Fluids and Electrolytes

Acid Base Balance

Prepared by :
Dr. Malyn Basbas-Uy
Fluid volume deficit
(dehydration):
 mechanism that influences fluid balance
and sodium levels;
 decreased quantities of fluid and
electrolytes may be caused by deficient
intake (poor dietary habits, anorexia, and
nausea),
 excessive output (vomiting, nasogastric
suction, and prolonged diarrhea), or
 failure of regulatory mechanism that
influences fluid balance and sodium levels.
Fluid volume deficit (dehydration):

A. Pathophysiology:

Water moves out of the cells to

replace a significant water loss;
cells eventually become unable to
compensate for the lost fluid, and
cellular dehydration begins,
leading to circulatory collapse.
Fluid volume deficit (dehydration):

B. Risk factors:
1. No fluids available.
2. Available fluids not drinkable.
3. Inability to take fluids
independently.
4. No response to thirst; does not
recognize the need for fluids.
5. Inability to communicate need;
does not speak same language.
6. Aphasia.
Fluid volume deficit (dehydration):
cont.
7. Weakness, comatose.
8. Inability to swallow.
9. Psychological alterations.
10. Overuse of diuretics.
11. Increased vomiting.
12. Fever.
13. Wounds, burns.
14. Blood loss.
15. Endocrine abnormalities
Fluid volume deficit (dehydration):

C. Assessment:

1. Subjective data
a. Thirst.
b. Behavioral changes: apprehension,
apathy, lethargy, confusion,
restlessness.
c. Dizziness.
d. Numbness and tingling of hands and
feet.
e. Anorexia and nausea.
f. Abdominal cramps.
Fluid volume deficit (dehydration):

2. Objective data
a. Sudden weight loss of 5%.
b. Vital signs:
1. Decreased BP; postural
changes.
2. Increased temperature.
3. Irregular, weak, rapid pulse.
4. Increased rate and depth of
respirations.
Fluid volume deficit (dehydration):

c. Skin: cool and pale in absence of

infection; decreased turgor.
d. Urine: oliguria to anuria, high
specific gravity.
e. Eyes: soft, sunken.
f. Tongue: furrows.
g. Lab data:
1. Blood—increased hematocrit
and BUN.
2. Urine—decreased 17-
D. Nursing care plan/implementation:

1. Goal: restore fluid and electrolyte balance

—increase fluid intake to hydrate client.

a. IVs and blood products as ordered; small,

frequent drinks by mouth.

b. Daily weights (same time of day) to monitor

progress of fluid replacement.

c. I&O, hourly outputs (when in acute state).

d. Avoid hypertonic solutions (may cause fluid

shift when compensatory mechanisms
begin to function).
 D. Nursing care plan/implementation:

2. Goal: promote comfort.

a. Frequent skin care (lack of
hydration causes dry skin, which may
increase risk for skin breakdown).

b. Position: change every hour to

relieve pressure.

c. Medications as ordered:
antiemetics, antidiarrheal.
 D. Nursing care plan/implementation:

3. Goal: prevent physical injury.

a. Frequent mouth care (mucous membrane

dries due to dehydration; therefore, client is
at risk for breaks in mucous membrane,
halitosis).

b. Monitor IV flow rate—observe for

circulatory overload, pulmonary edema
related to potential fluid shift when
compensatory mechanisms begin or client is
unable to tolerate rate of fluid replacement.
E. Analysis/nursing diagnosis:

1. Fluid volume deficit related

to inadequate fluid intake

F. Evaluation/outcome criteria:
1. Mentally alert.
2. Moist, intact mucous membranes.
3. Urinary output approximately equal
to intake.
4. No further weight loss.
5. Gradual weight gain.
Fluid volume excess (fluid overload):

 most common cause is an increase

in sodium;
 excessive quantities of fluid and
electrolytes may be due to
increased ingestion, tube feedings,
intravenous infusions, multiple tap-
water enemas, or
 a failure of regulatory systems,
resulting in inability to excrete
excesses.
Fluid volume excess (fluid overload):

A. Pathophysiology:
 hypo-osmolar water excess in
extracellular compartment leads to
intracellular water excess because
the concentration of solutes in the
intracellular fluid is greater than that
in the extracellular fluid. Water
moves to equalize concentration,
causing swelling of the cells. The
most common cause is an increase in
Fluid volume excess (fluid overload):

B. Risk factors:
1. Excessive intake of electrolyte-free fluids.
2. Increased secretion of ADH in response
to stress, drugs, anesthetics.
3. Decreased or inadequate output of urine.
4. Psychogenic polydipsia.
5. Certain medical conditions: tuberculosis;
encephalitis; meningitis; endocrine
disturbances; tumors of lung, pancreas,
duodenum, heart failure.
6. Inadequate kidney function or kidney
failure.
Fluid volume excess (fluid overload):

C. Assessment:
1. Subjective data

b. Behavioral changes: irritability,

apathy,
confusion,
disorientation.
b. Headache.
c. Anorexia, nausea, cramping.
d. Fatigue.
e. Dyspnea.
 Fluid volume excess (fluid
overload):

2. Objective data

a. Vital signs: elevated blood

pressure.
b. Skin: warm, moist; edema—
eyelids, facial, dependent, pitting.
c. Sudden weight gain of 5 lb.
d. Pink, frothy sputum; productive.
e. Constant, irritating cough.
Objective data
(cont.)

f. Crackles in lungs.
g. Pulse, bounding.
h. Engorgement of neck veins in
sitting position.
i. Urine: polyuria, nocturia.
j. Lab data:
1. Blood—decreasing
hematocrit, BUN.
2. Urine—decreasing specific
gravity.
 Fluid volume excess (fluid overload):

D. Analysis/nursing diagnosis:
1. Fluid volume excess related to
excessive fluid intake or
decreased fluid output.
E. Nursing care plan/implementation:

1. Goal: maintain oxygen to all cells.

a. Position: semi-Fowler's or Fowler's

to facilitate improved gas
exchange.

b. Vital signs: PRN, minimum q4hr.

c. Fluid restriction.
2. Goal: promote excretion of excess
fluid.
a. Medications as ordered:
diuretics.

b. Monitor electrolytes, especially

Mg++, K+

c. If in kidney failure: may need

dialysis; explain procedure.

d. Assist client during

paracentesis, thoracentesis,
phlebotomy.
 Nursing care plan/implementation:

3. Goal: obtain/maintain fluid balance.

a. Daily weights; 1 kg = 1000 mL

fluid.
b. Measure: all edematous parts,
abdominal girth, I&O.
c. Limit: fluids by mouth, IVs,
sodium.
d. Strict monitoring of IV fluids.
Fluid volume excess (fluid overload):
Nursing care plan/implementation:

4. Goal: prevent tissue injury.

a. Skin and mouth care as needed.

b. Evaluate feet for edema and
discoloration when client is out of
bed.
c. Observe suture line on surgical
clients
d. IV route preferred for parenteral
medications; Z track if medications
5. Goal: health teaching.
a. Improve nutritional status with low
sodium diet.

b. Identify cause that put client at risk for

imbalance.

c. Desired and side effects of diuretics

and other prescribed medications.

d. Monitor urinary output, ankle edema;

e. Limit fluid intake when kidney/cardiac

function Impaired.
Fluid volume excess (fluid overload):
Nursing care plan/implementation
Evaluation/outcome criteria

F. Evaluation/outcome criteria:
1. Fluid balance obtained.
2. No respiratory, cardiac
complications.
3. Vital signs within normal limits.
4. Urinary output improved, no
evidence of edema.
Common electrolyte imbalances

 electrolytes are taken into the body in foods

and fluids;

 normally lost through sweat and urine.

 May also be lost through hemorrhage,
vomiting, and diarrhea.

 Electrolytes have major influences on:

body water regulation and osmolality,
acid-base regulation, enzyme reactions,
and neuromuscular activity.
 Clinically important electrolytes:

A. Sodium (Na+):
Normal 135–145 mEq/L.
– Most prevalent cation in
extracellular fluid.
– Controls osmotic pressure;
essential for neuromuscular
functioning and intracellular
chemical reactions.
– Aids in maintenance of acid-base
balance.
– Necessary for glucose to be
1. Hyponatremia
—sodium deficit, resulting from
either a sodium loss or water excess.
Serum-sodium level below 135
mEq/L;
symptoms usually do not occur until
below 120 mEq/L unless rapid drop.

2. Hypernatremia
—excess sodium in the blood, resulting
from either high sodium intake,
water loss, or low water intake.
Serum-sodium level above 145 mEq/L.
 Clinically important electrolytes:

B. Potassium (K+):
normal 3.5–5.0 mEq/L.
• Direct effect on excitability of nerves
and muscles.
• Contributes to intracellular osmotic
pressure and influences acid-base
balance.
• Major intracellular cation.
• Required for storage of nitrogen as
muscle protein.
 Clinically important electrolytes:

1. Hypokalemia
—potassium deficit related to dehydration,
starvation, vomiting, diarrhea, diuretics.
Serum-potassium level below 3.5 mEq/L;
symptoms may not occur until below 2.5
mEq/L.

2. Hyperkalemia
—potassium excess related to severe tissue
damage, renal disease, excess
administration of oral or IV potassium.
Serum-potassium level above 5 mEq/L;
symptoms usually occur when above 6.5
 Clinically important electrolytes

C. Calcium (Ca++):
Normal 4.5–5.5 mEq/L.

• Essential to muscle metabolism,

cardiac function, and bone health.

• Controlled by parathyroid hormone;

reciprocal relationship between
calcium and phosphorus.
 Calcium (Ca++):

1. Hypocalcemia
—loss of calcium related to
inadequate intake, vitamin D deficiency,
hypoparathyroidism, damage to the
parathyroid gland, decreased absorption
in the GI tract, excess loss through
kidneys.
Serum-calcium level below 4.5 mEq/L.

2. Hypercalcemia
—calcium excess related to
hyperparathyroidism, immobility, bone
tumors, renal failure, excess intake of
Ca++ or vitamin D. Serum-calcium level
 Clinically important electrolytes

D. Magnesium (Mg++):
Normal 1.5–2.5 mEq/L.
• Essential to cellular metabolism of
carbohydrates and proteins.

1. Hypomagnesemia
—magnesium deficit related to
impaired absorption from GI tract,
excessive loss through kidneys, and
prolonged periods of poor nutritional
intake. Hypomagnesemia leads to
neuromuscular irritability. Serum-
magnesium level below 1.5mEq/L.
 Magnesium (Mg++):

2. Hypermagnesemia
—magnesium excess related to
renal insufficiency, overdose during
replacement therapy, severe
dehydration, repeated enemas with
Mg++ sulfate.
Serum-magnesium level above 2.5
mEq/L.
Electrolyte Imbalances
Hyponatremia

Disorder and Related Condition:

• Addison's disease

• Starvation

• GI suction

• Thiazide diuretics

• Excess water intake, enemas

• Fever

• Fluid shifts

• Ascites

• Burns

• Small-bowel obstruction

• Profuse perspiration
Electrolyte Imbalances
Hyponatremia
Assessment

Subjective Data:
• Apathy, apprehension, mental
confusion, delirium
• Fatigue
• Vertigo, headache
• Anorexia, nausea
• Abdominal and muscle cramps
Electrolyte Imbalances
Hyponatremia
Assessment

Objective Data:
• Pulse: rapid and weak
• BP: postural hypotension
• Shock, coma
• GI: weight loss, diarrhea, loss
through NG tubes
• Muscle weakness
Electrolyte Imbalances
Hyponatremia

» Analysis/Nursing Diagnosis:
– Diarrhea
– Fluid volume excess
– Altered nutrition, less than body
requirements
– Sensory-perceptual alteration
(kinesthetic)
Hyponatremia

» Nursing Care Plan/Implementation:

– Obtain normal sodium level: identify cause
of deficit, increase sodium intake PO (salty
foods), IVs–hypertonic solutions
– Prevent further sodium loss: irrigate NG
tubes with saline; hourly I&O to monitor
kidney output
– Prevent injury related to shock, dizziness,
decreased sensorium; dangle before
ambulation
– Skin care
Electrolyte Imbalances
Hyponatremia

» Evaluation/Outcome Criteria:
– Na+ 135–145 mEq/L
– No complications of shock present
– Return of muscle strength
– Alert, oriented
– Limits intake of plain water
Electrolyte Imbalances
Hypernatremia

Disorder and Related Condition:

 High sodium intake

 Low water intake

 Diarrhea

 High fever with rapid respirations

 Impaired renal functions

 Acute tracheobronchitis
Electrolyte Imbalances
Hypernatremia
Assessment

Subjective Data:
• Lethargy
• Restlessness, agitation
• Confusion

Objective Data:
• BP and temperature: elevated
• Neuromuscular: diminished reflexes
• Skin: flushed; firm turgor
• GI: mucous membrane dry, sticky
• GU: decreased output
Electrolyte Imbalances
Hypernatremia

» Analysis/Nursing Diagnosis:
– Fluid volume deficit
– Fluid volume excess
– Altered nutrition, less than body
requirements
– Sensory-perceptual alteration
(kinesthetic)
Electrolyte Imbalances
Hypernatremia

» Nursing Care Plan/Implementation:

– Obtain normal sodium level:

decrease sodium in take
– I&O to recognize signs and
symptoms of complications (e.g.,
heart failure, pulmonary edema)
Electrolyte Imbalances
Hypernatremia

» Evaluation/Outcome Criteria:
– Na+ 135–145 mEq/L
– No complaint of thirst
– Alert, oriented
– Relaxed in appearance
– Identifies high sodium foods to
avoid
– K+ 3.5–5.0 mEq/L
Hypokalemia
Disorder and Related Condition:
Decreased intake:
» Poor potassium food intake
» Excessive dieting
» Nausea
» Alcoholism
» IV fluids without added potassium
Increased loss:
» GI suctioning, vomiting, diarrhea
» Ulcerative colitis
» Drainage: ostomy, fistulas
» Medications: potassiumlosing diuretics, digoxin,
cathartics
» Increased aldosterone production; Renal
disorders
Hypokalemia
» Assessment

Subjective Data:
• Apathy, lethargy, fatigue,
weakness
• Irritability, mental confusion
• Anorexia, nausea
• Leg cramps
Hypokalemia
» Assessment

Objective Data:

• Muscles: weakness, paralysis, paresthesia,

hyporeflexia
• Respirations: shallow to respiratory arrest
• Cardiac: decreased BP; elevated, weak, irregular
pulse; arrhythmias
• ECG: low, flat T waves; prolonged ST segment;
elevated U wave; potential arrest
• GI: vomiting, flatulence, constipation; decreased
motility distention paralytic ileus
• GU: urine not concentrated; polyuria, nocturia;
kidney damage
• Speech: slow
Hypokalemia

» Analysis/Nursing Diagnosis:
– Decreased cardiac output
– Fatigue
– Altered cardiopulmonary tissue
perfusion
– Ineffective breathing patterns
– Constipation
– Bathing/hygiene self-care deficit
– Impaired home maintenance
management
– Sensory-perceptual alteration
Hypokalemia

» Nursing Care Plan/Implementation:

• Replace lost potassium: increase
potassium in diet; liquid PO
potassium medications—dilute in
juice to aid taste; give potassium
only if kidneys functioning
• Prevent injury to tissues: prevent
infiltration, pain, tissue damage
• Prevent potassium loss: Irrigate NG
tubes with saline, not water
Hypokalemia

» Evaluation/Outcome Criteria:

– Identifies cause of imbalance

– Lists foods to include in diet
– Lists signs and symptoms of
imbalance
– Return of muscle strength
– No cardiac arrhythmias
Hyperkalemia
Disorder and Related
Condition:
 Burns
 Crushing injuries
 Kidney disease
 Excessive infusion or ingestion of
K+
 Adrenal insufficiency
 Mercurial poisoning
Hyperkalemia

» Assessment
– Subjective Data:
• Irritability
• Weakness, muscle cramps
• Nausea, intestinal cramps
Hyperkalemia
» Assessment
Objective Data:

• Muscles: paresthesia, flaccid muscle

paralysis (later)
• Cardiac; irregular pulse; arrhythmias;
bradycardia asystole
• ECG: high T waves; depressed ST
segment; widened QRS complex;
diminished or absent P waves;
ventricular fibrillation
• GI: explosive diarrhea;
hyperactive bowel sounds
• Kidney: scanty to no urine
Hyperkalemia

» Analysis/Nursing Diagnosis:
• Decreased cardiac output

• Altered urinary elimination

• Activity intolerance

• Ineffective breathing patterns

• Diarrhea

• Impaired home maintenance

management
Hyperkalemia

» Nursing Care Plan/Implementation:

• Decrease amount of potassium in body;
identify and treat cause of imbalance;
give foods low in K+; avoid drugs or IV
fluids containing K+
• If kidney failure present, may need to
prepare for dialysis

» Evaluation/Outcome Criteria:
 K+ 3.5–5.0 mEq/L
 No complications (e.g., arrhythmias,
acidosis, respiratory failure)
Hypocalcemia
Disorder and Related
Condition:
• Acute pancreatitis
• Diarrhea
• Peritonitis
• Damage to parathyroid during thyroidectomy
• Hypothyroidism
• Burns
• Pregnancy and lactation
• Low vitamin D intake
• Multiple blood transfusions
• Renal disorders
• Massive infection
Hypocalcemia

» Assessment

Subjective Data:
• Fatigue
• Tingling/numbness; fingers and
circumoral
• Abdominal cramps
• Palpitations
• Dyspnea
Hypocalcemia
» Assessment

Objective Data:
• Muscle spasms: tonic muscles,
carpopedal, laryngeal
• Neuromuscular: grimacing,
hyperirritable facial nerves
• Tetany convulsions
• Orthopedic: osteoporosis fractures
• Cardiac: arrhythmias arrest
• GI: diarrhea
Hypocalcemia

» Analysis/Nursing Diagnosis:
• Pain

• Diarrhea

• Altered nutrition, less than body

requirements
• Risk for injury

• Sensory-perceptual alteration
(gustatory)
Hypocalcemia

» Nursing Care Plan/Implementation:

• Prevent tetany (medical emergency):
calcium gluconate IV, 2.5–5.0 mL 10%
solution; repeated q10min to
maximum dose of 30 mL
• Prevent tissue injury due to hypoxia
and sloughing; administer slowly;
avoid infiltration
Nursing Care Plan/Implementation:
(cont.)

• Prevent injury related to

medication administration.
Caution: drug interaction with
carbonate, phosphate, digitalis;
avoid hypercalcemia
• In less acute condition: increase
calcium intake—calcium
gluconate or lactate
Hypocalcemia

» Evaluation/Outcome Criteria:

 Ca++ 4.5–5.5 mEq/L

 No signs of tetany
 Absent Trousseau's and
Chvostek's signs
 Lists foods high in vitamin D and
calcium
Hypercalcemia
Disorder and Related Condition:

• Parathyroid glands: overactive,

tumor
• Increased immobility
• Decreased renal function
• Bone cancer
• Increased vitamin D and calcium
intake
• Milk-alkali syndrome—self-
administration of antacids;
Hypercalcemia

» Assessment

Subjective Data:
• Pain: flank, deep bone, shin
splints
• Muscle weakness, fatigue
• Anorexia, nausea
• Headache
• Thirst polyuria
Hypercalcemia
» Assessment

Objective Data:
• Muscles: relaxed
• GU: kidney stones
• GI: increased milk intake,
constipation, dehydration
• Neurological: stupor coma
Hypercalcemia

» Analysis/Nursing Diagnosis:
– Decreased cardiac output
– Constipation
– Activity intolerance
– Altered urinary elimination
– Pain
Hypercalcemia
Nursing Care Plan/Implementation:

 Reduce calcium intake: decrease

foods high in calcium; identify
cause of imbalance; give steroids,
diuretics as ordered; isotonic
saline IV
 Prevent injury: prevent
pathological fractures (e.g.,
advanced cancer); prevent renal
calculi by increasing fluid intake
Hypercalcemia

» Evaluation/Outcome Criteria:
 Ca++ 4.5–5.5 mEq/L

 No pain reported

 No fractures/calculi seen on x-ray

exam
Hypomagnesemia
Disorder and Related
Condition:

• Impaired GI absorption
• Prolonged malnutrition or
starvation
• Alcoholism
• Excess loss of magnesium
through kidneys, related to
increased aldosterone production
• Prolonged diarrhea
• Draining GI fistulas
Hypomagnesemia
» Assessment

Subjective Data:
• Agitation
• Depression
• Confusion
• Paresthesia

Objective Data:
• Muscles: irritable, tremors, spasticity,
tetany convulsions
• Cardiac: arrhythmias, tachycardia
Hypomagnesemia

» Analysis/Nursing Diagnosis:
– Risk for injury related to seizure
activity
– Decreased cardiac output
 Hypomagnesemia

» Nursing Care Plan/Implementation:

– Provide safety: prevent injury to client
who is disoriented; administer
magnesium salts PO or IV
– Health teaching: prevention; diet—high
magnesium foods: fruits, green
vegetables, whole grain cereals, milk,
meats, nuts

» Evaluation/Outcome Criteria:
 Mg++ 1.5–2.5 mEq/L
Hypermagnesemia
Disorder and Related Condition

• Renal failure
• Diabetic ketoacidosis
• Severe dehydration
• Antacid therapy
Hypermagnesemia
» Assessment

Subjective Data:
• Drowsiness, lethargy

Objective Data:
• Neuromuscular: loss of deep
tendon reflexes
• Respiratory: depression
• Cardiac: arrest, hypotension
Hypermagnesemia

» Analysis/Nursing Diagnosis:

• Ineffective breathing pattern

• Decreased cardiac output
• Fluid volume deficit
• Fluid volume excess
• Altered cardiopulmonary tissue
perfusion
Hypermagnesemia

» Nursing Care Plan/Implementation:

– Obtain normal magnesium level: IV
calcium, fluids; possible dialysis

» Evaluation/Outcome Criteria:
 Mg++ 1.5–2.5 mEq/L
 No complications (e.g., respiratory
depression, arrhythmias)
 Identifies magnesium-based antacids
 (e.g., Gelusil)
 Deep-tendon reflexes 2+
Acid-Base Balance

 concentration of hydrogen ions in

extracellular fluid is determined by the
ratio of bicarbonate to carbonic acid.
 The normal ratio is 20: 1. Even when
arterial blood gases are abnormal, if
the ratio remains at 20: 1, no
imbalance will occur.

A. Causes of blood gas abnormalities: *

Acid-base balance

B. Types of acid-base imbalance:

1. Acidosis: hydrogen ion concentration

increases and pH decreases.

2. Alkalosis: hydrogen ion concentration

decreases and pH increases.

3. Metabolic imbalances: bicarbonate is the

problem. In primary conditions, the level of
bicarbonate is directly proportional to pH.
Metabolic imbalances

a. Metabolic acidosis: excessive acid is

produced or added to the body,
bicarbonate is lost, or acid is retained due to
poorly functioning kidneys. Deficit of
bicarbonate.

b. Metabolic alkalosis: excessive acid is lost or

bicarbonate or alkali is retained. Excess of
bicarbonate.

c. As compensatory mechanism, Pco2 will be

low in metabolic acidosis, as the body
attempts to eliminate excess carbonic acid
and elevate pH. Pco2 will become elevated
Acid-base balance

4. Respiratory imbalances: carbonic acid

is the problem. In primary conditions,
Pco2 is inversely proportional to the
pH.

a. Respiratory acidosis: pulmonary

ventilation decreases, causing an
elevation in the level of carbon dioxide
or carbonic acid. Excess of Pco2.
Respiratory imbalances

b. Respiratory alkalosis: pulmonary

ventilation increases, causing a
decrease in the level of carbon dioxide
or carbonic acid. Deficit of Pco2.

c. As a compensatory mechanism, the

level of bicarbonate will increase in
respiratory acidosis and decrease in
respiratory alkalosis.
 Acid-base balance

C. Assessment: *

D. Analysis/nursing diagnosis:

1. Impaired gas exchange related to

hyperventilation.
2. Ineffective breathing pattern related to
decreased thoracic movements.
3. Ineffective airway clearance related to
retained secretions.
4. Risk for injury related to poorly functioning
kidneys.
5. Altered renal tissue perfusion related to
 6. Altered urinary elimination related

to renal failure.
7. Fluid volume excess related
to altered kidney function.
8. Fluid volume deficit related
to diarrhea or dehydration.
9. Knowledge deficit (learning need)
related to self-administration of
antacid medications.

E. Nursing care plan/implementation *

F. Evaluation/outcome criteria *
 Acid-Base Imbalances
Respiratory Acidosis

 Disorder and Related Conditions:

Acute bronchitis
Emphysema
Respiratory obstruction
Atelectasis
Damage to respiratory center
Pneumonia
Asthmatic attack
Drug overdose
Acid-Base Imbalances
Respiratory Acidosis
» Assessment

 Subjective Data:

• Headache
• Irritability
• Disorientation
• Weakness
• Dyspnea on exertion
• Nausea
Acid-Base Imbalances
Respiratory Acidosis
» Assessment

Objective Data:
• Hypoventilation: rate or rapid and shallow
• Cyanosis; Tachycardia
• Diaphoresis
• Dehydration
• Coma (CO2 narcosis)
• Hyperventilation to compensate if no
pulmonary pathology present
• HCO3, normal
• Paco2, elevated; pH <7.35
Acid-Base Imbalances
Respiratory Acidosis

Nursing Care Plan/Implementation:

 Assist with normal breathing:

encourage coughing; suction airway;

postural drainage; pursedlip breathing;
 Protect from injury:

oxygen as needed; encourage fluids;

avoid sedation; medications as ordered—
antibiotics, bronchial dilators

 Health teaching: identify cause, prevent

future episodes; increase awareness
regarding risk factors and early signs of
impending imbalance; encourage
Acid-Base Imbalances
Respiratory Acidosis

» Evaluation/Outcome Criteria:
 Normal acid-base balance obtained
 Respiratory rate: 16–20
 No signs of pulmonary infection
(e.g., sputum colorless, breath
sounds clear)
 Demonstrates breathing exercises
(e.g., diaphragmatic breathing)
 Metabolic Acidosis
Disorder and Related Conditions:

 Diabetic ketoacidosis
 Hyperthyroidism
 Severe infections
 Lactic acidosis in shock
 Renal failure uremia
 Prolonged starvation diet; low protein diet
 Diarrhea, dehydration
 Hepatitis
 Burns
 Metabolic Acidosis
» Assessment

 Subjective Data:

 Headache
 Restlessness
 Apathy, weakness
 Disorientation Thirst
 Nausea, abdominal pain
Metabolic Acidosis
» Assessment

Objective Data:

 Kussmaul's respirations: deep, rapid air

hunger;
 Temperature
 Vomiting, diarrhea
 Dehydration
 Stupor convulsions coma
 HCO3, below normal
 Paco2 normal
 K+ >5
 pH <7.35
Metabolic Acidosis

Nursing Care Plan/Implementation:

 Restore normal metabolism:

– correct underlying problem; sodium

bicarbonate PO/IV; sodium lactate; fluid
replacement, Ringer's solution; diet: high
calorie
 Prevent complications:

– regular insulin for ketoacidosis; hourly

outputs; prepare for dialysis if in kidney
failure
 Health teaching:

– identify signs and symptoms of primary

illness, prevent complications, cardiac
arrest; diet instructions
Metabolic Acidosis

Evaluation/Outcome Criteria:
 Normal acid-base balance obtained
 No rebound respiratory alkalosis
following therapy
 No tetany following return of normal
pH
 Alert, oriented
 No signs of K+ excess
Respiratory Alkalosis
Disorder and Related Conditions:

 Hyperventilation—CO2 loss
 Hypoxia, high altitudes
 Fever
 Metabolic acidosis
 Increased ICP, encephalitis
 Salicylate poisoning
 After intensive exercise
Respiratory Alkalosis
» Assessment

Subjective Data:

 Circumoral paresthesia
 Weakness

 Apprehension
Respiratory Alkalosis
» Assessment

Objective Data:
 Increased respirations

 Increased neuromuscular irritability;

hypereflexia, muscle twitching, tetany,
positive Chvostek's sign
 Convulsions

 Unconsciousness

 Hypokalemia

 HCO3, normal

 Paco2 decreased


 Respiratory Alkalosis

Nursing Care Plan/Implementation:

> Increase carbon dioxide level:

rebreathing into a paper bag; adjusting
respirator for CO2 retention and oxygen
inspired; correct hypoxia
> Prevent injury:
safety measures for those who are
unconscious; hypothermia for elevated
temperature

> Health teaching:

recognize stressful events; counseling if
problem is hysteria
Respiratory Alkalosis

Evaluation/Outcome Criteria:
 Normal acid-base balance obtained

 Recognizes psychological and

environmental factors causing
condition
 Respiratory rate returns to normal
limits
 No cardiac arrhythmias

 Alert, oriented
 Metabolic Alkalosis
Disorder and Related Conditions:
 Potassium deficiencies
 Vomiting
 GI suctioning
 Intestinal fistulas
 Inadequate electrolyte replacement
 Increased use of antacids
 Diuretic therapy, steroids
 Increased ingestion/injection of
bicarbonates
Metabolic Alkalosis
» Assessment

Subjective Data:

 Lethargy
 Irritability
 Disorientation
 Nausea
 Metabolic Alkalosis
» Assessment

Objective Data:

 Respirations: shallow; apnea, decreased

thoracic movement; cyanosis
 Pulse: irregular cardiac arrest
 Muscles: twitching tetany, convulsions
 G. I.: vomiting, diarrhea, paralytic ileus
 HCO3, elevated above 26
 Paco2 normal,
 K+ <3.5,
 pH >7.45
Metabolic Alkalosis

Nursing Care Plan/Implementation:

 Obtain, maintain acid-base balance:
irrigate NG tubes with saline; monitor
I&O; IV saline, potassium added; isotonic
solutions PO; monitor vital signs

 Prevent physical injury:

monitor for potassium loss, side effects
of medications

 Health teaching: increase sodium when loss

expected; instructions regarding self-
administration of medications (e.g., baking
soda)
Metabolic Alkalosis

Evaluation/Outcome Criteria:

 Normal acid-base balance obtained

 No signs of potassium deficit
 Respiratory rate: 16–20
 No arrhythmias—pulse regular
 Lists food sources high in potassium
 Blood Gas Abnormalities: Causes

Decreased Po2
 Collapsed alveoli (atelectasis)
– 1. Airway obstruction
 a. By the tongue
 b. By a foreign body

– 2. Failure to take deep breaths

 a. Pain (rib fracture, pleurisy)
 b. Paralysis of respiratory muscles (spinal cord
injury, polio)
 c. Depression of the respiratory center (head
injury, drug overdose)

– 3. Collapse of the whole lung (pneumothorax)

Blood Gas Abnormalities: Causes
(cont.)

Decreased Po2
 Fluid in the alveoli
– 1. Pulmonary edema
– 2. Pneumonia
– 3. Near-drowning
– 4. Chest trauma
 Other gases in the alveoli
– 1. Smoke inhalation
– 2. Inhalation of toxic chemicals
– 3. Carbon monoxide poisoning
 Respiratory arrest
Blood Gas Abnormalities: Causes

• Elevated Pco2
 Decreased CO2 elimination
(hypoventilation)
1. Decreased tidal volume
a. Pain (rib fractures, pleurisy)
b. Weakness (myasthenia gravis)
c. Paralysis (spinal cord injury, polio)
2. Decreased respiratory rate
a. Head injury
b. Depressant drugs
c. Stroke
 Increased CO2 production
1. Fever
2. Muscular exertion
3. Anaerobic metabolism
“Always treat your patients as you
would treat your family.”
- Dra. Uy