 Help maintain body

temperature and cell

shape

 Help transport
nutrients, gasses
and wastes
 Fluid
 Isused to indicate that other
substances are also found in
these compartments and that
they influence the water balance
in and between compartments.
 Fluids
 60% of an adult’s body weight
* 70 Kg adult male: 60% X 70= 42
Liters
 Infants = more water
 Elderly = less water
 More fat = ↓water
 More muscle = ↑water
 Infants and elderly - prone to fluid
imbalance
 60 %

Intracellular Fluid 40% or Extracellular Fluid 20% or 1/3

2/3

Arterial
Fluid 2%
Intravascular Interstitial
15% or 3/4
5% or 1/4
Venous
Fluid 3% Transcellular fluid 1-2%
ie csf, pericardial,
synovial, intraocular,
sweat
 Third-space fluid shift/Third
“spacing”

- loss of ECF into a space that

does not contribute to equilibrium
between ICF and ECF
ie ascites, burns, peritonitis,
bowel obstruction, massive
bleeding
 Fluid Movement From
Pressure Changes
 fluids from different compartments
move from one compartment to the
other to maintain fluid balance.

 movementis dictated by the transport

mechanism principle :
A. PASSIVE
B. ACTIVE TRANSPORT
A. Passive Transport Process

– substances transported across the

membrane w/o energy input from the
cell

- high to low concentration

2 Types of Passive Transport
1. Diffusion – substances/solutes move from high
concentration to low concentration
ie exchange of O2 and CO2 b/w pulmonary
capillaries and alveoli
2. Filtration – water and solutes forced
through membrane by fluid or hydrostatic
pressure from intravascular to interstitial
area
- solute containing fluid (filtrate)
from higher pressure to lower pressure
B. Active Transport Process

- Cell moves substances across a

membrane through ATP because:
2. They may be too large
3. Unable to dissolve in the fat core
4. Move uphill against their concentration
gradient
Types of Active Transport
1. Active transport – requires protein carriers
using ATP to energize it
ie Amino acids
Sodium potassium pump – 3Na out, 2K in

2. Endocytosis – moves substances into the

cell

3. Exocytosis – moves substances out of the

cell
Active Transport
Osmosis

 Movement of water from low solute to high

solute concentration in order to maintain balance
between compartments.

 Osmotic pressure – amount of hydrostatic

pressure needed to stop the flow of water by
osmosis

 Oncotic pressure – osmotic pressure exerted by

proteins
Osmosis
Osmosis

Diffusion
Regulation of Body Fluid

1. The Kidney
 Regulates primarily fluid output by
urine formation 1.5L
 Releases RENIN
 Regulates sodium and water balance
2. Endocrine regulation
 thirst mechanism – thirst
center in hypothalamus
 ADH increase water
reabsorption on collecting
duct
 Aldosterone increases
Sodium and water retention
retention in the distal
nephron
 ANP Promotes Sodium
excretion and inhibits thirst
mechanism
Atrial Natriuretic Peptide: Regulates Na+ & H2O Excretion
 ADH Regulation
 ADH - produced by the Hypothalamus
- stored and secreted by the posterior
pituitary gland
 less water in plasma, ADH secreted to
conserve water by reducing urine output
 fluid overload in plasma, ADH secretion
stops to excrete fluid in the kidneys by
increasing urine output
 ADH Disorder

 Abnormally high ADH concentration - SIADH

reduced urine output (oliguria)
water retention (fluid overload)

 Abnormally low ADH – Diabetes Insipidus

increased urine output (polyuria)
water loss (fluid deficit)
3. Gastro-intestinal regulation
- GIT digests food and absorbs water
- Only about 200 ml of water is
excreted in the fecal material per day

4. Heart and Blood Vessel Functions

- pumping action of heart circulates
blood through kidneys

5. Lungs – insensible water loss through

respiration
Other Mechanisms

1. Baroreceptors – carotid sinus and aortic

arch
- causes vasoconstriction and increased
blood pressure

Dec arterial pressure SNS inc cardiac

rate, contraction, contractility, circulating
blood volume, constriction of renal
arterioles and increased aldosterone
2. Osmoreceptors – surface of
hypothalamus senses changes in Na
concentration

Inc osmotic pressure neurons

dehydrated release ADH
Evaluation of fluid status
Osmolality – concentration of fluid that
affects movement of water between fluid
compartments by osmosis
- measures the solute concentration per
kg in blood and urine
- reported as mOsm/kg
- normal value= 280-300 mOsm/kg

Osmolarity – concentration of solutions

- mOsm/L
Intake and Output

 I and O must be equal

 2.6 L per day
 Essential = Measurable = Sensible
 Non essential = estimated Measurement=
Insensible
 Sources of Fluids
Fluid Intake
1. Exogenous sources
 Fluid intake
2, 600 ml
oral liquids – 1, 300 ml
water in food – 1, 000 ml
water produced by metabolism – 300 ml

 IVF
 Medications
 Blood products

2. Endogenous sources
 By products of metabolism
 secretions
 Fluid Output

Sensible loss
 Urine - 1, 500 ml
 Fecal losses – 200 ml 2, 600 ml

Insensible loss
 skin – 600 ml
 Lungs – 300 ml
 I&O Imbalance

Fluid Volume Deficit

 ↑output, normal intake

 Normal output, ↓ intake
 No intake or prolonged decreased intake
Causes of FVD

 Vomiting, diarrhea, GI suctioning,

sweating
 Diabetes Insipidus
 Adrenal insufficiency
 Osmotic diuresis
 Hemorrhage
 3rd space fluid shift
Assessment of FVD

 ICF
cellular dehydration Acidosis
 ITF
skin poor skin turgor
 IVF
artery ↓BP, pulse (rapid thready)
vein ↓CVP, ↓PAWP
Clinical manifestations
 Weight loss
 Oliguria
 Concentrated urine
 Postural hypotension
 Flattened neck veins
 Increased Temp
 Dec CVP
 Thirst, anorexia
 Muscle weakness and cramps
Laboratory

 BUN:Crea > 20:1

 Inc Hct – RBC suspended in Dec plasma
volume
 Dec K – GI and renal losses
 Inc K – adrenal insufficiency
 Dec Na – inc thirst and ADH
 Inc Na – insensible losses and DI
Medical Management

 Oral intake when mild

 IV route, acute or severe
 Isotonic fluids ie LR for hypotensive
patients to expand plasma volume
 Assess I and O, weight, CVP, LOC, breath
sounds and skin color
 Fluid challenge test – 100-200 ml x 15 min
Nursing Management

 Monitor and measure I and O

 Monitor VS closely
 Monitor skin turgor and tongue furrows
 Monitor urinary concentration
 Monitor mental function
Fluid Volume Excess

 ↑ intake, normal output

 Normal intake, ↓ output
 No output
Nursing Management

 Measure intake and output

 Weigh daily 2 lb wt gain = 1 L fluid
 Assess breath sounds
 Monitor degree of edema
ie ambulatory – feet and ankles
bedridden – sacral area
 Promote rest – favors diuresis/inc venous return
 Administer appropriate medication
Causes of FVE

 Heart failure, renal failure, cirrhosis of the liver –

d/t aldosterone stimulation/Congestion
 Increased consumption of table salt
 Excessive administration of Na containing fluids
in a patient w/ impaired regulatory mechanism
 SIADH
Assessment of FVE
 ICF
cellular edema ↓LOC
pulmonary edema crackles (bibasilar), wheezing,
shortness of breath, Inc RR

 ITF
skin bipedal pitting edema, periorbital edema and
ANASARCA

 IVF
artery ↑BP, pulse (rapid bounding)
vein ↑CVP, ↑PAWP
Clinical Manifestations

 Distended neck veins

 Tachycardia
 Inc weight
 Increased urine output
 Shortness of breath and
wheezing/crackles
 Inc CVP
Edema
 common manifestation of FVE
 d/t inc capillary fluid pressure, decreased
capillary oncotic pressure, increased
interstitial oncotic pressure
 Localized or generalized
 Etiology: obstruction to lymph flow, plasma
albumin level < 1.5-2 g/dl, burns and
infection, Na retention in ECF, drugs
 Labs: Dec Hct, respiratory alkalosis and
hypoxemia, dec serum Na and osmolality,
inc BUN Crea, Dec Urine SG, dec urine
Na level

 Mgmt: diuretics, fluid restriction, elevation

of extremities, elastic compression
stockings, paracentesis, dialysis
Laboratory

 Dec BUN
 Dec Hct
 CRF – serum osmolality and Na level dec
 Cxr – pulmonary congestion
Medical Management

 Discontinue administration of Na solution

 Diuretics
ie Thiazide – block Na reabsorption in
distal tubule
Loop diuretics – block Na reabsorption
in ascending loop of Henle
 Restrict fluid and salt intake
 Dialysis
Types of Fluid

• Tonicity - ability of solutes to cause osmotic driving

forces
Isotonic Fluid
- no movement of fluid.
Isotonic Fluids
 0.9% NaCl/ Normal Saline/NSS
-Na=154
-Cl=154
-308 mOsm/L
- not desirable as routine maintenance solution
- only solution administered with blood products
Rx: hpovolemia, shock, DKA, metabolic
alkalosis, hypercalcemia, mild NA deficit
CI: caution in renal failure, heart failure and
edema
 D5W - 5% Dextrose in water
- 170 cal and free water
- 252 mOsm/L
Rx: hypernatremia, fluid loss and dehydration
CI: early post op when ADH inc d/t stress, sole
treatment in FVD (dilutes plasma), head injury
(inc ICP), flid resuscitation (hyperglycemia),
caution in renal and cadiac dse (fluid overload),
px with NA deficiency (peripheral circulatory
collapse and anuria)

 10% Dextran 40 in 5% Dextrose isotonic (252

mOsm/L)
 Lactated Ringer’s Solution isotonic
- Na 130 mEq/L
- K 4 mEq/L
-Ca 3 mEq/L
- Cl 109 mEq/L
- 273 mOsm/L
Rx:hypovelemia, burns, flids lost as
bile/diarrhea, acute blood loss
CI: ph>7.5, lactic acidosis, renal
failure(cause HyperK)
Hypotonic Fluid
- fluid will enter the cell, the cell will
swell
Hypotonic Fluids

 0.45% NaCl (half strength saline)

- provides Na, Cl and free water
- Na 77 mEq/L
- Cl 77 mEq/L
- 154 mOsm/L
Rx: hypertonic dehydration, Na and Cl
depletion, gastric fluid loss
CI : 3rd space fluid shifts and inc ICP
Hypertonic Fluid
- fluid will go out from the cell, the cell
will shrink
Hypertonic Fluids
 3% NaCl (hypertonic saline)
- no calories
- Na 513 mEq/L
- Cl 513 mEq/L
-1026 mOsm/L
Rx: critical situations to treat HypoNa, assist in removing
ICF excess
CI: administered slowly and cautiously (IVF overload and
pulmonary edema)
 5% NaCl
 D10W - 10% Dextrose in water hypertonic (505
mOsm/L)
 D10W - 20% Dextrose in water hypertonic (1011
mOsm/L)
 D50W - 50% Dextrose in water hypertonic (1700
mOsm/L)

 D5NS - 5% Dextrose & 0.9NaCl hypertonic (559

mOsm/L)
 D10NS - 10% Dextrose & 0.9NaCl hypertonic (812
mOsm/L)
 D5LR - 5% Dextrose in Lactated Ringers hypertonic (524
mOsm/L
Colloid solutions

 Dextran 40 in NS or 5% D5W
- volume/plasma expander
- decrease coagulation
- remains for 6H in circulatory system
Rx: hypovolemia in early shock, improve
microcirculation (dec RBC aggregation)
CI: hemorrhage, thrombocytopenia, renal
disease and severe dehydration
ELECTROLYTES
 elements or compounds when dissolved in
water will dissociate into ions and are able
to conduct an electric current.

FUNCTIONS:
1. Regulate fluid balance and osmolality
2. Transmission of nerve impulse
3. Stimulation of muscle activity
 ANIONS - negatively
charged ions:
Bicarbonate, chloride,
PO4-, CHON

 CATIONS - positively
charged ions:
Sodium, Potassium,
magnesium, calcium
Regulation of Electrolyte Balance

1. Renal regulation
 Occurs by the process of glomerular
filtration, tubular reabsorption and tubular
secretion
 Urine formation
 If there is little water in the body, it is conserved
 If there is water excess, it will be eliminated
2. Endocrinal regulation
 Aldosterone promotes Sodium retention
and Potassium excretion
 ANP promotes Sodium excretion
 Parathormone increased bone resorption
of Ca, inc Ca reabsorption from renal tubule
or GI tract
 Calcitoninoppose PTH
 Insulin and Epinephrine – promotes uptake
of Potassium by cells
The Cations

 SODIUM
 POTASSIUM
 CALCIUM
 MAGNESIUM
SODIUM (Na)

 MOST ABUNDANT cation in the ECF

 135-145 mEq/L
 Aldosterone increases sodium reabsorption
 ANP increases sodium excretion
 Cl accompanies Na

FUNCTIONS:
1. assists in nerve transmission and muscle
contraction
2. Major determinant of ECF osmolality
3. Primary regulator of ECF volume
a. HYPERNATREMIA
 Na > 145 mEq/L

 Assoc w/ water loss or sodium gain

 Etiology: inadequate water intake, excessive

salt ingestion /hypertonic feedings w/o water
supplements, near drowning in sea water,
diuretics, Diabetes mellitus/ Diabetes Insipidus
S/SX: polyuria, anorexia, nausea, vomiting, thirst,
dry and swollen tongue, fever, dry and flushed
skin, restlessness, agitation, seizures, coma,
muscle weakness, crackles, dyspnea, cardiac
manifestations dependent on type of
hypernatremia

Dx: inc serum sodium and Cl level, inc serum

osmolality, inc urine sp.gravity, inc urine
osmolality
Mgmt: sodium restriction, water restriction, diuretics,
isotonic non saline soln. (D5W) or hypotonic soln,
Desmopressin Acetate for Diabetes Insipidus

Nsg considerations
History – diet, medication
Monitor VS, LOC, I and O, weight, lung sounds
Monitor Na levels
Oral care
initiate gastric feedings slowly
Seizure precaution
b. HYPONATREMIA

 Na < 135 mEq/L

 Etiology: diuretics, excessive

sweating, vomiting, diarrhea, SIADH,
aldosterone deficiency, cardiac, renal,
liver disease
 Dx:
dec serum and urine sodium and
osmolality, dec Cl

 s/sx:headache, apprehension,
restlessness, altered LOC,
seizures(<115meq/l),coma, poor skin
turgor, dry mucosa, orthostatic
hypotension, crackles, nausea,
vomiting, abdominal cramping
Mgmt: sodium replacement, water restriction,
isotonic soln for moderate hyponatremia,
hypertonic saline soln for neurologic
manifestations, diuretic for SIADH

Nsg. Consideration
Monitor I and O, LOC, VS, serum Na
Seizure precaution
diet
Hyponatremia

Hypernatremia
Potassium (K)
 MOST ABUNDANT cation in the ICF
 3.5-5.5 mEq/L
 Major electrolyte maintaining ICF balance
 maintains ICF Osmolality
 Aldosterone promotes renal excretion of K+
 Mg accompanies K

FUNCTIONS:
1. nerve conduction and muscle contraction
2. metabolism of carbohydrates, fats and proteins
3. Fosters acid-base balance
a. HYPERKALEMIA
 K+ > 5.0 mEq/L

 Etiology: IVF with K+, acidosis, hyper-alimentation and

excess K+ replacement, decreased renal excretion,
diuretics, Cancer

 s/sx: nerve and muscle irritability, tachycardia, colic,

diarrhea, ECG changes, ventricular dysrythmia and
cardiac arrest, skeletal muscle weakness, paralysis
 Dx: inc serum K level
ECG: peaked T waves and wide QRS
ABGs – metabolic acidosis
Mgmt:
K restriction (coffee, cocoa, tea, dried fruits, beans, whole grain
breads, milk, eggs)
diuretics
Polystyrene Sulfonate (Kayexalate)
IV insulin
Beta 2 agonist
IV Calcium gluconate – WOF Hypotension
IV NaHCo3 – alkalinize plasma
Dialysis

Nsg consideration:
Monitor VS, urine output, lung sounds, Crea, BUN
monitor K levels and ECG
observe for muscle weakness and dysrythmia, paresthesia and GI
symptoms
b. HYPOKALEMIA

 K+ < 3.5 mEq/L

 Etiology: use of diuretic, corticosteroids and penicillin,

vomiting and diarrhea, ileostomy, villous adenoma,
alkalosis, hyperinsulinism, hyperaldosteronism

 s/sx: anorexia, nausea, vomiting, decreased bowel

motility, fatigue, muscle weakness, leg cramps,
paresthesias, shallow respiration, shortness of breath,
dysrhythmias and increased sensitivity to digitalis,
hypotension, weak pulse, dilute urine, glucose
intolerance
Dx: dec serum K level
ECG - flattened , depressed T waves, presence of “U”
waves
ABGs - metabolic alkalosis

Medical Mgmt:
diet ( fruits, fruit juices, vegetables, fish, whole grains,
nuts, milk, meats)
oral or IV replacement

Nsg mgmt:
monitor cardiac function, pulses, renal function
monitor serum potassium concentration
IV K diluted in saline
monitor IV sites for phlebitis
Normal ECG

Hypokalemia

Hyperkalemia
 CALCIUM (Ca)
 Majority of calcium - bones and teeth
 Normal serum range 8.5-10.5 mg/dL
 Ca has an inverse relationship with PO4

FUNCTIONS
1. formation and mineralization of bones/teeth
2. muscular contraction and relaxation
3. cardiac function
4. blood coagulation
5. Promotes absorption and utilization of Vit B12
Regulation:
 GIT absorbs Ca+ in the intestine with the help
of Vitamin D
 Kidney Ca+ is filtered in the glomerulus and
reabsorbed in the tubules
 PTH increases Ca+ by bone resorption, inc
intestinal and renal Ca+ reabsorption and
activation of Vitamin D
 Calcitonin reduces bone resorption, increase
Ca and Phosphorus deposition in bones and
secretion in urine
a. HYPERCALCEMIA
 Serum calcium > 10.5 mg/dL
 Etiology: Overuse of calcium supplements and
antacids, excessive Vitamin A and D, malignancy,
hyperparathyroidism, prolonged immobilization, thiazide
diuretic
 s/sx: anorexia, nausea, vomiting, polyuria, muscle
weakness, fatigue, lethargy

 Dx: inc serum Ca

ECG: Shortened QT interval, ST segments
inc PTH levels
xrays - osteoporosis
 Mgmt:
0.9% NaCl
IV Phosphate
Diuretics – Furosemide
IM Calcitonin
corticosteroids
dietary restriction (cheese, ice cream, milk, yogurt,
oatmeal, tofu)

Nsg Mgmt:
Assess VS, apical pulses and ECG, bowel sounds, renal
function, hydration status
safety precautions in unconscious patients
inc mobility
inc fluid intake
monitor cardiac rate and rhythm
b. HYPOCALCEMIA
 Calcium < 8.5 mg/dL
 Etiology: removal of parathyroid gland during
thyroid surgery, Vit. D and Mg deficiency,
Furosemide, infusion of citrated blood,
inflammation of pancreas, renal failure, thyroid
CA, low albumin, alkalosis, alcohol abuse,
osteoporosis (total body Ca deficit)

 s/sx: Tetany, (+) Chovstek’s (+) Trousseaus’s,

seizures, depression, impaired memory,
confusion, delirium, hallucinations, hypotension,
dysrythmia
 Dx:
dec Ca level
ECG: prolonged QT interval
 Mgmt:
Calcium salts
Vit D
diet (milk, cheese, yogurt, green leafy vegetables)

 Nsg mgmt
monitor cardiac status, bleeding
monitor IV sites for phlebitis
seizure precautions
reduce smoking
Magnesium Mg
 Second to K+ in the ICF
 Normal range is 1.3-2.1 mEq/L

FUNCTIONS
1. intracellular production and utilization of
ATP
2. protein and DNA synthesis
3. neuromuscular irritability
4, produce vasodilation of peripheral arteries
a. HYPERMAGNESEMIA

 M > 2.1 mEq/L

 Etiology: use of Mg antacids, K sparing

diuretics, Renal failure, Mg medications, DKA,
adrenocortical insufficiency

 s/sx: hypotension, nausea, vomiting, flushing,

lethargy, difficulty speaking, drowsiness, dec
LOC, coma, muscle weakness, paralysis,
depressed tendon reflexes, oliguria, ↓RR
 Mgmt: discontinue Mg supplements
Loop diuretics
IV Ca gluconate
Hemodialysis

Nsg mgmt:
monitor VS
observe DTR’s and changes in LOC
seizure precautions
b. HYPOMAGNESEMIA

 Mg < 1.5 mEq/l

 Etiology: alcohol w/drawal, tube feedings, diarrhea,

fistula, GIT suctioning, drugs ie antacid,
aminoglycosides, insulin therapy, sepsis, burns,
hypothermia

 s/sx: hyperexcitability w/ muscle weakness, tremors,

tetany, seizures, stridor, Chvostek and Trousseau’s
signs, ECG changes, mood changes
 Dx: serum Mg level
ECG – prolonged PR and QT interval, ST
depression, Widened QRS, flat T waves
low albumin level

 Mgmt:
diet (green leafy vegetables, nuts, legumes,
whole grains, seafood, peanut butter, chocolate)
IV Mg Sulfate via infusion pump

 Nsg Mgmt:
seizure precautions
Test ability to swallow, DTR’s
Monitor I and O, VS during Mg administration
The Anions

 CHLORIDE
 PHOSPHATES
 BICARBONATES
Chloride (Cl)
 The MAJOR Anion in the ECF
 Normal range is 95-108 mEq/L
 Inc Na reabsorption causes increased Cl
reabsorption

FUNCTIONS
1. major component of gastric juice aside from H+
2. together with Na+, regulates plasma osmolality
3. participates in the chloride shift – inverse
relationship with Bicarbonate
4. acts as chemical buffer
a. HYPERCHLOREMIA

 Serum Cl > 108 mEq/L

 Etiology: sodium excess, loss of bicarbonate

ions

 s/sx: tachypnea, weakness, lethargy, deep

rapid respirations, diminished cognitive ability
and hypertension, dysrhytmia, coma
 Dx: inc serum Cl
dec serum bicarbonate

Mgmt:
Lactated Ringers soln
IV Na Bicarbonate
Diuretics

Nsg mgmt:
monitor VS, ABGs, I and O, neurologic, cardiac
and respiratory changes
b. HYPOCHLOREMIA
 Cl < 96 mEq/l

 Etiology: Cl deficient formula, salt restricted

diets, severe vomiting and diarrhea

 s/sx: hyperexcitability of muscles, tetany,

hyperactive DTR’s, weakness, twitching, muscle
cramps, dysrhytmias, seizures, coma
 Dx: dec serum Cl level
ABG’s – metabolic alkalosis

Mgmt:
Normal saline/half strength saline
diet ( tomato juice, salty broth, canned
vegetables, processed meats and fruits
avoid free/bottled water)

Nsg mgmt:
monitor I and O, ABG’s, VS, LOC, muscle
strength and movement
Phosphates (PO4)
 The MAJOR Anion in the ICF
 Normal range is 2.5-4.5 mg/L
 Reciprocal relationship w/ Ca
 PTH inc bone resorption, inc PO4 absorption
from GIT, inhibit PO4 excretion from kidney
 Calcitonin increases renal excretion of PO4

FUNCTIONS
1. component of bones
2. needed to generate ATP
3. components of DNA and RNA
a. HYPERPHOSPHATEMIA

 Serum PO4 > 4.5 mg/dL

 Etiology: excess vit D, renal failure, tissue

trauma, chemotherapy, PO4 containing
medications, hypoparathyroidism

 s/sx: tetany, tachycardia, palpitations, anorexia,

vomiting, muscle weakness, hyperreflexia,
tachycardia, soft tissue calcification
 Dx: inc serum phosphorus level
dec Ca level
xray – skeletal changes

Mgmt:
diet – limit milk, ice cream, cheese, meat, fish,
carbonated beverages, nuts, dried food, sardines
Dialysis

Nsg mgmt:
dietary restrictions
monitor signs of impending hypocalcemia and changes
in urine output
b. HYPOPHOSPHATEMIA
 Serum PO4 < 2.5 mg/dl

 Etiology: administration of calories in severe

CHON-Calorie malnutrition (iatrogenic), chronic
alcoholism, prolonged hyperventilation, poor
dietary intake, DKA, thermal burns, respiratory
alkalosis, antacids w/c bind with PO4, Vit D
deficiency

 s/sx: irritability, fatigue, apprehension,

weakness, hyperglycemia, numbness,
paresthesias, confusion, seizure, coma
 Dx: dec serum PO4 level

Mgmt:
oral or IV Phosphorus correction
diet (milk, organ meat, nuts, fish, poultry, whole
grains)

Nsg mgmt:
introduce TPN solution gradually
prevent infection
Acid Base Balance

 Acid
- substance that can donate or release hydrogen
ions
ie Carbonic acid, Hydrochloric acid

** Carbon dioxide – combines with water to

form carbonic acid
 Base
- substance that can accept hydrogen ions
Ie Bicarbonate
 BUFFER- substance that can
accept or donate hydrogen
- prevent excessive changes in pH

TYPES OF BUFFER
1. Bicarbonate (HCO3): carbonic acid
buffer (H2CO3)
2. Phosphate buffer
3. Hemoglobin buffer
Dynamics of Acid Base Balance

 Acids and bases are constantly produced in

the body
 They must be constantly regulated
 CO2 and HCO3 are crucial in the balance
 A HCO3:H2CO3 ratio of 20:1 should be
maintained
 Respiratory and renal system are active in
regulation
Kidney

- Regulate bicarbonate level in ECF

1. RESPIRATORY/METABOLIC ACIDOSIS
- kidney excrete H and reabsorbs/generates
Bicarbonate
2. RESPIRATORY/METABOLIC ALKALOSIS
- kidney retains H ion and excrete
Bicarbonate
Lung

- Control CO2 and Carbonic acid content of ECF

1. METABOLIC ACIDOSIS
- increased RR to eliminate CO2

2. METABOLIC ALKALOSIS
- decreased RR to retain CO2
 pH - measures degree of acidity and
alkalinity
- indicator of H ion concentration
- Normal ph 7.35-7.45
 ACIDOSIS
- decreased pH; < 7.35
- increased Hydrogen
 ALKALOSIS
- increased pH-; > 7.45
- decreased Hydrogen
ACUTE AND CHRONIC
METABOLIC ACIDOSIS
- Low pH
- Increased H ion concentration
- Low plasma Bicarbonate
Etiology: diarrhea, fistulas, diuretics, renal
insufficiency, TPN w/o Bicarbonate,
ketoacidosis, lactic acidosis
S/sx: headache, confusion, drowsiness, inc
RR, dec BP, cold clammy skin,
dysrrythmia, shock
 Dx: ABG – low Bicarbonate, low pH,
Hyperkalemia, ECG changes

 Rx: Bicarbonate for pH < 7.1 and

Bicarbonate level < 10
monitor serum K
dialysis
ACUTE AND CHRONIC
METABOLIC ALKALOSIS

 High pH
 Decreased H ion concentration
 High plasma Bicarbonate

Etiology: vomiting, diuretic, hyperaldosteronism,

hypokalemia, excesive alkali ingestion

s/sx: tingling of toes, dizziness, dec RR, inc PR,

ventricular disturbances
 Dx:ABG – pH > 7.45, serum Bicarbonate >
26 mEq/L, inc PaCO2

 Rx: restore normal fluid balance

correct hypokalemia
Carbonic anhydrase inhibitors
ACUTE AND CHRONIC
RESPIRATORY ACIDOSIS
 Ph < 7.35
PaCO2 > 42 mmHg

Etiology: pulmonary edema, aspiration, atelectasis,

pneumothorax, overdose of seatives, sleep
apnea syndrome, pneeumonia

s/sx: sudden hypercapnia produces inc PR, RR,

inc BP, mental cloudinesss, feeling of fullness in
head, papiledema and dilated conjunctival blood
vessels
 Dx: ABG – pH < 7.35
PaCO2 - > 42 mmHg

 Rx: improve ventilation

pulmonary hygiene
mechanical ventilation
ACUTE AND CHRONIC
RESPIRATORY ALKALOSIS

 pH > 7.45
 PaCO2 < 38 mmHg

Etiology: extreme anxiety, hypoxemia

s/sx: lightheadednes, inability to concentrate,

numbness, tingling, loss of consciousness
 Dx: ABG – pH > 7.45
PaCO2 < 35
dec K
dec Ca

Rx: breathe slowly

sedative
ARTERIAL BLOOD GAS ANALYSIS

Parameter Normal Value

pH 7.35 – 7.45

PaCO2 35 – 45 mmHg

HCO3 22-26mEq/L

O2 saturation 93 - 98%
Evaluating ABG’s

1. Note the pH
pH = 7.35 – 7.45 (normal)
pH = < 7.35 (acidosis)
pH = > 7.45 (alkalosis)

compensated – normal pH
uncompensated – abnormal pH
2. Determine primary cause of disturbance
2.1 pH > 7.45
a. PaCo2 < 40 mmHg – respiratory
alkalosis
b. HCO3 > 26 mEq/L – metabolic alkalosis

2.2 pH < 7.35

a. PaCo2 > 40 mmHg – respiratory
acidosis
b. HCO3 < 26 mEq/L – metabolic acidosis
3. Determine compensation by looking at the
value other than the primary disturbance

pH PaCO2 HCO3

7.20 60 24 Uncompensated
mmHg mEq/L Respiratory
acidosis
7.40 60 37 Compensated
mmHg mEq/l Respiratory
acidosis
 4. Mixed acid-base pH 7.21 Dec acid
disorders

PaCO2 52 Inc acid

Metabolic
and
Respiratory
Acidosis HCO3 13 Dec acid
Thank You!