SEE-SAW: HOMEOSTASIS

Fluids, Electrolytes & Acid-Base
Christian Steve C. Valenzuela, R.N
Lecturer

Homeostasis
• Walter Bradford Cannon
•maintenance of a relatively constant environment within a body.
• state of balance.
•body’s ability to regulate physiologically its inner environment to ensure stability in response to fluctuations in the outside environment & the weather.
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•process that stimulate or amplify similar changes that causes movement away from normal state.
Homeostasis
•regulating mechanism in which an increase/decrease in the level of substance decreases/increases the function of the organ producing the substance.

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F & E Homeostasis

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F & E Homeostasis

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F & E Homeostasis

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F & E Homeostasis

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F & E Homeostasis

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Body Fluids

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Functions of water
1. Move electrolyte and O2 into and out of cells.
2. Aid in digestion
3. Cleanse the body of waste.
4. Regulate body temperature
5. Lubricates joints and mucous membranes.

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Fluid Locations:

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I wonder how much water do they have in their bodies?hmm
Total Body Water

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Fluid Intake & Fluid Loss
Ingested fluids
Water in foods
Oxidation
Skin
Lungs
Feces
Kidneys

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• Passive Transport
•a process that transport ions across the cell membrane against a concentration gradient.
•does not require use of energy.
• Active Transport
•use of energy to move ions across a semipermeable membrane against a concentration, chemical or electrical gradient.
Fluid Balance Mechanisms

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Passive Transport
• Osmosis
•movement of fluids from lower solute to higher solute concentration.
D2.5W
0.45% NSS
0.3% NSS
0.2% NSS
D50W
D5W
D10W
D5NSS
D5LR
3%NSS
0.9% NSS
LRS

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Passive Transport
• Diffusion
•movement of solutes from an area of higher to lower concentration gradient.
• Filtration
•removal of particles from a solution through a movement of fluid across the membrane.

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Hydrostatic Pressure
Oncotic
Pressure

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D’ Renin-Angiotensin-Aldosterone System

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Predict:
Drowning in freshwater is different from drowning in saltwater. In fact, more people drown in freshwater than salt water. Why?

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Fluid Imbalances

•the loss of water and electrolyte exceeding the intake of fluid.
Mild: Moderate: Severe:
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•Common causes:
• intake,  output
• Hemorrhage
• Vomiting
• NGT feeding, meds
• Prolonged G.I suctioning
Hypovolemia

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Hypovolemia: Signs & Symptoms
• HTN
• Wt. loss
• Tented, dry skin
•  RR,  PR
• Cool skin
• Flat neck veins
• Oliguria
• Lethargy
• subjective cue/s:

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Hypovolemia: Diagnostics
BUN levels
Hematocrit
Urine spec.gravity

1.Monitor intake and output.
2.Monitor daily weights.
3.Monitor v/s, skin turgor.
4.Offer fluids orally as tolerated.
5.Adm. antiemetics a.p
6.Provide frequent oral care.
7.Teach patient to change position slowly.
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Hypovolemia: Nursing Management

•isotonic expansion of the ECF caused by abn retention of water and electrolytes.
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•Common causes:
• CHF
• Excessive fluid intake, IVF administration
• Renal Failure
• Liver Cirrhosis
• Cushing’s dse
Hypervolemia

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Hypervolemia: Signs & Symptoms
•HPN
•Wt.gain
•Crackles
•Distended neck veins
•Frothy sputum
•Edema
•Bounding pulse
• CVP
•subjective cue/s:

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Hypervolemia: Diagnostics
BUN/ Crea levels
Urine spec.gravity
C-XR

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Hypervolemia: Nursing Management
1.Monitor I & O, v/s, weight, edema and breath sounds.
2. Diet:
3. Position:
4.Adm. diuretics a.p
5.Skin care daily

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1
The client at the highest risk for fluid volume deficit is a: a. 36-year-old client with diarrhea. b. 4-month-old client with fever. c. Healthy 80-year-old client with a fractured wrist. d. 26-year-old pregnant client with n/v.
FLUID IMBALANCE

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2
A 32-year-old client has a nursing Dx of FVE. A nurse examining the client would expect to find:
a. Postural HTN
b. Cool extremities
c. Moist mucous membranes
d. Weak, rapid pulse
FLUID IMBALANCE

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Electrolytes
Let there be…
– LYTES!

•major cation in the ECF.
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Functions:
1. Assists with nerve generation & nerve transmission.
2. Partcipates in Na-K pump
3. Controls water distribution throughout the body.
4. Maintains body fluid volume.
Sodium
Normal Value:
Sources:
Inversely proportional to:
Table salt, processed foods, ham, bacon, pickles, preserved foods, baking products, ketchup

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Hyponatremia
Causes:
Psychogenic Polydypsia
Decreased Aldosterone

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Hyponatremia
S/Sx:
Lethargy and Confusion
Muscle weakness
Decreased DTRs
Muscle twitching/Convulsions
Postural HTN

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Hyponatremia
Medical & Nursing Intervention/s:
1.Provide SAFETY!
2.MIO, daily weights, v/s
3.Provide Na replacement a.d.
4.Encourage food high in Na.
5.Monitor clients on lithium therapy.
6.Restrict water intake.

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Hypernatremia
Causes:
M
O
D
E
L

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Hypernatremia
S/Sx:
F
R
I
E
D
ever
estless
nc. fld retention
dema
ec. UO

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Hypernatremia
1. SAFETY PRECAUTION!
2.Adm. IVF a.d, diuretics.
3.Adm. Desmopressin acetate a.d
4.Increase OFI
5.MIO
6.Low-Na diet

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3
Why does excessive administration of D5W cause hyponatremia? a. The kidneys excrete the excess potassium. b. The lungs exhales the excess vapor. c. Water in the solution dilutes the serum Na level. d. Dextrose in the sol/n concentrates the Na level.
ELECTROLYTE IMBALANCE

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4
The nurse evaluates which of the ff clients to be at risk for developing hypernatremia?
a. 50-year-old with Pn, diaphoresis and high fever.
b. 39-year-old with diarrhea and vomiting.
c. 62-year-old with CHF taking Lasix.
d. 60-year-old client with lung CA and SIADH.

•most abundant cation in the ICF.
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Potassium
Normal Value:
Sources:
Fruits, vegatables, nuts, milk, coffee & cola, milk
Functions:
1. Skeletal and cardiac muscle contraction.
2. Maintains acid-base imbalance.
3. Part of Na-K pump

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Hypokalemia
Causes:
Medications
GI suction/vomiting
NPO, Diarrhea
Cushing’s Dse
Hyperventilation
IV Insulin

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S/Sx:

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Hypokalemia
1. Provide oral/IV K replacement.
2. Encourage K-rich foods.
3. Monitor ECG, digitalis precaution!

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Hyperkalemia
Causes:
M
A
C
H
I
N
E
edications
cidosis
ellular destruction
emolysis
ntake
ephrons
xcretion

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Hyperkalemia
1.Monitor cardiac status.
2.Adm.meds a.p
• Calcium gluconate, Insulin + glucose, NaHCO3, Kayexalate, diuretics
3.Low-K diet
4.Assist in hemodialysis.

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The nurse knows that when caring for the client on a telemetry unit, she would expect to find which EKC changes in a hypokalemic patient?
a. Tall T-wave
b. shortened PR interval
c. Absent P waves
d. U wave

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A client is being discharged from the hospital after being treated hypokalemia. In order for the client to maintain an appropriate K+ level, the nurse suggests which food when providing discharge teaching?
a. Baked potatoes
b. Peas
c. Fowl
d. Nuts

•most abundant electrolyte in the entire body.
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Calcium
Normal Value:
Sources:
Milk and milk products, tofu, broccoli, sardines, green leafy vegetables
Functions:
1. Bones and teeth formation.
2. Muscular contraction and relaxation.
3. Needed for vit. B12 absorption.
4. Needed for normal blood clotting
5. Nerve transmission

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Causes:
Hypocalcemia
Decreased Ca Intake
Kidney illness
Corticosteroids
Pancreatitis
Hypoparathyroidism
Thyroidectomy

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Hypocalcemia
1.Adm.meds a.d:
•Ca gluconate, Ca chloride
•Ca citrate, lactate, carbonate, vit. D
2.High Ca diet
3.SZ Precautions!

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Causes:
Hypercalcemia
Hyperparathyroidism
Immobilization
Increased Ca Intake
Increased Vit.D Intake
Diuretics
Metastatic CA

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Hypercalcemia
S/Sx:
Decreased DTRs
Arrhythmia
Lethargy, Coma
Pathologic Fx, calculi
Muscle weakness
Cardiac/Respi arrest

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Hypercalcemia
1.Surgery
2.Low-Ca diet
3.IV flushing
4.Meds: biphosphonates, plicamysin, diuretics
5.Dialysis
6.Prevent Fx

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The client’s calcium level is 8.8 mg/dL. An appropriate nursing intervention at this time is:
a. Notify the physician stat!
b. Administer oral calcium supp.a.d.
c. Limit intake of foods rich in calcium.
d. No intervention required at this time.

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A client with recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum Ca is low? a. Bone pain b. Depressed DTRs c. Carpopedal spasm d. Constipation

•second most abundant intracellular cation.
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Magnesium
Normal Value:
Sources:
Green leafy vegetables, nuts, legumes, seafood, whole grains, bananas, oranges, cocoa, chocolate
Functions:
1. Muscle sedatives/ Cardiac output
2. Maintains intracellular activity.
3. Maintains normal heart rhythm.
4. Promotes vasodilation of peripheral arterioles.

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Causes:
Hypomagnesemia
Chronic alcoholism
Diuretics
Diarrhea
Antibiotics
IBD, SBR
Excess caffeine

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S/Sx:
Hyperactive DTRs
Epileptic fits
Neuromuscular irritability
Laryngeal stridor
(+) Chvostek, Trousseau’s signs
Hypomagnesemia

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1. Promote SAFETY!
2. Adm. meds as prescribed.
• MgSO4, Mg oxide, Mg-based antacids
3. High-Mg diet
Hypomagnesemia

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Causes:
Hypermagnesemia
A
I
R

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S/Sx:
Hyporeflexia
 BP, RR
Weakness, lethargy, coma
Facial warmth
Hypermagnesemia

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1. Adm. diuretics as prescribed.
2. Decrease Mg salt administration.
3. Respiratory support!
4. Dialysis
5. 0.45% saline and/or Ca gluconate
Hypermagnesemia

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A client presents to the ED with tachycardia, HPN, and SZ. Further assessment reveals a history of chronic pancreatitis, causing the nurse to expect: a. Magnesium deficit b. Sodium deficit c. Potassium excess d. Calcium excess

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The nurse evaluates which of the ff clients to have hypermagnesemia?
a. A client with chronic alcoholism, Mg level: 1.3 mEq/L.
b. A client who has hyperthyroidism, Mg level: 1.6 mEq/L.
c. A client who has renal failure, takes antacids, Mg level: 2.9 mEq/L
d. A CHF client, takes diuretic, Mg level 2.3 mEq/L.

•Primary intracellular anion.
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Phosphorous
Normal Value:
Sources:
Red & organ meats, poultry, fish, eggs, milk, legumes, whole grains, nuts, carbonated drinks
Functions:
1. Promotes muscles & nerve fxn
2. Assists with CHO, CHON HCHO metabolism.
3. Bone/teeth formation & strength
4. Part of ATP
5. Phospholipids

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Causes:
Hypophosphatemia
Hyperparathyroidism
Immobilization
Al- & Mg- antacids
Increased vit. D absorption

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Hypophosphatemia
S/Sx:
Anemia, bruising
SZ, Coma
Constipation
Muscle weakness
Hypoactive bowel sounds

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1. Adm. supplemental phosphorous.
• Na Phosphate/ K Phosphate
• Neutraphos, K-Phos
2. Avoid Phos-binding antacids
3.Diet:
4.Monitor joint stiffness, arthralgia, Fx, bleeding
Hypophosphatemia

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Causes:
Hyperphosphatemia
Acidosis
Renal failure
Hypocalcemia
Massive BT
Hyperthyroidism

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Hyperphosphatemia
S/Sx:
Calcification of kidney, cornea, heart
Muscle spasms
Tetany
Hyperreflexia

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1. Administer meds as prescribed:
• Al-containing antacids
• Ca carbonate
2. Avoid phosphate laxatives/ enemas
3. Increase OFI
4. Diet:
Hyperphosphatemia

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The nurse should monitor for clinical manifestations of hypophosphatemia in which of the ff client? a. A client with osteoporosis taking vit.D and Ca supplements. b. A client who is alcoholic and with renal failure. c. A client with CRF awaiting for the first dialysis run. d. A client with hypoparathyroidism secondary to thyroidectomy.

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A nurse reviews a client lab result and note a serum P level: 2.0 mg/dL. Which condition most likely caused this serum P level? a. Alcoholism b. Renal failure c. Hyperparathyroidism d. Hyperthyroidism

•extracellular anion
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Chloride
Normal Value:
Sources:
Salt, canned foods, cheese, milk, eggs, crab, oil
Functions:
1. Helps regulate BP, serum osmolality.
2. Part of HCl
3. Acid/Base balance

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Causes:
Hypochloremia
Diuresis
Metabolic alkalosis
Addison’s dse
Hyponatremia

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S/Sx:
Slow, shallow RR
HTN
Hypochloremia

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1. Administer meds as prescribed:
• KCl, NaCl
2.Diet:
Hypochloremia

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Causes:
Hyperchloremia
Metabolic acidosis
Hypernatremia
Hyperkalemia

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S/Sx:
Deep, rapid RR
S/Sx of hyperNa, -K
Hyperchloremia

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1. IVF
• Hypotonic sol’ns
2. Diuretics
3. Diet:
Hyperchloremia

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ACID
BASE

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ABG Review: Normal Values
pH
pCO2
HCO3
PaO2
SaO2
7.35 – 7.45
35 – 45
22 – 26
80 – 100
95 – 100

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ABG Review: Interpretation
pH
pCO2
HCO3
alkalosis
acidosis
acidosis
alkalosis
alkalosis
acidosis

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pH: 7. 28
ABG Review: Interpretation
pCO2: 50mmHg
pCO2: 29 mEq/L
How am I going to interpret this ABG result?
Rule:
1. Look at the pH:
acidosis/alkalosis.
2. Determine the cause:
respiratory/metabolic.
3. Determine if un/-compensated.
4. Identify if it is fully/partially.

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Exercise: Interpret the following ABG results:
1. pH: 7.54 ; pCO2: 30 mmHg ; HCO3: 19 mEq/L

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10. pH: 7.38; pCO2: 36 mmHg ; HCO3: 24 mEq/L
Exercise: Interpret the following ABG results:

• a primary deficit in the concentration of base bicarbonate in the ECF.
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Metabolic Acidosis
pH
HCO3
pCO2
• common stimuli:
 DKA & starvation
 Tse hypoxia
 A/C Renal failure
 Excessive HCO3 loss
 diarrhea

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1. Assess v/s, I&O, Neuro, GI, Respi status.
2. Correct the underlying cause.
3.Restore fluid balance, prevent DHN
4.Correct hyperkalemia!
5.Adm. IV sodium bicarbonate.
6.Semi-Fowler’s
 pH,  HCO3

• a primary excess in the concentration of base bicarbonate in the ECF.
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Metabolic Alkalosis
pH
HCO3
pCO2
• common stimuli:
 Vomiting, gastric suctioning
 Hypokalemia
 Cushing dse, hyperaldosteronism
 Dialysis
 Use of antacids

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1. Assess v/s, I&O, Neuro, GI, Respi status.
2. Correct the underlying cause.
3.Restore fluid volume and correct electrolyte imbalance.
4.Encourage breathing into a paper bag.
5.Adm. acetazolamide a.p.
 pH,  HCO3

• a primary excess in the concentration of PCO2.
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Respiratory Acidosis
pH
HCO3
pCO2
• common stimuli:
 Airway obstruction
 Over sedation
 Traumatic injuries
 Cystic fibrosis, CVA

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1. Maintain patent airway & promote lung expansion!
2. Adm. Supplemental oxygen as directed
3. Treat underlying cause.
4. Reverse effect of anethesia/narcotics.
5. Adm. bronchodilators, antibiotics a.p.
6. Increase OFI, postural drainage, pursed- lip breathing.
 pH,  PCO2

• a primary deficit in the concentration of PCO2
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Respiratory Alkalosis
pH
HCO3
pCO2
• common stimuli:
 Anxiety, Fear
 Hyperventilation
 Fever, Asthma
 SNS medication overdose
 High altitude

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1. Encourage to conserve CO2.
2. Provide emotional support and reassurance.
3. Adm. anti-anxiety meds, sedation.
4. Adjust ventilator settings
5. Provide adequate rest.
 pH,  PCO2

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A client with Pn presents with the ff ABG: pH: 7.28, pCO2: 74, HCO: 28, pO2: 45, which of the following is the most appropriate nursing intervention?
a. Administer sedative a.d
b. Place client in left lateral position.
c. Place client in High-Fowler’s position.
d. Assist the client to rebreath in a paper bag.
Acid-Base Balance

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A client with COPD feels SOB after walking in the bathroom on 2 liters of O2 via nasal cannula. The morning ABGs were: pH: 7.36, pCO2: 62, HCO3: 35, SaO2: 88%. Which of the following is your first intervention? a. Call the physician and report the client’s condition. b. Turn the O2 up to 4Lpm via nasal cannula. c. Encourage the client to sit down and take deep breaths d. Provide rest and teach pursed-lip breathing
Acid-Base Balance

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A client with renal failure enters the ER after skipping three dialysis treatment to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?
a. pH: 7.43, pCO2: 36, HCO3:26
b. pH: 7.41, pCO2: 49, HCO3:30
c. pH: 7.33, pCO2: 35, HCO3:17
d. pH: 7.25, pCO2: 56, HCO3:28
Acid-Base Balance

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A client with small bowel obstruction has had an NG tube connected to low intermittent suction for 2 days. The nurse should monitor for s/sx of which acid-base d/o? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis
Acid-Base Balance

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A client suffers from an anxiety d/o and is very upset, RR: 32 and complaining of light-headedness and tingling in fingers. ABG values: pH: 7.48, pCO2: 29, HCO3: 24. The nurse performs which of the following as a priority nursing intervention?
a. MIO
b. Encourage client to increase activity.
c. Institute purse-lip breathing every hour.
d. Provide reassurance to the client and administer sedatives a.d
Acid-Base Balance

“A diffused light has little power or impact. A focused light can set grass or paper on fire. When focused even more, it can cut through steel.” - Rick Warren
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- Sir Cstive

SEE-SAW: HOMEOSTASIS

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