Notes

Normal Sodium - 135-145 mEq/L

Normal potassium - 3.5-5 mEq/L

Normal BUN - 7-20 mg/dl

Normal hematocrit - 40-50%

Normal urine specific gravity - 1.002-1.030

Normal glucose - 60-110 mg/dl

Normal osmolality - 275-295

FVD classic signs - Dry mucous membranes, come later

FVD late sign - Hypotension

FVD, temp changes - Decreased temp, blood shunted to central area

FVD, respiratory - Increased respiratory rate bc acidotic, blowing of CO2; Thick and sticky secretions

Anasarca - Severe, generalized third spacing

Most common site, 3rd spacing - Abdomen (ascites, in peritoneal cavity?)

Primary mediator of fluids - Hypothalamus

2nd spacing - Stage where fluid moves from one space to another

3rd spacing - Fluid in interstitial compartments

FVD sodium - Normal to high (Hemoconcentration)

FVD potassium - Normal to high (if intracellular, if enough cell death or should sodium levels could be high)

FVD BUN - High (Hemoconcentration); in children may be low but not pathologic

FVD glucose - Normal to high (stress response , greater 120)

FVD urine specific gravity - High greater 1.030

FVD osmolality (Serum) - Greater 300, more particles number of particles, concentration

FVE hemodynamic signs - Full bounding pulses, hypertension, increased CVP, neck vein distension, CHF

Cerebral edema - Seen with FVE, confusion, dizziness, convulsions, coma

Pulmonary edema - Seen with FVE, Dyspnea, Tachypnea, hacking cough, crackles, o2 sat down

FVE, general signs - Weight gain, nonpitting interstitial edema, hepatomegaly/splenomegaly

FVE first sign seen - Pulmonary edema

Neck vein distension - Sign of FVE but not seen in kids, make sure known baseline for adults

Goal of Rx for FVE - Prevent cerebral edema

Causes of FVE (10)
1. Renal failure
2. Heart failure
3. Excess fluid intake (with out electrolytes)
4. High corticosteroids
5. High aldosterone
6. Plain water enema
7. NG irrigations
8. Excess hypotonic IV fluids
9. SIADH
10. Inappropriately prepared formula (Dilute formula)

Excess fluid intake examples - Excessive hypertonic fluids, binge drinking contest, psych disorders, drowning in fresh water, inappropriate dialysis

FVE, potassium - Normal to high (potassium shift out of cells, rasing levels)

FVE, sodium - Very low, less 125

FVE, BUN - Low (Hemodilution)

FVE, urine specific gravity - Low, less 1.005

FVE, glucose - Normal to high (stress response, greater 120)

Decreased sodium and potassium signs - Lethargy, weakness

Increased sodium and potassium signs - Increased excitability

Acid - Releases H+ ions in water

Base - Binds to H+ ions in water

Buffers - Prevent major acid - base changes; carbonic acid bicarbonate, protien, and phosphate buffer system

Carbonic acid - Measure as CO2

Acid-base homeostasis - Bicarb: carbonic acid= 20:1

Carbonic acid-bicarb system - Primary system, 50% of activity, to maintain balance l/t have to also use protein and phosphate buffer system, 1-2 hours to kick in, bicarb is the major EFC buffer

Alkaline environment - Hard for cells to grow

Respiratory buffer system, carbonic acid - Carbonic acids compensates and dissociates into CO2 and H2O, CO2 exhaled by lungs, system activates rapidly but exhausted quickly

Respiratory buffer system, breathing changes - Changes in depth/rate of resp. alter it: hypoventilation retains CO2/ carbonic acid and causes acidosis, Hyperventilation loses CO2 and causes alkalosis

Renal buffer system; Time and effectiveness - Work within hours/days, more efficient than respiratory can go for longer periods of time

Renal buffering system, bicarbonate - Primary renal component, can be absorbed as needed, combines HCI with ammonia to make ammonium, which is easily excreted by kidneys into urine

Compensation - Regulatory mechanism to return pH to normal level by transforming acids and bases within the body

Primary metabolic disturbance - Causes a respiratory compensation

Acute primary respiratory disturbance - Causes an acute metabolic response

Complete compensation - pH is fully corrected (normal)

Partial compensation - Buffers are in the process of working; pH is low but bicarb is elevating to compensate (or pH is high but CO2 is elevating to compensate)

pH- *Negative logarithm of H+ ion concentration in mEq/L (as H+ ion concentration increases, pH decreases) *normal values 7.35-7.45 (less is acidotic, more is alkalotic)

HCO3-(bicarb) - *Normal 22-26 mEq/L (decreases in acidosis, increases in alkalosis)

BE "base excess" - Indicates the amount of bicarb available in the EFC normal value: +/- 2 mEq/L

Serum anion gap - *Concentration of anions (HCO3-, CL- Protein, phosphate, and sulfates) and cations (Na+, K+, MG++, & Ca++) *10-12 mEq/L normal -increased in metabolic acidosis (but can be normal) *calculated by Na - Cl +bicarb

SaO2 - The percent of Hb saturated with O2, a calculated value (indirect measurement), calculated with pH and PaO2 (combination of O2 sat, PaO2 and Hb), indicates tissue oxygenation

PaO2 - Amount of oxygen available to bind with hemoglobin, amount of pressure exerted on O2 by plasma

The lower the PaO2 pressure, the - Less oxygen available to bind with Hb

Dramatic drops in PaO2- Correlate with dramatic drops in oxygen saturation

PaO2 normal values - 75-100 mmHg (for every year above 60 drop 1 mmHg)

PaCO2 - * Partial pressure of CO2 *reflects adequacy of alveolar ventilation, regulated by lungs, alterations indicate resp. disturbance *normal values 35-45 mmHg (less is alkalotic, more is acidotic)

Respiratory alkalosis management (4) -
1. Correct cause
2. Rebreathe CO2 as needed
3. Alter ventilation rate
4. Sedative (for anxiety)

Respiratory alkalosis assessment (7)
1. VS
2. ABGs
3. RR/depth
4. LOC/anxiety
5. Neuro checks
6. Injury potential
7. I&O

Respiratory alkalosis CV signs - Tachycardia, palpitations, increased myocardial irritability

Respiratory alkalosis respiratory signs - Rapid shallow breathing (trying to retain CO2, oxygenate), chest tightness

Respiratory alkalosis CNS signs (10)
1. Paresthesia
2. Dizziness
3. Confusion
4. Tetany
5. Convulsion
6. Numb/Tingling
7. Light headed
8. Anxiety/panic
9. Loss of consciousness
10. Hyperactive reflexes

Respiratory alkalosis causes (4)
1. Hyperventilation
2. Sepsis/infection
3. Over ventilation
4. Hepatic cirrhosis

Respiratory alkalosis; labs - Low CO2, pH high greater 7.45, bicarb normal if no compensation or decreased if compensation, hypokalemia, hypocalcemia

Respiratory acidosis management (7)
1. Correct cause
2. CPT
3. TCBD if able
4. Suction as needed
5. Semi- Fowlers
6. Fluids to thin secretions
7. Low-flow O2 as needed

Respiratory acidosis assessment (8)
1. VS
2. ABGs
3. RR/depth
4. Apical pulse
5. LOC
6. EKG
7. Skin color/nail beds/mucous membranes
8. I&O

Respiratory acidosis cardiac signs - Hypotension, peripheral vasodilation weak thread pulse, tachycardia, warm flushed skin

Respiratory acidosis respiratory signs - Dyspnea, slow shallow respirations, hypoxia and hypoventilation, cyanosis

Respiratory acidosis CNS signs (6)
1. HA
2. Seizures
3. Altered LOC
4. Papilledema
5. Twitching/Tremors
6. Drowsy coma

Respiratory acidosis causes (4)
1. Respiratory depression/arrest
2. Inadequate chest expansion
3. Airway obstruction
4. Interference with alveolar capillary exchange

Respiratory acidosis: labs - pH low less 7.35, PaCO2 high greater 42, HCO3- normal (or elevated with compensation), hyperkalemia

Metabolic alkalosis mgmnt (3)
1. Correct cause
2. Restore normal fluid balance
3. Adequate chloride (enhance renal absorption of sodium and excretion of bicarb)

Metabolic alkalosis assessment (6)
1. VS
2. ABGs
3. RR/depth
4. LOC
5. I&O
6. ECG

Metabolic alkalosis GI signs (3)
1. N/V
2. Anorexia
3. Paralitic ileus (Hypokalemia)

Metabolic alkalosis CNS signs (10)
1. Dizzy
2. Nervous
3. Tremors
4. Hyperreflexia
5. Paresthesia's
6. Irritability
7. Confusion/Apathy/Stupor
8. Cramps
9. Tetany
10. Seizures

Met alkalosis respiratory signs (2)
1. Hypoventilation
2. Respiratory failure

Met alkalosis CV signs (5)
1. Tachycardia
2. HTN
3. PVC
4. Atrial tachycardia
5. Dysrhythmias (from FVE)

Met alkalosis causes (4)
1. Vomiting
2. NG suctioning
3. Eating bicarb-base antacids
4. Diuretics

Met alkalosis: labs- Increased pH, increased BE, increased bicarb, Decreased anion gap (low K and Na)

Met acidosis mgmnt (6)
1. Correct causes
2. Treat ketoacidosis (fluids, insulin)
3. Give alkaline fluids
4. Hydrate
5. Mechanical ventilation if needed
6. Possible dialysis

Insulin - Used to treat metabolic acidosis (ketoacidosis), forces potassium back into cells

Alkaline fluids for met action - If severe, sodium bicarb if pH less 7.20, salts of organic acid (lactate, citrate), tromethamine THAM

Met acidosis assessment (7)
1. VS
2. ABGs
3. RR/depth
4. Apical and Peripheral pulses
5. ECG (bc of dramatic K changes)
6. LOC
7. I&O

Metabolic acidosis CV signs (4)
Dramatic affects:
1. Hypotension
2. Dysrhythmias
3. Peripheral vasodilation
4. Warm flushed skin (from dilation, leaking of capillaries)

Metabolic acidosis resp. signs - Kussmaul/deep/rapid respirations, trying to blow off CO2

Metabolic acidosis CNS signs (6)
Think of septic patient:
1. Drowsy
2. HA (from cerebral edema)
3. Lethargy
4. Coma
5. Confusion/restless
6. Weakness

Metabolic acidosis GI signs (3)
1. N/V
2. Diarrhea
3. Abdominal pain

Causes of metabolic acidosis - Chronic diarrhea, malnutrition, starvation, renal failure, DKA, Trauma, shock, sepsis, fever, salicylate toxicity

Metabolic acidosis: labs - Low bicarb, decreased BE, increased anion gap, hyperkalemia (from breakdown of cells form acidosis), high metabolic acids (Lactic acids, Ketoacids)