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ELECTROLYTES . . .
• These are active chemicals in the body fluids
• These chemicals unite in varying combinations
• It is expressed I terms of mEq per Liter ( a measure of chemical activity rather than mg which is a unit of
weight)
Electrolytes
Cations
• Carry positive charges
• Major cations in the body fluid:
Sodium
Potassium
Calcium
Hydrogen ions
Magnesium
Anions
• Carry negative charges
• Major anions
Chloride
Bicarbonate
Phosphate
Sulfate
Proteinate ions
OUTPUT
• Urine 1,500
• Stool 200
• Insensible
lungs 300
skin 600
HOMEOSTATIC MECHANISMS:
Keep the composition and volume of body fluid within narrow limits of normal.
Kidney Functions
• Regulation of ECF volume and osmolality by selective retention and excretion of body fluids
• Regulation of electrolyte levels in the ECF by selective retention of needed substances and
excretion of unneeded substances
• Regulation of pH of the ECF by rention of hydrogen ions
• Excretion of metabolic wastes and toxic substances
Heart and Blood Vessel Functions
• Pumping action of the heart circulates blood through the kidneys under sufficient pressure to allow
for urine formation
Lung functions
• Through exhalation, the lungs remove approx. 300 ml of water daily
• Has a major role in acid-base balance
Pituitary Functions
• ADH maintain the osmotic pressure of the cells by controlling the retention or excretion of water by
the kidneys and by regulating blood volume.
Adrenal Functions
• Aldosterone and cortisol
Parathyroid Function
• Regulate calcium and phosphate balance by means of parathyroid hormone (PTH)
• PTH influences bone resorption, calcium absorption from the intestines, and calcium reabsorption
from the renal tubules
Other Mechanisms:
Baroreceptors
• Are small nerve receptors that detect changes in pressure within blood vessels and transmit this
information to the central nervous system.
Renin-Angiotensin-Aldosterone System
• Renin is an enzyme that converts angiotensin
• ACE
• Aldosterone is a volume regulator and is also released as serum K+ increases, serum sodium
decreases
ADH and Thirst
• Oral intake is controlled by hypothalamus
• Water excretion is controlled by ADH, Aldosterone and baroreceptors
• ADH determines whether the urine that is excreted is concentrated or dilute
Osmoreceptors
• Sense changes in Na+ concentration
Release Of Atrial Natriuretic peptide
• ANP is released by cardiac cells in the atria in response to increased atrial pressure.
Causes of FVD:
• Vomiting
• Diarrhea
• GI suctioning
• Sweating
• Decreased intake (inability to gain access to fluids)
Clinical Characteristics
• Acute weight loss
• Decreased skin turgor
• Oliguria
• Concentrated urine
• Postural hypotension
• Weak rapid pulse
• Flattened neck veins
• Increased temperature
• Decreased CVP
• Cool clammy skin
• Thirst
• Anorexia
• Muscle weakness and cramps
Gerontologic Considerations:
• Fluid balance in the elderly client is often marginal because of physiologic changes
• Decrease muscle mass
• Decreased cardiorespiratory functions
• Hormonal regulatory functions
• Assessment should be modified from that of younger adults
• Perform functional assessment
• Some elderly clients deliberately restrict their fluid intake to avoid embarrassing episodes of
incontinence
Clinical Manifestations:
• Edema
• Distended neck veins
• Crackles
• Tachycardia
• Increased blood pressure
• Pulse pressure
• Central venous pressure
• Increased weight
• Increased urine output
• Shortness of breath
IMPORTANCE OF SODIUM
• It is the most abundant electrolyte in the ECF (135 to 145 mEq/L)
Primary determinant of ECF osmolality
Primary regulator of ECF volume
• Control water distribution throughout the body
• Also function in establishing the electrochemical state necessary for muscle contraction and transmission of
nerve impulses.
Nursing Management:
• Identify clients at risks for hyponatremia
• Monitor fluid intake and output
• Monitor body weights
• Alert for CNS changes, neurologic signs
Causes:
• Unconscious patients
• Very old
• Very young
• Cognitively impaired
• Diabetes insipidus
• Heat-stroke
• Near-drowning in sea water 500mEq/L
• IV administration of hypertonic saline or excessive use of Na+ bicarbonate
Clinical Manifestations:
• Restlessness & weakness
• Disorientation & delusions
• Thirst
• Dry, swollen tongue
• Sticky mucous membranes
• Postural hypotension
Medical Management:
• Administration of hypotonic solution (.3%NaCl) or isotonic nonsaline solution (D5water
• General Rule: serum Na+ level is reduced at a rate no faster than 0.5 to 1 mEq/L
Nursing Management:
• Obtain history of the client
• Monitor changes in behavior
• Monitor temperature and thirst
• Prevention and correcting hypernatremia
SIGNIFICANCE OF POTASSIUM
• It is the major intracellular electrolyte
• 98% of the body’s K+ is inside the cells
• Influences skeletal and cardiac muscle activity
• Primary regulator of K+ balance is the KIDNEY (80%, 20% bowel and sweat)
Potassium Deficit (Hypokalemia)
Causes:
• Vomiting
• Frequent gastric suction
• Diarrhea
• Alterations in Acid-base balance
• Hyperaldosteronism
• Medications: K+ lossing diuretics
• Patients with persistent insulin hypersecretion
• Unable and unwilling to eat normal diet
Clinical Manifestations:
• Fatigue
• Anorexia
• Nausea and vomiting
• Muscle weakness
• Leg cramps
• Paresthesias
• Decreased bowel motility
• Cardiac or respiratory arrest
• Death
Medical Management:
• Increased K+ intake in daily diet (59 to 100 mEq/day)
• Oral or IV replacement therapy
Nursing Management:
• Monitor for its early presence in client’s at risk
• Monitor and assess for dysrhythmias
• Monitor intake and output (40mEq K+/L of urine output)
• Refer if urine output is less than 20mL/Hr for 2 consecutive hours: STOP!
Clinical Manifestations:
• Cardiac effects
• Peaked,narrow T waves
• ST-segment depression
• Short QT-interval
• Prolonged PR-interval followed by disappearance of P waves
• Prolongation of QRS complex
• Ventricular dysrhythmias and cardiac arrest
• Skeletal muscle weakness and paralysis
• Quadriplegia
• Paralysis of the respiratory and speech muscles
Assessment and Diagnostic Findings:
• Serum potassium levels
• Electrocardiogram
• Arterial Blood Gas Analysis: Metabolic Acidosis
Medical Management:
• ECG and repeat serum K+ should be obtained
• Restriction of dietary potassium and K= containing medications
• Administer Calcium gluconate(antagonizes K+)
• IV administration of insulin and a hypertonic dextrose solution (30 min. onset)
• Cation exchange: Hemodialysis or peritoneal dialysis
Nursing Management:
• Identify clients at risks
• Physical assessment
• Check serum K+ levels
• Blood sample should be delivered to laboratory ASAP
SIGNIFICANCE OF CALCIUM
• It is the major component of bones and teeth
• More than 99% of the body’s Ca is located in the skeletal system
• Transmit nerve impulse
• Regulate muscle contraction and relaxation
• Plays a role in blood coagulation
• 8.5 to 10.5 mg/dL ; 2.1 to 2.6 mmol/L
Medical Management:
• Administer parenteral calcium salts:Ca gluconate,Ca chloride, Ca gluceptate
• IV calcium should be diluted with D5W and given as IV bolus or slow IV infusion
Calcium Excess (Hypercalcemia)
Causes:
• Malignancies
• Hyperparathyroidism
• Immobilization
• Thiazide diuretics
Clinical Manifestations:
• Muscle weakness
• Incoordination
• Anorexia
• Nausea
• vomiting
• Constipation
• Abdominal
• & bone pain
• Polyuria
• Lethargy & confusion
Assessment and Diagnostic Findings:
• Serum Calcium level
• Electrocardiogram
• Double-antibody PTH test
• X-rays
Medical Management:
• Treat underlying cause
• Administer fluids to dilute serum Ca+
• Restrict dietary intake of calcium
• Administer furosemide
• Administer IV phospahate(reciprocal drop of Ca+)
• Adminster Calcitonin
• Lowers serum Ca+ level
• Reduces bone resorption
• Increase s deposit of Ca+ & phosphorus in the bones
• Increases urinary excretion of Ca+ & phosphorus
Nursing Management:
• Increase patients mobility
• Encourage oral fluids
• Watch out for ECG changes
• Health teachings
SIGNIFICANCE OF MAGNESIUM
• Plays a role both in carbohydrate and protein metabolism
• Mg balance is important in neuromuscular function,irritability and contractility
• It has sedative effect at the neuromuscular junction
• Has effect on the cardiovascular system
• Have a direct effect on the peripheral arteries and arterioles
SIGNIFICANCE OF PHOSPHORUS
• It is essential to function of muscle and red blood cells, the formation od adenosine triphosphate (ATP) and
2,3- diphosphoglycerate
• Normal values: 2.5 to 4.5 mg/dL
• 0.8 to 1.5 mmol/L
• 85% is located in the bones & teeth
• 14% tissue
• Less than 1% in the ECF
• It decreases with age
*** Vit. D regulates intestinal ion reabsorption, therefore a deficiency of vit D may cause decreased CA+ ,
phosphorus levels = OSTEOMALACIA
Clinical Manifestations:
• Irritablity
• Fatigue
• Apprehension
• Weakness and numbness
• Paresthesias
• confusion
• Seizures
• Tissue anoxia
• Hypoxia– tachypnea—resp. alkalosis
Assessment and Diagnostic Findings:
• Serum phosphorus level: low
• Insulin affects results of phosphorus= a slight decrease
• PTH : increased in parathyroidism
• X-ray: skeletal changes
• Alkaline Phosphatase: increased
Medical Management:
• Monitor lphosphorus levels
• Administration of adequate amount of phosphorus oral or IV
• Carefully check the infusion site because of tissue sloughing & necrosis
Nursing Management:
• Monitor of phosphorus levels
• Report and document early signs of hypophosphatemia (LOC)
Phosphorus Excess: Hyperphosphatemia
• Is a serum phosphorus level that exceeds normal
Causes:
• Renal failure
• Chemotherapy
• Hypoparathyroidism
• Respiratory acidosis
• Increased phosphorus intake
Clinical Manifestations:
• Has reciprocal relationship bet. Ca+
• Symptoms are similar to Ca+ depletion
• Tetany
• Tingling sensations in fingertips & around mouth
• Muscle weakness
• Nausea and vomiting
• Anorexia
• tachycardia
Assessment and Diagnostic Findings:
• Serum phosphorus level
• X-ray studies : skeletal changes with abnormal bone development
• BUN and CREATININE: assess renal function
• PTH : decreased in hypoparathyroidism
Medical Management:
• Treatment is directed to the underlying disorder
• Dialysis
• Dietary restriction
• Administration of Vit. D preparations
Nursing Management:
• Health teachings on foods high in phosphorus
• Monitor urine output and serum levels of phosphorus.
SIGNIFICANCE OF CHLORIDE
• It is the major anion of the ECF
• More in the interstitial and lymph fluid compartments than in the blood
• It is contained in the gastric & pancreatic juices & sweat
• Direct proportion to sodium
• Bicarbonate has an inverse relationship with Chloride
• Normal level: 96 to 106 mEq/L
Nursing Care of Clients with Burns
I. Background
A. Definition
1. A burn is an injury resulting from heat, chemicals, radiation, electrical current
2. The transfer of energy from source of heat causes physiologic changes and damage to tissues
3. Systemic infection is the leading cause of death in major burn clients
C. Types of burns
1. Thermal
a. Results from exposure to dry heat, as with flame; or moist heat, as with steam or hot
fluids
b. Most common type of burn injuries
2. Chemical
a. Direct skin contact with acid or alkaline agents and agent destroys tissue protein
b. Alkali burns are deeper and more severe than acid burns
c. Organic compound burns, as from petroleum distillates, cause cutaneous damage
through fat solvent action; also cause liver and kidney damage
3. Electrical
a. Severity dependent on type and duration of current, and amount of voltage
b. Destructive process from electrical burn is concealed, persists for weeks post
c. Electricity follows path of least resistance: along muscles, bones, blood vessels, nerves
d. Blood coagulation at site of injury leads to impaired blood flow and necrosis of tissue
e. Alternating current from manufactured electricity burns results in sustained muscles
contractions and respiratory arrest
f. Direct current, as with a lightening strike, is high voltage for an instant; have entry and
exit wounds and flash over the skin, which can mean less internal damage
4. Radiation
a. Often from sunburn or radiation treatments as with treatment for cancer
b. Functions of skin are left intact
Severity
Minor Burns
- Less than 15% TBSA burn in adults less than 40 years old.
- Less than 10% TBSA burn in adults more than 40 years old.
- Less than 10% TBSA burn in children below 10 years old.
With
- Less than 2% TBSA full thickness burn and no cosmetic or functional risk to face, eyes,
ears, hands, feet or perineum.
Moderate Burns
- 15-25% TBSA burn in adults less than 40 years old.
- 10-20% TBSA burn in adults more than 40 years old.
- 10-20% TBSA burn in children less than 10 years old.
With
- Less than 10% TBSA full thickness burn without cosmetic or functional risk to face,
eyes, ears, hands, feet or perineum.
Severe/Major Burns
>25% TBSA burn in adults less than 40 years old.
>20% TBSA burn in adults more than 40 years old.
>20% TBSA burn in children less than 10 years old.
or
- Burns face, eyes, ears, hands, feet, or perineum that will result in cosmetic or
functional disability.
or
- High voltage electrical burn injury.
or
- All burn injuries with concomitant inhalation injury or major trauma.
E. Process of healing with burn occurs more slowly than with other types of injuries
1. Physiologic events
a. Hemostasis: Platelets aggregate, thrombus formation, wound walled off
b. Inflammation: Local vasodilatation; increased capillary permeability
c. Proliferation: Granulation tissue begins to form to reepithelialization (peak 14 days post
burn)
d. Remodeling: Collagen fibers reorganized, scars contract
2. Two types of excessive scarring, if burn injury extended into dermal layer
a. Hypertrophic scar: overgrowth of dermal tissue but remains within boundaries of wound
b. Keloid: scar extends beyond boundaries of wound
Goals of collaborative management include:
- Maintaining airway breathing, circulation, and fluid balance.
- Preventing infection.
- Supporting nutrition and healing.
- Relieving pain.
- Preventing disability.