Homeostasis, Stress, Fluid & Electrolyte Balance,Shock NURS 2016 Chapters 6, 14, 15
Homeostasis • Homeostasis: processes that occur quickly in response to stress – adjustments made rapidly to maintain internal environment. • Adaptation: processes resulting in structural or functional changes over time. This is a desired goal. • Coping: a compensatory mechanism so that a person can reach equilibrium.
Stress • A state produced by change in the environment that is threatening or damaging
Responses to Stress • Psychological: appraisal – coping • Physiological: • Alarm, resistance, exhaustion • Maladaptive: • Faulty appraisal • Ineffective coping
The S&S of Stress Write down at least 10
Nursing Care • Intervene when individual’s own compensatory processes are still functioning. • Relate S&S of distress to physiological happenings. • Identify person’s position on a continuum of function from wellness/compensation to pathophysiology/disease.
Stress at the Cellular Level • Individual cells may cease to function without posing threat to the organism; however as the number of dead cells increases, the specialized function of the tissue is altered – health is threatened.
Nursing Care • Assess S&S for indicators of physiologic processes. • Relate symptoms/complaints to physical signs. • Assist individual to respond to stress with stress management.
Weight loss Restlessness Dry mucous membranes Increased respirations Decreased urine output Thirst Flushed skin Poor skin turgor Systolic drop 10-15mmHg Sunken eyes Fluid Volume Deficit (FVD)Hypovolemia
Nursing Care • Monitor I&O • Daily weight (1kg = 1000ml fld) • Vital signs • Skin turgor- consider age • Moisture level • Lung sounds • Urine concentration
Preventing and Correcting FVD • Who’s at risk? Replacement • Oral • Enteral • Parenteral
Weight gain Edema Abnormal lung sounds Increased urine output Puffy eyelids Distended neck veins Tachycardia Increased BP and pulse pressure. Fluid Volume Excess (FVE)Hypervolemia
Nursing Care • Monitor I & O • Daily weight • Assess lung sounds • Check edema: degree of pitting measure extremities.
Preventing and Correcting FVE • Promote rest: favours diuresis and increases circulation (lower) • Na+ and fluid intake restrictions • Monitor parenteral fluids • Positioning
Edema • Localized or generalized • Occurs when there is a change in capillary member ANASARCA: severe generalized edema ASCITES: edema in peritoneal cavity Dependent area: ankles, feet, sacrum, scrotum, periorbital regions Pulmonary edema: increased fluid in pulmonary interstitium and alveoli
Electrolytes Sodium • Normal 135-145mmol/L Potassium • Normal 3.5-5mmol/L Calcium • Normal2.25-2.74mmol/L
Sodium: Hyponatremia • At Risk • Loss of Na • Dilution of Na Nursing Care: Monitor I&O Daily weight Encouraging foods high in Na (normal requirement 500mg) Fluid restriction:800ml/day Clinical Manifestations: Anorexia, muscle cramps, exhaustion. Poor skin turgor, dry mucosa/skin Confusion, headache
Sodium: Hypernatremia At Risk Loss of water Gain of sodium Nursing Care I&O No added salt diet Monitor meds high in Na If IV hypotonic solution used -- want gradual decrease in serum Na 9prevent cerebral edema Clinical Manifestations Thirst, dry mouth Restlessness, disorientation Edema Increased BP
Potassium: Hypokalemia Nursing Care ECG for flattened T-wave ID cause Diet – high K Teaching – use of diuretics, laxatives IV K replacement At Risk Vomiting/gastric suctioning Alcoholics/cirrhosis Anorexia nervosa Non-K sparing diuretics Clinical Manifestations Muscle weakness, fatigue, anorexia, N&V, leg cramps, dysrrythmia
Potassium: Hyperkalemia At Risk Kidney disease Addison’s disease Extreme tissue trauma K replacement Nursing Care Verify high serum levels Restrict K foods Teaching re K supplements Clinical Manifestation Ventricular dysrrhythmia, muscle weakness, peaked t-wavwes, respiratory paralysis
Calcium:Hypocalcemia Nursing Care Seizure precautions Airway status Nutritional intake and supplements Limit alcohol and caffeine At Risk Renal failure Postmenopausal Low Vit D consumption Antacids, caffeine Hypoparathyroidism Clinical manifestations Tetany, seizures, depression,impaired memory, confusion
Calcium: Hypercalcemia Nursing care Increase activity Encourage fluids Encourage fluids Na – favour Ca excretion Safety/comfort At Risk Hyperparathyriodism Bone/mineral loss during inactivity Thiazide diuretics Clinical Manifestations Reduced neuromuscular activity, weakness, incoordination, anorexia, constipation
Respiratory Acidosis • Individuals at risk • Inadequate excretion of carbon dioxide • Chronic emphysema, bronchitis • Obstructive sleep apnea • Obesity • Clinical Manifestations • Increased cerebrovascular flow (vasodilation)Increased pulse, respirations and BP • Mental cloudiness, feelings of fullness in head
Respiratory Acidosis Nursing care • Improve ventilation • Clear respiratory tract • Ensure adequate hydration
Respiratory Alkalosis • Individuals at risk • Hyperventilation • Increased anxiety • Hypoxemia • Clinical Manifestations • Lightheadedness, low concentration, numbness/tingling, tinnitus
Respiratory Alkalosis Nursing Care • Recycle carbon dioxide • Treat underlying cause
Shock • Physiological state in which there is inadequate blood flow to tissues and cells of body • Cells try to produce energy anaerobically • Leads to low energy yield and acidotic intracellular environment
Categories of Shock • Hypovolemic • Cardiogenic • Circulatory/Distributory
Stages of Shock • Compensatory • Progressive • Irreversible
BP normal Vasoconstriction Fight or flight Increased HR Increased contractility Blood shunted to heart and brain. Compensatory Stage
Nursing Care in Compensatory Stage • Close assessment and catch subtle changes before decrease in BP occurs • Monitor tissue perfusion. • Report deviations in hemodynamic status • Reduce anxiety • Promote safety
Progressive Stage: Mechanism for regulating BP no longer compensates • Respiratory: shallow, rapid • Cardiac: dysrrhythmia, ischemia, tachycardia • Neurologic: decrease status • Renal:failure • Hepatic:decrease met. of meds and waste • Hematologic:DIC • Gastrointestinal: Ischemia, increase risk infection
Nursing Care in Progressive Stage • Usually care for in ICU (increased monitoring) • Preventing complications • Promote comfort and rest • Support family members
Irreversible Stage • Individual in not responding to treatment. • Renal and hepatic failure lead to release of necrotic tissue toxins
Nursing Care inIrreversible Stage • Similar to progressive stage • Brief explanations to patient • Supportive presence for patient and significant others. • In collaboration with significant stakeholders, discuss end of life wishes/decisions.
Overall Management of Shock • Fluid replacement • Crystalloids: electrolyte solution • Colloids: plasma proteins • Blood components
Risks of Fluid Replacement • Cardiovascular overload • Pulmonary edema
Fluid Replacement: Nursing Care • Monitor I& O • Mental status • Skin perfusion • Vital signs • Lung sound
Vasoactive medication to improve hemodynamic stability. Myocardial contract Myocradial resistence vasoconstriction Nutritional support Meet needs of increased met. Often parenteral feeding Overall Management of Shock
Hypovolemic Shock • Decreased intravascular volume due to fluid loss
Prevention Fluid and blood administration Monitor for cardiac overload and pulmonary edema Monitor vital signs I&O Temperature Lung sounds Cardiac rhythm and rate. Nursing Care in Hypovolemic Shock
Cardiogenic Shock • Heart’s ability to contract and pump is impaired • General management • Correct cause • Administer oxygen • Control chest pain • Monitor hemodynamic status
Nursing Care in Cardiogenic Shock • Prevention • Monitor hemodynamic status • Administer IV fluids and medications • Promote safety and comfort
Distributive Shock • Blood is abnormally placed in the vasculature • Septic - wide spread infection. Number one cause of death in ICU • Neurogenic • Anaphylactic
Hyperdynamic phase Hypodynamic phase ID site and source of infection Antipyretic if T >40 Monitor response to medications Comfort measures Oxygen needs Nursing Care in Septic Shock
Results from loss of sympathetic tone Spinal cord injury Spinal anesthesia Nervous system damage Preventative: elevate head 30 degrees Support CV and neuro functions Elastic stockings Elevate head of bed Check Homan’s sign Passive ROM Nursing Care inNeurogenic Shock
Systemic antigen-antibody reaction Prevention: assess for allergies and observe response to new medications/ blood administration Remove causative agent Support cardiac and pulmonary systems Nursing Care inAnaphylactic Shock