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| If both CO2 and HCO3- are abnormal... |
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| see which one has a change that matches the change in the pH. This will be the primary imbalance...the other is compensating. |
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| Bicarbonate (as CO2 combining power) |
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2.2-2.5 mEq/L
4.4-5.9 mg/dl |
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1.5-2.5 mEq/L
1.8-3.0 mg/dl |
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| Blood urea nitrogen (BUN) |
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Volume X Drop Factor
divided by
Time in Minutes
= gtt (drops) per minute |
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| Increase HCO3 to raise pH |
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| Decrease HCO3 to lower pH |
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Respiratory acidosis
Common Etiologies |
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| COPD, sedative or barbituate overdose, chest wall abnormalities, pneumonia, atelectasis, respiratory muscle weakness, hypoventilation |
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Respiratory alkalosis
Common Etiologies |
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Definition
| Hyperventilation cause by hypoxia, fear, fever, pain, exercise, anxiety, pulmonary embolus, mechanical overventilation, septicemia (respiratory center stimulation), brain injury, encephalitis, salicylate poisoning |
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Metabolic acidosis
Common Etiologies |
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Definition
| Diabetic ketoacidosis, lactic acidosis, starvation, severe diarrhea, renal tubule acidosis, renal failure, GI fistulas, shock |
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Metabolic alkalosis
Common Etiologies |
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Definition
| Severe vomiting, excessive NG suctioning, diuretic therapy, hypokalemia, excess licorice intake, excessive NaHCO3 use, excessive mineralcorticoids |
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Respiratory acidosis
Clinical Manifestations |
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Definition
| Resp. rate increase and shallow to attempt to blow off CO2, hypotension, heart block, peaked T waves, prolonged PR interval, weak and thready pulse, tachycardia, warm and flushed skin, headache, papilledema, decreased LOC, drowsiness, coma |
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Respiratory alkalosis
Clinical Manifestations |
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Definition
| Increased myocardial irritability, increase heart rate, increased sensitivity to Digitalis preparations, dyspnea, chest tightness, dizziness, anxiety, panic, tetany, seizures, blurred vision |
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Metabolic acidosis
Clinical Manifestations |
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Definition
| Hypotension, dysrhythmias, peripheral vasodilation, cold and clammy skin, deep rapid resp. pattern (Kussmaul's respirations), drowsiness, coma, headache, confusion, lethargy, weakness, nausea and vomiting, diarrhea, abdominal pain |
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Metabolic alkalosis
Clinical Manifestations |
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Definition
| Increase heart rate, dysrhythmias secondary to hypokalemia, hypotension, PVCs, atrial tachycardia, hypoventilation, respiratory failure, dizziness, irritability, nervousness, confusion, tremors, muscle cramps, tetany, hyperreflexia, parenthesias of the fingers and toes, seizures |
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Hyponatremia
Manifestations |
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Definition
| Bounding pulse, increased pulse, low BP (with low ECV - extracellular volume), pale dry skim with dry mucous membranes (with low ECV), edema and weight gain (with elevated ECV), thirst, weakness, headache, confusion, seizures, abdominal cramps, anorexia, N/V, diarrhea, lethargy, agitation, dizziness |
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| Increase Na in foods, salt tablets if ordered; With normal fluid volume (euvolemia), use water restriction and treat cause; with hypovolumia, use normal IV saline and Lactated Ringers to correct ECF deficit,; with hypertonic dehydration, treat with fluid restriction and treat cause. Use isotonic saline (not water) to prevent fluid shifting. Treat PRN with 3% saline (hypertonic) using agency protocols, loop diuretics as ordered for water excretion, dialysis if needed, monitor I & O and daily weight. |
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Hypernatremia
Manifestations |
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Definition
| Increase pulse and BP, decreased cardiac contractility, dry and sticky mucous membranes, rough dry tongue, flushed skin, thirst, increase urine output, twitching, tremors, increase DTRs (deep tendon reflexes), agitation and CNS irritability, hallucinations, coma, watery diarrhea, nausea |
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Definition
| Restrict Na (including hidden sources); With euvolemia, use water replacement and treat cause; with hypovolemia, treat with NS to correct water deficit; with hypervolemia; remove sodium excess, administer diuretics and water PRN; monitor I&O and weights; watch for CNS changes |
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Hypokalemia
Manifestations |
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Definition
| Variable pulse, weak tready pulse, increased risk of digitalis toxicity, decreased breath sounds, shallow resp, dyspnea, polyuria and nocturia, myoglobinuria (if severe), decreased DTRs, muscle weakness, paresthesias, soft flabby muscles, fatigue and lethargy, depression and coma (if severe), abdominal distention, decreased or absent bowel sounds, vomiting, diarrhea, paralytic ileus |
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| Monitor vitals, BP (orthostatic hypo), changes in ECG, heart rate or rhythm; watch serum levels of digoxin and K levels with loop and thiazide diuretics, safe environment needed due to weakness, encourae increase fiber and water intake, also K increase in diet, maintain I&O, give K suppl. through IV solution (NEVER IV push; infusion pump only) |
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Hyperkalemia
Manifestations |
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Definition
| Irregular, slow heart rate, low BP, ECG changes, possible cardiac arrest, resp unaffected until high levels, leading to muscle weakness, paralysis, resp. failure; muscle twitching, muscle cramps, irritability, anxiety, flaccid paralysis, increased bowel sounds, diarrhea, abdominal cramping, nausea |
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| Decrease K intake and adher to restrictions; No K supplements; give polystyrene sulfonate (Kayexalate) enema or oral with osmotic agent to decrease constipation; give K wasting diuretics to eliminate via kidneys or 50% dextrose with regular insuline to drive K into cells; monitor cardiac status |
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Hypocalcemia
Manifestations |
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Definition
| Tetany, Chvostek's and Trousseau's signs, increase DTRs, laryngospasm, seizures, hyperactive bowel sounds, abdominal cramps, diarrhea, depression, apprehension, confusion, delusions, hallucinations, memory impairment, convulsions, anxiety, hypotension, decreased cardiac contractility, ECG changes, cardia or resp arrest; oliguria, anuria, increased bleeding/bruising; dry brittle nails and hair |
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Definition
| Increase Ca intake; calcium gluconate by IV push or infusion with D5W or NS, vitamin D supplmts, phosphorus binding antacids, thiazide diuretics possible to lower urinary excretion of Ca, seizure and safety precautions due to risks, quiet environment, monitor resp. and airway. Have emergency tracheostomy kit and IV calcium gluconate for postop thyroidectomy patients (inadvertant remove of parathyroid gland) |
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Hypercalcemia
Manifestations |
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Definition
| Muscle weakness, increase fatigue, decreased DTRs, hypoactive bowel sounds, N/V, constipation, anorexia, headache, personality changes, acute psychosis, confusion, bizarre behavior, lethargy, memory impairment, coma, increase BP, heart block, cardiac arrest, polyuria, polydipsia, renal colic, kidney stones |
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| Decrease Ca intake and Ca supplements (antacids); use loop diuretics like furosemide (Lasix) or ethacrynic acid (Edecrin). Provide hydration and fluids high in acid (cranberry, prune juice); Infuse NS at 300-500 mL/hr up to 6L until volume status restored; then NaCl; watch for fluid overload. Corticosteriods (prednisone) for decreased GI absorption of Ca; parathyroidectomy for hyperparathyroidism. |
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Hypomagnesemia
Manifestations |
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Definition
| Muscle twitching, tremors, increased DTRs, convulsions, hallucinations, laryngeal stridor, supraventricular tachycardia, PVCs (premature ventricular contractions), V fib, increased susceptability to digitalis toxicity, mood changes (apathy, depression, confusion); N/V, diarrhea, anorexia (concurrent hypokalemia), possible growth failure in children. |
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Definition
| Promote dietary changes, increase Mg, supplmts as ordered; ECG monitoring and seizure precautions, stidor and swallowing monitoring; bed rails if client is confused; I&O recording; monitor DTR (deep tendon reflexes) with those receiving IV Mg solutions, decreased DTRs indicate Mg levels high. |
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Hypermagnesemia
Manifestations |
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| Decreased DTRs, decreased neuromuscular activity like hyperkalemia, low BP, decreased pulse, bradyrhythmias, flushing and warm sensations, possible cardiac arrest; somnolence, weakness and lethargy, respiratory depression and coma |
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Hypermagnesemia
Treatments |
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Definition
| Decrease Mg in food and medications (antacids and enemas). Promote excretion with diuretics (when stable renal function); dialysis for those with renal failure; correct diabetic ketoacidosis with insuline and IV dextrose to halt cellular catabolism; rehydrate; emergency treatment with IV calcium gluconate to antagonize Mg and reverse cardiac/resp signs |
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Hyperchloremia
Manifestations |
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Definition
| Deep raid respirations (metabolic acidosis due to loss of bicarbonate), weakness, lethargy, stupor, loss of consciousness |
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| Decrease Cl intake; diuretics to promote excretion; correct dehydration with oral and IV fluids; monitor acid-base balance, respiratory and cardiac status |
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Hypochloremia
Manifestations |
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Definition
| Slow and shallow respirations (metabolic alkalosis due to bicarbonate retention); low BP with severe CL and ECF loss, muscle tremors and twitching |
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Definition
| Give oral salt tabs or increase Cl in diet; Cl by IV infusion if levels are critical or if client doesn't tolerate PO administration; monitor vitals and I&O; maintain safety precautions if tremors or low BP |
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Hypophosphatemia
Manifestations |
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Definition
| Anemia, bruising, bleeding, slurred speech, confusion, apprehension, circumoral and fingertip/extremity numbness; muscle weakness; paresthesias; tremors, spasms, tetany, seizures, coma, chest pain, dysrhythmias, heart failure, shock, alkalosis, respiratory muscle fatigue, hypoactive bowel sounds, anorexia, dysphagia, vomiting, gastric atony and ileus. |
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Hypophosphatemia
Treatments |
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Definition
| Replace phosphorus via diet or IV; avoid phosphorus-binding antacids; watch for development of hypercalcemia; watch for difficulty speaking, weaking respiratory efforts; assess serial hand grasps for increasing weakness; seizure precautions |
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Hyperphosphatemia
Manifestations |
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Definition
| Hypocalcemia, soft tissue calcification (oliguria, corneal haziness, conjunctivitis), ECG changes, increased pulse, figertip numbness and tingling, muscle spasms and weakness, increased DTRs, tetany, Chvostek's or Trousseau signs (concurrent with increase Ca) anorexia, N/V |
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Hyperphosphatemia
Treatments |
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Definition
| Decrease PO4 intake in diet and meds; increase GI and renal excretion; dialysis in those with renal failure; maintain fluid volume and adequate BP to aid excretion of PO4. |
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Definition
Elicitation: Tapping on the face at a point just anterior
to the ear and just below the zygomatic bone
Postitive response: Twitching of the ipsilateral facial
muscles, suggestive of neuromuscular excitability
caused by hypocalcemia |
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Definition
Elicitation: Inflating a sphygmomanometer cuff above
systolic blood pressure for several minutes
Positive response: Muscular contraction including flexion
of the wrist and metacarpophalangeal joints,
hyperextension of the fingers, and flexion of the thumb
on the palm, suggestive of neuromuscular excitability
caused by hypocalcemia |
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