NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Fluids and Electrolytes Miss Debbie F.

. Tejam, RN MN 50-60% (40L) in adults is composed of Body fluids 75% in children 50% in females because women have more fat cells; fluids cannot occupy fat cells 60% in males because men are more vascular 10% of fluid loss is serious (dehydration, diarrhea, excessive vomiting, more severe in children 20% of fluid loss is fatal; person may die (extensive burns, hypovolemia, hemorrhage, dec fluids in intravascular space Body Fluid Compartments 1. Intracellular Fluid Compartments - Fluids inside the cells - 35-40% or 2/3 or 25L 2. Extracellular Fluid Compartments - Fluids outside the cell; more complex - 15-20% - ***must be in respective fluid compartments - Further classified into - E.g. CSF, fluids in the joints (synovial fluids), GI Fluids a. Intravascular Fluid Compartments o Fluid in the blood stream o 5% b. Interstitial Fluid Compartments o Fluids between the cells and in the body tissues o 10-15% c. Transcellular Fluid o Outside the ICF Manifestation of Shifting Edema - Excess accumulation of fluid in the interstitial space Localized Edema - Occurs as a result of traumatic injury (E.g. accident, injury or surgery) ANASARCA/Brawny Edema - Generalized edema - Excessive accumulation of fluid in the interstitial spaces all throughout the body (may be caused by CHF, Renal Failure, Hepatic Failure Nursing Responsibilities Detect signs and symptoms of fluid imbalance IV Fluid source of fluid directly intravascular space; excess in fluid may be caused by improper regulation Renal failure excess fluid imbalance in fluid ad electrolytes

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NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Functions of Fluids 1. Maintain Blood Volume - Direct relationship between volume of fluid blood volume and BP 2. Transport System - Fluid as a vehicle to transport nutrients to nourish cell and get rid of waste materials away from cell 3. Maintenance of Normal Body temperature. (independent nursing intervention in cases of hyperthermia: increase oral fluid intake) 4. Elimination of Waste Products Standard Fluid Requirement - Depends on the weight of the patient: 100mL/kg for the first 10 kg if BW + 50mL/kg for the next 10kg of BW + 15mL/kg for remaining weight - E.g. Weight of the patient is 60kg 10kg = 50 kg 100mL/kg x 10kg = 1000mL 50kg 10kg = 40 kg; 50mL/kg x 10kg = 500mL 15mL/kg x 40kg = 600mL For a 60 kg patient 1000mL + 500mL = 600mL = 2100mL for that day - Contraindication : CHF, RF Mechanisms of Fluid Balance o Kidneys: Control fluid and electrolytes; secrete renin (when there is decrease urine output); renin convert angiotensin 1 angiotensin 2 via ACE stimulate adrenal gland to secrete aldosterone(hormone that retains Na and water) o Lungs: Control CO2 levels and H2O vapor insensible loss (we are not aware of) o Skin: Fluid losses insensible loss (we are not aware of) o Hormonal Control o ADH (water retainer; inhibits dieresis or production of urine) o Aldosterone (Na and water retainer hormone) Average Fluid Losses and Gains in 24 Hours Intake Output Oral Liquid 1300mL Urine 1500mL Water in Stool 1000mL Stool 200mL Water from metabolism 300mL Insensible Losses Lungs 300mL Skin 600mL Total 2600mL Total 2600mL Electrolytes - Substances that carries electrical charge (+ cation or - anion); like fluids located in certain compartments; they are suppose to occupy that environment; minor shift will lead to serious problem esp K person may die - Amount of cations and anions must be equal to maintain homeostasis o Sodium (Na ) o + charge cation o Major ECF Cation o Most abundant in ECF 84

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN o Regulate Fluid volume b/c it can retain water o Maintain neuromuscular excitability o Control H2O distribution between ECF and ICF o Potassium (K) o Cation o Located inside the cell o Major ICF cation; most abundant in ICF o Necessary for transmission and conduction of nerve impulses o Contraction of skeletal, cardiac, and smooth muscles o Excreted in kidneys and GIT. Kidneys does not have a mechanism to retain potassium o Chloride (CI) o Main ECF anion o Affect body pH o Vital Role in maintaining acid base balance o Calcium o Occupies same space as Na and Cl ECF o Necessary for none and teeth formation, blood coagulation, nerve impulses transmission and N muscle contraction o Mg o Main ICF same with K o Transmit nerve impulses o Stimulate parathyroid hormone section o P (-) o Main ICF anion o Promotes energy storage and CHO, CHON and fat metabolism o HCO3 o Present in ECF o Regulates acid-base balance o anion Normal Lab Values (308-314 Daniels) o Na (135-145mEq/L) o K (3.5-5mEq/L) o Ca (4.5-5.5mEq/L) o P (1.7-2.6 mEq/L) o Cl (98-108 mEq/L) o Mg (1.5-2.5 mEq/L) o HCO3(22-26 mEq/L) Fluid Imbalance (fluid volume deficit or dehydration hypovolemia (there is a low volume in the ECF); and fluid volume excess o Hypovolemia o Definition a low volume of ECF; especially in the intravascular space relate to decrease in blood volume o fluid volume deficit/dehydration (not only Intravascular Volume is only depleted but all fluid compartments are decreased) 85

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Etiology o inadequate fluid intake o Fluid loss/inadequate fluid replacement o Inc urinary output o Diuretics o Types of DHN 1. Isotonic: H2O and dissolved electrolytes are lost in equal proportions, most common(see book for IV fluids for replacement 2. Hypertonic: H2O loss exceeds electrolyte loss causing cellular DHN and shrinkage; 3. Hypotonic: electrolyte loss exceeds water loss, causing a plasma volume deficit and causing cells to swell o Manifestation/Assessment o Thirst earliest sign o Postural hypotension (dec BP when there is a change in position 20mmHG drop causing lingin ang ulo o Weight loss (relate weight loss to volume; 1kg=1L) o Poor skin turgor o Inc HR inc RR o Dry mucous membranes o Urine: dec in volume, dark, odorous, inc specific gravity (reflects hydration status of patient, and ability of kidney to either concentrate or dilute urine) o Interventions/Implementations o Correct cause, prevent further loss o Replace fluid (PO or IV) o Weigh client daily o MIO, serum electrolytes o Measure urine Sp. Gravity o NDx: Deficient fluid volume r/t fluid loss greater than intake AEB vomiting, diarrhea, weight loss Hypervolemia inc in ECF compartment especially the Intravascular compartment o Definition: 1. High volume of water in the intravascular fluid compartment 2. Fluid volume excess, overhydration or fluid overload o Etiology o Excessive fluid intake o Excess or rapid IV infusion o Inadequate fluid elimination RF o Hypernatremia o Heart failure o Manifestations o Weight gain o Inc BP, pulse CVP (N = 4-10cmH2O) o Edema, dyspnea o Dec Hct, Dec Sp Gr o Neck Vein Distention 86 o

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Implementation o Diuretics o Restrict fluids o MIO, weigh daily o Semi-fowlers (for DOB) o Low Na diet o Monitor serum electrolytes o Third Spacing (can be related to hypovolemia) - Movement/translocation of fluids from vascular space to other space such as abdominal cavity (abdominal third spacing Ascites) o 3 Common Sites 1. Peritoneal cavity 2. Pleural cavity 3. Pericardial sac o Manifestations o Hypovolemia (no weight loss because of shifting to different compartment) o Ascites o Generalized (anasarca) edema in all interstitial spaces o Pallor o Implementation o Restore circulatory volume o Restore colloidal osmotic pressure o Diuretic IV o Nursing Management o Assess to detect hypovolemia and Hypervolemia Electrolyte Imbalance o Imbalance whenever there is excess or deficit of electrolytes o Hyper- or Hypo- to help describe deficit or excess o emia presence of which in the blood Potassium (K) o NV=3.5-5mEq/L o Deficit or excess may lead to cardiac failure o Hyperkalemia is more deadly (7mEq/L) than the common hypokalemia o Causes: over ingestion if K+, rapid infusion of K+; K+ sparing diuretics, RF; Addisons disease; Burns o Assessment Nausea Irregular HR, slow weak pulse rate, dec BP Muscle cramps, paresthesias, weakness o Nursing Interventions Cardiac monitor D/C IV K+ and hold oral K+ Diuretics Monitor renal function Avoid food high in K+ 87 o

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Hypokalemia (Serum K < 3.5mEq/L) loop diuretics (potassium wasting) May be caused by: diuretics [loop diuretics (potassium wasting)], vomiting and diarrhea (GI fluids contain a lot of K), if patient has renal disease Assessment Weakness Disorientation, coma N and V, abdominal distention Cardiac dysrhythmias ECG changes: ST depression, flat or inverted T wave, prominent U wave Nursing Interventions (inc serum K) MIO, serum electrolytes K+ supplements Check renal function (potassium may not be excreted in cases of renal failure causing Hyperkalemia); check if patient can void freely; Started KCl drip after patient voided freely, never give K IV push or IV bolus Dilute before administration (20-40mEq of K dilute in 1000mL in solu set); if PO dilute the potassium in 4-8oz of water or juice Maximum recommended infusion rate 5-10 mEq/h, never to exceed 20mEq/hr Cardiac monitor Sodium (Na+) o NV: 135-145mEq/L o Hyponatremia Causes Diuretics, wound, drainage Dec secretion of aldosterone, renal disease Prolonged vomiting Assessment (HypoNa) Lethargy, cramps, vomiting, confusions Muscular weakness Anorexia Convulsion in severe deficit Nursing Interventions Administer IVF with Na+ (3% or 5% saline) Restrict water intake, MIO o Hypernatremia Causes Excessive Na+ intake Dec h20 intake Sever GI losses Assessment Delirium, convulsion, coma Dry, flaky skin Edema Nursing Interventions 88 o

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Restrict Na Oral/Parenteral Fluids Safety Measures

Calcium (Ca+) o NV: 4.5-5.5mEq/L) o Hypocalcemia: Causes Inadequate oral intake of Ca Lactose intolerance Vit. D deficiency Removal or destruction of the parathyroid glands Assessment Circumoral paresthesia Muscle cramps, Tetany (+) Trousseaus (carpopedal spasm/carpal spasm) use BP cuff, parameter is systolic blood pressure inflate for 4 minutes a little higher than systolic BP, assess for carpal spasms and Chvosteks Sign tap facial nerve and check for facial spasm Implementation Administer Ca supplements PO or IV Warm IV Ca before administration Observe for infiltration; monitor for hypercalcemia 10% Ca Gluconate Monitor sign of fracture Diet: High in Ca+ o Hypercalcemia Causes: Excessive intake of ca, Vit. D RF Hyperparathyroidism Hyperthyroidism Immobility (may cause urinary stasis) Assessment Muscles weakness Renal Calculi Anorexia, nausea, constipation Nursing Interventions Ambulation, avoid large doses of Vit. D Adequate Hydration (at least 3L) Strain Urine to be able to collect stones and send to Lab for analysis for the management of the patient using the different diets Acid-ash fluids helps acidify the urine, alkaline stone such as Ca may not form

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NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Acid-Base Balance A. Hydrogen Ion, Acids and Bases o H ions (H+) o Vital to life o Expressed as pH N pH range is 1-14 o Neutral pH is 7 o The more hydrogen ion a compound has the more acidic it is B. Acids o Produces as end produces of metabolism o Contains H ions; if acid gives out H, the concentration of the acidity of that compound weakens o H+ ions C. Bases o Contains no H+ o May accept H+ from acid to neutralize or dec the strength of a base, therefore becoming a weaker acid Mechanism for Maintaining Acid-Base Balance 3regulatory mechanisms A. Buffer Mechanism - the fastest acting regulatory system - provide immediate protection against changes in H+ concentration in the ECF (by adding (made acidic) or removing H (becomes basic) - absorb or release H+ as needed - major chemical regulator of plasma pH is.HCO3-H2CO3 buffer system B. Respiratory Mechanism - 2nd fastest - CO2 is one of the component of H2CO3 - CO2 + H2O = H2CO3 - Lungs regulate H2CO3 levels by releasing or conserving CO2 by in or dec RR - In acidosis, RR and depth go up to blow up acids - In alkalosis, RR and depth, go down; the CO2 is retained, and the carbonic acid builds to neutralize and dec the strength of excess HCO3 C. Renal or Urinary Mechanisms - The ultimate correction if acid base disturbances - Kidney restore HCO3 by the release of H- by holding the HCO3 ions - In acidosis, pH goes down - In alkalosis, pH goes up 3 Important Assessment to determine acid base imbalance - Obtained through ABG radial artery, ideal site for ABG, heparinized syringed - pH of blood 7.35 (<acidosis)-7.45(>alkalosis) - PaCO2 35 (<alkalosis)-45mmHg(>acidosis) - HCO3 22(<acidosis)-26mEq/L(>alkalosis) - PO2 N value is 80-100% - O2Sat N value is 97-100% ROME respi opposite metabolic equal 90

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Acid-Base Imbalance 1. Alkalosis excessive accumulation of base and excessive loss of acid in body fluids 2. Acidosis this is an excessive accumulation of acid and excessive loss if base in body fluids 4 General Classes of Acid-Base Imbalance 1. Metabolic indicator is HCO3 Metabolic Acidosis most severe - Decrease HCO3 - Decreased plasma pH Causes - Starvation - Malnutrition - Ketogenic Diet - Systemic Infection - Diarrhea (base goes out, patient becomes acidic; excessive loss of HCO3) - RF, DM Manifestations - Kussmauls respirations, confusion, stupor, disorientation - Ketone breath, Hyperkalemia - N and V Nursing Interventions - Treat underlying cause - Promote food air exchange - Give NaHCO3 - Monitor K Level Metabolic Alkalosis - HCO3 excess Causes - Vomiting - Alkali ingestion - Gastric suction - Long term diuretic therapy Manifestations - Shallow respirations - Confusion, irritability, agitation, coma - Hypokalemia, hypocalcemia - Dysrhythmias - Muscle tremors Nursing Interventions - Restore fluid volumes, monitory serum L- and CA++ levels, institutes safety measure 2. Respiratory indicator is PaCO2 Respiratory Acidosis - Excess PaCO2, dec pH - Retention of PaCO2 , hypoventilation 91

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Causes - Acute: respiratory suppression or obstruction duets pulmonary edema, over sedation, pneumonia - Chronic: chronic airflow limitation or COPD Manifestations - Hypoventilation - Respi insufficiency - pH <7.35, PaCO2 > 45 - Tachycardia - Confusion, lethargy, coma Nursing Interventions - Administer NaHCO3 - Monitor ABG, O2 - Promote good air exchange - Semi-fowlers - Encourage patient to turn to sides and deep breathing (q2h) - bronchodilators

Respiratory Alkalosis most common - PaCO2 deficit Causes - Hyperventilation - Hypoxia - Anxiety - Fever, pain - Pneumonia, ARDS - CHF Manifestations - Inc RR (early manifestation) - PaCO2: <35; pH increase - Numbness, tingling of fingers and toes - Chest pain - Convulsion Nursing Interventions - Breathe into paper nag or cupped hands - Provide emotional support - Monitor electrolyte levels Guidelines 1. Check if acidosis or alkalosis 2. Determine if metabolic or respiratory 3. Determine if fully or partially compensated Compensated if both are abnormal; if compensated, ID if fully or partially compensated; parameter is pH; if pH normal it is fully compensated, if abnormal-partially compensated Uncompensated if one is normal and the other is abnormal 92

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Ex. 1 pH 7.58 alkalosis PaCO2 21 alkalosis HCO3 20 acid Respiratory alkalosis, partially compensated Ex. 2 pH 7.37 (N), change the reference point to 7.4 :. < 7.4 acidosis ~ acidosis; >7.4 ~ alkalosis PaCO2 56 acidosis HCO3 29 alkalosis Respiratory acidosis, fully compensated Ex. 3 pH 7.26 acid PaCo2 39N HCO3 19 acid Metabolic acidosis, uncompensated Blood Gases (See Book) ABGs o Most accurate means of assessing respi function

Care of Patient with Burns Burns - Injury from heat, electric current, chemical, friction, or excessive sunlight exposure - Classified according to depth (1st, 2nd, 3rd, 4th) Characteristics of 1st Degree Burn (Superficial) a. Superficial tissue destruction b. Painful and Erythema c. Without blister (never break blisters to prevent excessive fluid loss and risk of infection) d. Discomfort 48-72 hours e. Desquamation in 3-7 days 2nd Degree Burn/Partial Thickness (Could be superficial partial thickness or deep partial thickness) Second degree superficial partial thickness burns: A. Tissue destruction (entire epidermis and some of the epidermis) B. Form wet, thin walled blisters after surgery C. Painful D. Healing less than 21 days Second degree deep partial thickness burns: A. Tissue destruction involving possibly the entire dermis B. Mottled appearance with large area of waxy white injury 93

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN C. Very sensitive to touch, air currents D. Healing takes more than 21 days E. Presence or absence of infection Third degree full thickness burns o Damage throughout the dermis, subcutaneous, muscles o Tissue appears charred or lifeless o Color variable (deep red, black, brown) o Extensive scarring and contractures o Painless to touch o Autografting require for healing Fourth Degree full thickness burns o Involves skin, fat, muscles, and bones o Color variable o Charring visible in deepest areas o Limited extremity movement o Insensate o Amputation of extremity o Autograft required for healing 1. Minor Burns a. Partial thickness burns of <15% TBSA b. Full thickness burns are <2% TBSA c. Burned areas do not involved the eyes, ears, hands, face, feet or perineum *1% = palm of the hand Eyes associated with corneal abrasions losing sight without normal functioning Hands and feet require physical therapy; to prevent contractures Face and chest associated with respiratory dysfunction; face compromises respiration Perineum associated with infection with autocontamination from urine/feces Ears balanced and equilibrium are affected 2. Moderate Burns a. Partial thickness burns are deep and 15-25% of TBSA b. Full thickness burns of <10% TBSA c. Burn areas do not involve eyes, hands, ears, face, feet, perineum d. No electrical burns or inhalation injuries 3. Major/Severe Burns a. Partial thickness burns of >25%of TBSA b. Full thickness burns of 10% TBSA or greater c. Burn areas involve eyes, ears, hands, face, feet or perineum d. Burn injuries was an electrical burns or inhalation injuries

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NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Estimating the Extent of Injury Rule of Nine - quick assessment tool to identify burn injury; all in all is a 100%; the exact amount of fluid resuscitation is dependent on the extent of burn injury;

Lund and Browder Method - modifies the percentages for body segments according to age; has diagram according to age; - provides more accurate estimate of burn size - uses a diagram of the body divided into section, with the representative % of the TBSA throughout the lifespan - should be reevaluated after initial wound debridement; time consuming Types of Burns A. Thermal Burns: caused by exposure to flames, hot liquids, steam or hot objects; most common type of burn; e.g. residential fire, explosive automobile accident B. Chemical Burns a. Caused by tissue contact with strong alkali, or organic compounds; e.g. household cleaning agents muriatic acid C. Electrical Burns a. Caused by heat generated by electrical energy; e.g. lightning strike, high voltage power line b. Results in internal tissue damage; cardiac failure D. Radiation Burns: caused by exposure to UV light, x-rays or radioactive source; e.g. sunburn Pathophysiology of Burns Burn Inc Vascular Permeability Edema Dec IV Volume Inc Peripheral Resistance Dec CO Hypovolemia Hemodynamic/Systemic Changes see book Oliguria 100-400cc/day Anuria 0-100cc/day 95 Inc Hct Inc Viscosity

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Patients with burns are put in reverse isolation room 40xgreater evaporative fluid losses and continue until complete wound complete wound closure occurs Nursing Diagnosis 1. Ineffective airway clearance r/t secretions, tracheobronchial edema, and obstruction 2. Acute pain r/t exposed nerve ending and associated trauma (may be caused by physical therapy, wound dressing, debridement) 3. Deficient in fluid volume r/t IV fluid shift and evaporation 4. Risk for infection r/t impaired skin integrity (break in the skin) 5. Impaired tissue integrity r/t impaired perfusion and burn injured skin 6. Impaired physical mobility r/t pain, contractures 7. Disturbed body image r/t altered body functions or appearance 8. Imbalance nutrition: less than body requirements r/t decrease appetite Planning and Implementation in Burns 1. Eliminate the source of the burn, depending on cause: A. Flame: Stop, Drag and Roll, wet blanket, splash cold water, remove clothing and cover person B. Scald: cold water as much as possible, remove clothing C. Chemicals: dilute the chemical with a copious amount of water, eyes-flush with running water for 20 minutes; PNSS for flushing D. Electric Current: turn off the main switch first 2. Ensure a patent airway 3. Assess and treat associated injuries. 4. Asses and treat CO inhalation: 100% oxygen until ABG demonstrate adequate oxygenation (80-100%) 5. Take special action for clients who had electrical burns: A. Apply a cervical collar and place patient on a spinal board ASAP (flat, hard surface) B. Monitor cardiac arrest C. Discuss potential late complications 6. Monitor and treat burn shock, occurs in major burn: massive fluid shift of plasma, electrolytes and proteins into burn wound. Usually occurs in major burn 7. Estimate the burn size 8. Estimate the adequacy of fluid resuscitation (basis is the urine output); if urine output is within N 3060cc/h:.px is hemodynamically stable 9. Promote optimum recovery A. Ensure optimum nutrition high protein, high carb, high fat, Vit. C B. Provide meticulous wound management to prevent infection and promote wound healing C. Initiate physical therapy to prevent contractures D. Provide psychosocial support to promote mental health of client E. Provide family centered care rehab may take several years Phases of Management of the Burn Injury Emergent - Time of injury until fluid resuscitation is complete, (36-48 hours) - Goal: prevent hypovolemic shock, preserve vital organ functioning 96

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Resuscitative - Initiation of fluid and ends when capillary integrity returns to near normal levels - Exact amount of fluid (LR) administered is based in the clients weight and extent of injury: Parkland formula = 2-4mL of LR x BW in kg x % burn Example: What is the fluid requirement of patient weighing 75 kg has 70% TBSA burn 4mL LR x 75kg x 70% = 21000mL in 24h *One half needed for the first 8 hours *1/2(21000) = 10500mL in 8hr 1312mL/h *one half is needed in the next 16h *1/2(21000) = 10500mL in 16h or 656mL/h - Goal: prevent shock, maintain vital organ function Acute Phase - 46-72h after injury - Emphasis: restorative therapy until wound closure - Focus: infection control, wound care, wound closure, nutritional support, pain management, and physical therapy Rehabilitative Phase - Final phase - Wound closure to discharge - Overlaps acute care phase - Goal: gain independence Fluid Shifting in Burns Oliguric Phase intravascular to interstitial Hct increased, renal output decreased, hyperK, HypoNa, metabolic acidosis Diuretic Phase interstitial to intravascular Hct dec, renal output inc, hypoK, HypoNa, metabolic acidosis

Fluid Resuscitation Indications: - Adults with burns (>15%-20% TBSA) - Electrical injury, elderly, cardiac or pulmonary disease and compromised response to burn injury Successful fluid resuscitation is evidenced by: - Stable vital signs - Palpable peripheral pulse - Adequate urine output - Clear sensorium Urinary output is the most common and most sensitive assessment parameter for cardiac output and tissue perfusion Pain Management in Burns administer premedication before any procedure Background Pain continuous and of low intensity; 97

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Procedural Pain acute and of high intensity; whenever there is performance of any therapeutic procedures to the client dressing, physical therapy, medication, debridement DOC: - MoSO4 92-24mg) or meperidine (Demerol) - Avoid IM or SC routes-the muscle and fats is affected in extensive burns - Avoid administering medication PO - Medicate prior to painful procedures Nutrition - Promote wound healing and prevent infection - Maintain NPO status if the px is on NPO (administer TPN if ordered) - Enteral tube feeding, peripheral parenteral nutrition, or TPN - 5-35 bowel sounds per minute in 4 quadrants - High CHON, CHO, fats and vitamins Surgical Management for Burn Clients Escharotomy - A lengthwise incision is made through the burn eschar (scab) - Apply topical antimicrobial agent as prescribed Fasciotomy - if there is no adequate tissue perfusion, the surgeon considers Fasciotomy - an incision is made, extending through the subcutaneous tissue and fascia. - Performed in OR under GA Wound Care considered in the acute phase - Daily wound care 1. Cleansing, debridement, and dressing of the burn wounds 2. Debridement (surgical debridement and mechanical debridement) a. Removal of eschar b. Deep partial or full thickness burn 3. Hydrotherapy a. Wounds are cleansed by immersion, showering or spraying b. Occurs for 30 minutes to the procedure c. Pre-medicated prior to the procedure d. Not used for hemodynamically unstable or those with new skin graft Topical Antimicrobial Agents for Burns Silver sulfadiazine (Silvadene) most widely used agent; has lesser side effects than others; can be administered through close method (impregnated in a gauze) and the open method (do not cover wound after application of medication) - Use open treatment, light or occlusive dressings - Apply OD or BID Mafenide acetate 10% cream or 5% solution (Sulfamylon) 98

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN - Painful during and after application - Reapply q12h - Close method or open method Silver Nitrate (0.5% solution) - Stains everything Wound Closure - Prevents infection and loss of fluid - Promotes healing - Prevent contracture - Performed on the 5th to 21st day - Can be permanent or temporary Permanent Autografting - Permanent wound coverage - Surgical removal of a thin layer of the clients own unburned skin - Monitor for bleeding - Immobilize after surgery (3-7 days) - Care of graft site immobilize, elevate, keeps site free from pressure, keep it dry, avoid weight bearing - Care of donor site keep site clean and dry, sterile dressing, avoid scratching Temporary Wound Coverings Biological - Amniotic membranes from human placenta - Change dressing q48h Allograft (Homograft) - Donated human cadaver skin is harvested within 24h after death - Rejection occur within 24h pruritus, fever, sign of allergies Xenograft (Heterograft) - From other species pigs - Porcine skin is harvested after slaughter and preserved - Rejection occur within 24-72h - Replaced q2-5 days until wound heals naturally

Urinary and Renal Diseases Kidney T12-L3 location of the kidney 1. Renal cortex 2. Renal medulla 3. Renal pelvis 1 million nephrons in each kidney The Nephron 2 important structures 1. Glomerulus filters the blood; remove metabolic waste is blood Glomerular Filtration Rate rate the kidney filters blood 180L of blood/day; 125mL of blood/min 99

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN 2 liters of urine is formed as waste product 2. Tubules Proximal Convoluted Tubules A. Functions of the Kidney 1. Urine formation 2. Regulate acid base balance 3. Excrete waste products 4. Secrete renin and erythropoietin 5. Maintain homeostasis of blood 6. Control of FE balance 7. Control of BP B. Bladder storage of urine 1. Ureterovesical sphincter 2. Capacity: 300-500mL (half full); may reach more than 1000mL C. Urethra 1. Conduit during urination 2. Male 24 cm female 4cm D. Urine Production 1. As fluid flows through the proximal tubules, H2O and solutes are reabsorbed 2. H2O and solute that are not reabsorbed become urine Urine Formation 1. Glomerular Filtration involves filtration of plasma by glomerulus; filtered substances include water, electrolytes, creatinine, glucose, uric acid. 2. Tubular Reabsorption filtered substances will enter BOMeN? Capsule will now move to the tubular system, either this filtered substances will be reabsorbed or excreted 3. Tubular Secretion the formed urine in the tubular section will now be drained from the collecting tubules Laboratory and Diagnostic Test Urine Studies 1. Urinalysis o Assess the nature of urine produce a. Evaluates color, pH, and specific gravity Color: Yellow Volume: 30-60cc/hour Appearance: Clear Odor: aromatic then strong ammoniacal odor Specific Gravity: 1.015-1.025 (24hour urine collection) for creatinine clearance Random specimen is 1.003-1.030 (random specimen) pH: 4-8.0

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3.

4.

5.

6.

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN b. Determines the presence of glucose should be absent unless DM, protein AGN or Nephrotic syndrome if present, ketones absent unless having Diabetic Ketone Acidosis and blood may imply calculi if present. c. Analyzes sediment for cells presence of WBC, casts bacteria RBC casts-presence would imply glomerular bleeding WBC casts-glomerular nephritis, Fatty cast-nephrotic syndrome, crystals Urine Culture and Sensitivity o Diagnose bacterial infection of the UT o Confirm the causative microorganism o Sterile specimen bottle Residual Urine o Amount of urine left in the bladder after voiding measure via catheter un the bladder o Normal residual urine is less than 100cc. Creatinine Clearance o Specimen is the urine of the patient; 24 hour collection for clearance o Determine amount of creatinine in the urine o Measures overall renal function; measure GFR 24 hour Urine Specimen o Preferred method for creatinine clearance test Have client void first and discard specimen; note time. That is the time started for 24 hour collection. Collect all subsequent urine specimens for 24 hours. If specimen is accidentally discarded, the test must be restarted. Record the exact start and end of collection; include date and time; and document in the nurses notes. BUN (blood) 10 is to o Measures renal ability to excrete urea nitrogen (end product of protein metabolism) o NV: 7-18mg/dL o Kidneys are capable of excreting urea nitrogen, result may be affected by protein intake of client Serum Creatinine (blood) 1 o Specific test for renal disorders o Not affected by dietary intake nor hydration status o Reflects the ability of kidneys to excrete creatinine o NV: M: 0.7-1.3mg/dL F: 0.6-1.1mg/dL X-ray of the abdominal body; to detect calculi

KUB -

IVP (Intravenous Pyelogram) - Fluoroscopic visualization of the urinary tract after injection with a radiopaque dye. - Injection of contrast media; radiopaque dye, in the form of iodine preparation Nursing Care (Pre-test) o Assess for iodine sensitivity (allergy to seafood) o Obtain consent o Cathartic or enema o NPO for 8 hours 101

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Post-test o o o Force fluids Assess venipuncture signs for bleeding V/S MIO

Cystoscopy - Use of a lighted scope (cystoscope to inspect the bladder) Nursing Care (Pre-test) o Explain that procedure will be under GA/local anesthesia o Obtain consent o Sedatives 1 h before the test as ordered o GA: NPO 4-8 h o If local anesthesia, liquid may be given at breakfast Post-test o Monitor for urinary obstruction (e.g. blood clots) o MIO (pink tinged/tea colored urine is expected); report gross hematuria, dysuria, excessive pain, fever, or chills o Administer meds, antibiotics Disorders of the Genitourinary System Cystitis - Inflammation of the urinary bladder that is caused by invasion of bacteria esp E. Coli; lower urinary tract infection - More common in females Predisposing Factors o Stagnation of urine o Obstruction o Sexual intercourse Clinical Findings o Abdominal or flank pain (to where the kidneys are)/tenderness o Frequency or urgency to void o Pain on voiding o Nocturia, hematuria o Fever Diagnostic Tests o Urine C&S Presence of E. Coli (80-90% of the time is causative agents) Bactrin is DOC Nursing Care o Force fluids o Asses urine for odor, hematuria, and sediment o Strict aseptic technique in FC o Administer medications, antibiotics, antipyretic, analgesic o Client teaching Void when there is urge to urinate 102

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Inc oral fluid intake up to 3L daily Personal hygiene Void and drink water after intercourse Acidify the urine acid ash diet (cranberry juice, plum juice, citrus, calamansi) to prevent UTI or cystitis, environment is made acidic Nephrolithiasis/Urolithiasis General Information - Presence of stones anywhere in the urinary tract - Problem is obstruction; men is of high risk than females - Compositions of stone o 90% is made of calcium; uric acid and cystine stones o Incidence: Men age 20-55 years Predisposing Factors o Diet: large amount of Ca, oxalate o Inc uric acid levels o Immobility urine stagnates, forms sediments, obstruction o Family history of gout or calculi Clinical Findings o Sudden sharp pain or severe flank pain o Hematuria, frequency , urgency or urination, N&V o Diaphoresis o Pallor o Pyuria Medical Management 1. Surgery A. Percutaneous Nephrostomy o Tube is inserted through the skin and underlying tissues into renal pelvis B. Percutaneous Nephrolithotomy o Delivers U/S waves through a probe placed on the calculus 2. Extracorporeal Shock-Wave Lithotripsy (ESWL) o Client is placed in water and exposed to shock waves that disintegrate the stones Nursing Care o Strain all urine with layered gauze o Force fluids o Encourage ambulation to prevent urinary stasis o Relieve pain analgesics as ordered o MIO o Provide modified diet according to the stones in the patient Diet Modified According to Stone Alkali Stones o Calcium Stones Provide acid-ash diet Cheese, whole grains, egg, poultry, meat, cranberry, prune juice, plums, Vit A, C, E, folic acid supplements and Riboflavin 103

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Oxalate Stones Avoid excess intake of foods/fluids high in oxalates avoid tea, chocolates, rhubarb, spinach Acid-ash diet Acidic Stones o Uric Acid Stones uric acid is a metabolic product of purines legumes, organ meats, Reduce foods high in purine Maintain alkaline urine Alkali-ash diet all fruits except those in acid ash diet o Cystine Stones Common in young men, rarely seen in adults Low methionine essential amino acid in which the non essential amino acid cystine is formed Limit CHON foods Maintain alkaline ash diet Nursing Care o Administer Allopurinol (Zyloprim) inc fluid intake o Client teaching and discharge planning Prevent urinary stasis ambulate, inc oral fluid intake, void if urge comes Adhere to prescribed diet Routine U/A, quarterly. Recognize and report recurrence (hematuria, flank pain) o Pyelonephritis - Upper urinary tract infection Acute Infection o Ascends from the UT or an invasive procedure o Can progress to chronic Pyelonephritis Assessment o Fever and chills, N/V o Tenderness, flank pain o Dysuria, nocturia o Frequency an urgency Chronic Infection o Obstruction and reflux o Recurrent infections Assessment o patient is usually unaware of disease o bladder irritability o slight dull ache over the kidneys o Develops HPN atrophy of the kidneys o Azotemia/Uremia excessive accumulation of metabolic wastes in the blood (BUN) Nursing Care o MIO 104

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NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Rest Administer antibiotics, analgesics Support client and SO and explain possibility of dialysis, transplant options Provide client teaching and discharge planning: Medication regimen Diet: high calorie, low protein

Renal Failure - Kidney has lost its functions already Acute Renal Failure a sudden and potentially reversible loss of kidney function 3 Causes o Prerenal Causes condition that diminishes the flow of blood to the kidneys Hypotension Cardiogenic Shock when contraction of heart is infection Acute vasoconstriction Hemorrhage Burns Septicemia CHF o Intrarenal Causes conditions that damages the kidneys Acute Tubular Necrosis (ATN) DM and HPN 2 most important contributing factor to renal failure Malignant HPN Acute Glomerulonephritis Tumors BT reactions Nephrotoxins o Postrenal Causes obstruction of urine outflow Calculi Tumors Blood Clots BPH Strictures narrowing Trauma Anatomic Malformations Stages and Clinical Findings o Oliguric Phase (1-2 weeks) edema, HPN, HyperNa, HypoCa, HyperK, Hyperphosphatemia, Hypermagnesemia, metabolic acidosis Dec fluid intake, inc BUN d/t nitrogenous waste accumulation o Diuretic Phase (last for 2 weeks) 5-17 liters/day, patient is at risk for DHN, inc fluid intake and IV, electrolyte imbalances like HypoNa, HypoK, Hypovolemia is problem o Convalescent Phase Normal Urine Volume, Inc LOC, BUN stable and normal, May develop CRF if does not improve 105

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Nursing Care o Monitor FE balance o Promote optimal nutritional status low salt and low protein o Prevent complication from impaired mobility o Prevent fever and infection Chronic Renal Failure a progressive irreversible deterioration of renal function that ends in fatal uremia or ESRD Stages o Stage 1 (Diminished Renal Reserve) GFR is only at 40-50%, nocturia, polyuria, little accumulation of metabolic wastes o Stage 2 (Renal Insufficiency) accumulation of the metabolic wastes in our blood, GFR is olnly at 20-40%, Oliguria and edema o Stage 3 (End Stage) GFR is less than 10%, uremia, most distinctive manifestation is Uremic Frostcardinal sign (white crystals)- precipitates of urea crystals; SpGr Fixed at 1.010 may mean isosthenuria Clinical Findings o N&V, Dec Urinary output, Azotemia, HPN (later), Uremic frost, dyspnea, Hypotension (early), lethargy, memory impairment, pericardial friction rub, congestive heart failure Nursing Care o Prevent neurologic complications o Promote optimal GI function o Monitor/prevent alteration in FE o Promote maintenance of skin integrity o Monitor bleeding complication, and prevent injury o Asses for Hyperphosphatemia Paresthesia Muscle cramps Seizures Abnormal reflexes o Administer Al(OH)3 gels as orders Amphogel, AltemaGEL o Promote/maintain maximal CV function o Provide care for client receiving dialysis Dialysis - an artificial means by removing metabolic wastes in the blood along with excess fluid and electrolytes for those who have renal failure Diffusion Osmosis Ultrafiltration makes use of positive pressure to cause the fluid across the medium or semi permeable membrane, faster than osmosis Types 1. Hemodialysis General Information 106

o o o 2. Peritoneal dialysis amount of exchanges dependent on the amount of metabolic waste is the blood. See book. Incision is 2cm below the umbilicus i. Continuous Ambulatory Peritoneal Dialysis (CAPD) a continuous type of peritoneal dialysis at home; Dialysate is delivered from flexible plastic container through a permanent peritoneal catheter. ii. Continuous Cycling Peritoneal Dialysis (CCPD) iii. Intermittent Peritoneal Dialysis (IPD) Nursing Care o Chart clients weight o Assess V/S o Assemble specially prepared Dialysate solution o Have the client void. Inflow: Allow Dialysate to flow unrestricted into the peritoneal cavity 10-20 minutes Dwell Period: allow fluid to remain in peritoneal cavity for prescribed period Drain: Unclamp outflow tube and allow to flow by gravity, change position to facilitate drainage of Dialysate solution o Observe characteristics of Dialysate outflow. Normal is clear, pale, yellow Cloudy implies peritonitis Brownish may be caused by bowel imperforation Bloody normal during the first few exchanges, abnormal if continuous o MIO and maintain records o Assess for complications (page 295 procedure manual) Respi insufficiency Leakage Abdominal pain Disequilibrium syndrome Types of Venous Access 1. External Arteriovenous Shunt or Graft can be used for several years, Nsg Resp check for the patency of conduit, assess for thrill (vibration) palpated and bruit auscultated; No BP, IM, Skin test, No drawing of blood, no constrictive clothing, no hyperextension , no weight bearing, shower instead of tub bath Can be used 14 days or more after creation. 2. Internal Arteriovenous Fistula side to side anastomosis; more preferred than EAS. Lesser risk for infection b/c it is internally located. Both require sterile dressing. Can be used 6 weeks after creation, can be used up to 5 years. Nsg Resp is the same with shunt o Large artery/vein are anastomosed below the surface Advantages of AV Fistula: i. No danger of dislodgement 107

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Shunting of blood form the clients vascular system through an artificial dialyzing system and return of dialyzed blood to the clients circulation. Dialysis coils acts as a semi-permeable membrane Dialysate is a specially prepared solution

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN ii. Less infection Disadvantages of AV Fistula o 2 venipuncture with each dialysis o Requires 4-6 weeks healing time Nursing Management i. Monitor weight, V/S, Se Electrolytes, and waste products ii. Access for (thrill and bruit) iii. Avoid constrictive clothing iv. Avoid venipuncture v. Assess for complication Complications During Dialysis i. Disequilibrium syndrome because of rapid removal of metabolic wastes ii. Hypotension iii. Hypertension iv. Transfusion reaction v. Psychological problem Nursing Care: before and during Hemodialysis o Have client void o Weigh client before and after o Assess V/S o Withhold antihypertensive, sedatives, and vasodilators o Bed rest o Headache and nausea may occur o Monitor signs of bleeding (hematoma etc), avoid trauma and injur Nursing Care Post Dialysis o Chart clients weight (usually decrease in weight) o Assess for complication (bleeding, hypovolemic shock, disequilibrium syndrome) A. Hypovolemic Shock B. Dialysis Disequilibrium Syndrome Assess for N&V, elevated BP, disorientation, leg cramps and peripheral paresthesias 3. Femoral Vein catheterization 4. Subclavian Catheterization Kidney Transplantation see the book Benign Prostatic Hypertrophy (BPH) General Information - Most common problem of the male reproductive system - 50% of men over age 50 - 75% of men over age 75 Etiology - Unknown Clinical Findings 108

NCM202B_A Fluids and Electrolytes Ms. Deborah F. Tejam, RN MN Nocturia o Frequency of urination o Decreased force and amount of urinary stream o Urinary Hesitancy caused by obstruction o Hematuria o Enlargement of prostate gland upon palpation by DRE Diagnostic Tests - Urinalysis o Alkalinity is increased o SpGr is inc - BUN and Creatinine inc - Prostate Specific Antigen (PSA) o NV: <4ng/mL - Cystoscopy to visualize enlargement of the prostate Nursing Care - Administer antibiotics - Provide teaching concerning medications o Terazocin (Hytrin) relax the bladder sphincter to make it easier to urinate o Finasteride (Proscar) shrinks the prostates Force fluids - Provide catheter care - Provide care for prostatic surgeries Prostatic Surgery - Indicate for BPH and Prostatic CA Types 1. Transurethral Resection of the Prostate (TURP) no abdominal incision 2. Transurethral Prostatectomy 3. Suprapubic Prostatectomy lower midline incision in the abdomen Retropubic Prostatectomy 4. Radical Perineal Prostatectomy done in the perineal area; highest risk for autocontamination and impotence, only considered for prostate CA Nursing Care: Pre-op - Provide routine pre-op care - Information about the procedure and the expected post-op care - Bowel prep - For fluids, administer antibiotics, acid ash diet Nursing Care: Post-Op - Provide routine post-op care - Maintain patency of catheter - Prevent infection: antibiotics - Relieve pain: analgesics - Reduce anxiety - Health education and health maintenance 109