH2PO4) in the kidneys.

Carbonic acid-Sodium bicarbonate buffer system

The ratio of carbonic acid (H2CO3), the most common acid in human body fluid, to the body's most common base, bicarbonate (HCO3−), is important for acid-base balance and is the most important buffer system of the body. Normal ECF has a ratio of 20 parts bicarbonate to 1 part carbonic acid. The exact quantities are unimportant for acid-base balance as long as they remain in a 20:1 ratio. Carbonic acid and bicarbonate must be carefully controlled to maintain this ratio; if either is increased or decreased, the 20:1 ratio is no longer in effect and pH will change. This system buffers as much as 90% of the H+ of ECF. The lungs help by regulating the production of carbonic acid resulting from the combination of carbon dioxide and water. The kidneys assist the bicarbonate system by regulating the production of bicarbonate.

Homeostasis of pH - respiratory mechanisms

The ratio of carbonic acid (H2CO3), the most common acid in human body fluid, to the body's most common base, bicarbonate (HCO3−), is important for acid-base balance and is the most important buffer system of the body. The lungs help by regulating the production of carbonic acid resulting from the combination of carbon dioxide and water.

What are the functions of the lungs in relation to acid-base balance (detailed)

The second line of defense against acid-base disturbances when chemical buffers do not minimize H+ changes is control of extracellular CO2 by the lungs. Increased ventilation decreases PCO2 and decreased ventilation increases PCO2. Blood PCO2 and pH are important regulators of ventilation. Chemoreceptors in the brainstem and peripheral chemoreceptors in the carotid and aortic bodies sense changes in PCO2 and pH and alter the ventilation rate. When the H+ concentration is above normal, the respiratory system is stimulated and ventilation is increased. This control of pH occurs within minutes and is maximal within 12 to 24 hours. Although the respiratory response is rapid, it does not completely return pH to normal. It is only about 50% to 75% effective as a buffer system. But in acting rapidly it prevents large changes in pH from occurring while waiting for the more slowly reacting kidneys to respond.

Protein buffer system

The third buffer system is a mixture of plasma proteins and the globin portion of hemoglobin in red blood cells. Because plasma proteins and hemoglobin possess chemical groups that can combine with or liberate hydrogen ions, they tend to minimize changes in pH and serve as excellent buffering agents over a wide range of pH values working both inside and outside the cells. For example, excess hydrogen ions in the blood cross over the plasma membrane of red blood cells and bind to the hemoglobin molecules that are plentiful in each red blood cell.

Third-space fluid shift

Third-space fluid shift refers to a distributional shift of body fluids into the transcellular compartment, such as the pleural, peritoneal (ascites), or pericardial areas; joint cavities; the bowel; or an excess accumulation of fluid in the interstitial space. The fluid moves out of the intravascular spaces (plasma) to any of these spaces. Once trapped in these spaces, the fluid is not easily exchanged with ECF. With third-space fluid shift, a deficit in ECF volume occurs. The fluid has not been lost but is trapped in another body space for a period of time and is essentially unavailable for use. These fluid shifts may be related to a disruption in the colloid osmotic pressure (decreased albumin), increased fluid volume (excess IV fluid replacement, renal dysfunction), increased capillary hydrostatic pressure (heart failure), hyponatremia, or an increase in the permeability of the capillary membrane (gross tissue trauma). A third-space shift may occur as a result of a severe burn, a bowel obstruction, surgical procedures, pancreatitis, ascites, or sepsis. Decreased body weight does not occur as it does with an ECF volume deficit (vomiting or diarrhea), and the fluid loss cannot be measured.

Three main causes of diabetic ketoacidosis (DKA)

Three main causes of DKA are (1) decreased or missed doses of insulin, (2) illness or infection, (3) undiagnosed / untreated diabetes (DKA may be the initial manifestation of type 1 diabetes).

Isotonic solutions are used when ...

Total osmolality close to that of the ECF with the plan to replace ECF that has been lost, such as 0.9% NaCl (which is known as normal saline). Not desirable as routine maintenance solution because it provides only Na+ and Cl−, which are provided in excessive amounts. May be used to expand temporarily the extracellular compartment if circulatory insufficiency is a problem; also used to treat hypovolemia, metabolic alkalosis, mild hyponatremia, hypercalcemia. Also used with administration of blood transfusions.

Sodium - Regulation

Transported out of the cell by the sodium-potassium pump. Regulated by renin-angiotensin-aldosterone system. Elimination and reabsorption regulated by the kidneys. Sodium concentrations affected by salt and water intake.

Metabolic alkalosis - intervention

Treatment for metabolic alkalosis focuses on the underlying condition that puts the patient at risk, replacing electrolytes and restoring fluids. Often when we are talking about replacing fluids, we think intravenously versus oral intake due to the nature of the patient illness. Sufficient chloride must be supplied for the kidney to absorb sodium with chloride (allowing the excretion of excess bicarbonate). NaCl fluids can be used to restore normal fluid volume.

Metabolic acidosis - intervention

Treatment of metabolic acidosis focuses on correcting the condition that caused the disorder and restoring the fluids and electrolytes that have been lost. If the cause of the problem is excessive intake of chloride, treatment obviously focuses on eliminating the source. Supplemental NaHCO3 is the mainstay of treatment for some. In most people with circulatory shock, cardiac arrest, or sepsis, impaired oxygen delivery to the lungs is the primary cause of lactic acidosis (a form of metabolic acidosis) because of the impaired circulatory function and oxygenation to the muscles of the body. With lactic acidosis, treatment measures to improve tissue perfusion are necessary, and with sepsis-related acidosis, treatment of the infection is essential. In chronic metabolic acidosis, low serum calcium levels are treated before the chronic metabolic acidosis is treated to avoid tetany resulting from an increase in pH and a decrease in ionized calcium. Alkalizing agents may be given. Treatment modalities may also include hemodialysis or peritoneal dialysis.

Respiratory acidosis - intervention

Treatment of respiratory acidosis focuses mainly on improving ventilation, potentially with mechanical ventilation with or without oxygen to support the person's respiratory needs, helping to optimize the lung tissue that is functioning with pulmonary toileting - like CPT, suctioning and cough assist, providing adequate hydration to help replace insensible losses, and pharmacological interventions like nebulizers that will open the airways for improved gas exchange. Adequate hydration.

Metabolic alkalosis - risk factors

Vomiting or gastric suction, hypokalemia, potassium-wasting diuretics, alkali ingestion (antacids), renal loss of H+ (e.g., from a steroid or diuretic).

What is the primary solvent in the body?

Water

Body water content

Water makes up 50% to 60% of body weight in a healthy person. 70% of total body water is found in intracellular fluid (ICF, within cells) and 30% is found in extracellular fluid (ECF, outside of cells). The capillary walls and cell membranes separate the intracellular and extracellular compartments.

Diabetic ketoacidosis (DKA)

Without insulin, the amount of glucose entering the cells is reduced, and the production and release of glucose by the liver (gluconeogenesis) are increased, leading to hyperglycemia. In an attempt to rid the body of the excess glucose, the kidneys excrete the glucose along with water and electrolytes (e.g., sodium, potassium). This osmotic diuresis, which is characterized by excessive urination (polyuria), leads to dehydration and marked electrolyte loss. Patients with severe DKA may lose up to 6.5 L of water and up to 400 to 500 mEq each of sodium, potassium, and chloride over a 24-hour period. Another effect of insulin deficiency is the breakdown of fat into free fatty acids. The free fatty acids are converted into ketone bodies by the liver. Ketone bodies are acids; their accumulation in the circulation due to lack of insulin then leads to metabolic acidosis.

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a. "Try to drink at least six to eight glasses of water each day." b. "Try to limit your fluid intake to 1 quart of water daily." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." e. "Temporarily increase foods containing caffeine for their diuretic effect." f. "Weigh yourself daily and report any changes in your weight."

a, c, d, f. In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? a. Remove the IV from the site and start at another location. b. Immediately notify the primary care provider. c. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. d. Aspirate the catheter and attempt to flush again.

a. If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? a. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. d. Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

a. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? a. Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. b. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. c. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. d. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

a. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? a. 1 b. 2 c. 3 d. 4

b. Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. b. Keeping fluids readily available for the patient. c. Emphasizing the long-term outcome of increasing fluids when the patient returns home. d. Planning to offer most daily fluids in the evening.

b. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? a. Encourage foods and fluids with high sodium content. b. Administer oral K supplements as ordered. c. Caution the patient about eating foods high in potassium content. d. Discuss calcium-losing aspects of nicotine and alcohol use.

b. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: a. Kidneys b. Lungs c. Adrenal glands d. Blood vessels

b. The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? a. 1+ pitting edema b. 2+ pitting edema c. 3+ pitting edema d. 4+ pitting edema

c. 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

c. A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? a. A pinched and drawn facial expression b. Deep, rapid respirations. c. Moist crackles heard upon auscultation d. Tachycardia

c. Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. a. 5% dextrose in 0.9% NaCl b. 0.9% NaCl (normal saline) c. Lactated Ringer's solution d. 0.33% NaCl (⅓-strength normal saline) e. 0.45% NaCl (½-strength normal saline) f. 5% dextrose in Lactated Ringer's solution

d, e. 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a. Recording intake and output. b. Testing skin turgor. c. Reviewing the complete blood count. d. Measuring weight daily

d. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? a. Reposition the extremity and raise the height of the IV pole. b. Apply pressure to the dressing on the IV. c. Pull the catheter out slightly and reinsert it. d. Put on gloves; remove the catheter

d. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

Cation

ion that carries a positive electric charge

Metabolic acidosis - ABGs, labs

pH < 7.35, HCO3− < 22 (primary), PaCO2 < 35 mm Hg. Hyperkalemia frequently present. The cardinal feature of metabolic acidosis is a decrease in the serum bicarbonate level. Hyperkalemia may accompany metabolic acidosis as a result of the shift of potassium out of the cells. Later, as the acidosis is corrected, potassium moves back into the cells and hypokalemia may occur. Hyperventilation decreases the CO2 level as a compensatory action. Calculation of the anion gap is helpful in determining the cause of metabolic acidosis. An ECG detects dysrhythmias caused by the increased potassium.

Respiratory acidosis - ABGs, labs

pH <7.35, HCO3− normal or increased, PaCO2 > 45 mm Hg.

Respiratory alkalosis - ABGs, labs

pH > 7.45, HCO3− < 22 (compensatory), PaCO2 < 35 mm Hg (primary).

Metabolic alkalosis - ABGs, labs

pH > 7.45, HCO3− > 26 (primary), PaCO2 > 45 mm Hg. Hypokalemia may be present.

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