chapter-9-fluids-and-electrolytes-水電解質(zhì)平衡-護(hù)理雙語

UNITIII

NursingSciencesUNITIIINursingSciencesChapter9FluidsandElectrolytesChapter10Acid-BaseBalanceChapter11LaboratoryValuesChapter12NutritionChapter13ParenteralNutritionChapter14IntravenousTherapyChapter15AdministrationofBloodProductsFluidsandElectrolytesChapter9CRITICALTHINKINGWhatShouldYouDo?ThenursenotesthepresenceofUwavesonaclient’scardiacmonitorscreen.Whataction(s)shouldthenursetake?PyramidtermsFluidvolumedeficit/excess體液不足/體液過多Homeostasis內(nèi)穩(wěn)態(tài)Hyper-過高Hypo-過低E.g.Hypertension高血壓Hypotension低血壓PyramidtermsSodium鈉135-145mEq/LHypernatremiaHyponatremiaCalcium鈣8.6-10mg/dLHypercalcemiaHypocalcemiaPotassium鉀3.5-5.1mEq/LHyperkalemiaHypokalemiaPyramidtermsMagnesium鎂1.6-2.6mg/dLHypermagnesemiaHypomagnesemiaPhosphorus磷2.7-4.5mg/DlHyperphosphatemiaHypophosphatemiaPropertiesofElectrolytesandTheirComponents(BOX9-1)Atom原子Molecule分子Ion離子Cation陽離子['k?ta??n]Anion陰離子BodyFluidCompartmentsIntracellular(ICF):allfluidinsidethecells(70%)細(xì)胞內(nèi)液Extracellular(ECF):fluidoutsidethecells(30%)細(xì)胞外液Interstitial細(xì)胞間液Intravascular:fluidinsideabloodvessel血管內(nèi)液Third-spacing第三間隙液DiseaseorinjuryFluidmaybetrappedinbodyspacessuchasthepericardial,pleural,peritoneal,orjointcavities;thebowel;ortheabdomen;orwithinsofttissuesaftertraumaorburnsEdema[i'di?m?]水腫BodyFluidInfantsandolderadultsneedtobemonitoredcloselyforfluidimbalances！ICFismostlywaterandisrichinK+，Mg2+，,SO4，HPO4，andproteinatoms.ECFcontainsmoreNa+,Cl-,HCO3-,andCa2+.BloodfluidtransportDiffusion擴散

–spreadthemoleculesfromanhigherconcentrationtoanareaof

Lowerconcentration.Osmosis滲透

–fromaLessconcentratedsoluteintoaMoreconcentratedsolute.Filtration過濾

–fromHigherhydrostaticpressure

toaLowerone.Regardingtotheweight.BodyfluidtransportHydrostaticpressure靜水壓Osmolality滲透壓BodyfluidintakeandoutputHomeostasisFluidVolumeDeficit體液不足Dehydration脫水TypesIsotonicdehydration等滲性脫水：水、鈉成比例丟失Hypertonicdehydration高滲性脫水：失水為主Hypotonicdehydration低滲性脫水：失鈉為主FluidVolumeDeficit體液不足DiminishedperipheralpulseDeeprespirationFeverDecreaseurineoutputDryskin，drymouthThirstTABLE9-1AssessmentFindings:FluidVolumeDeficitandFluidVolumeInterventionsIngeneral,isotonicdehydrationistreatedwithisotonicfluidsolutions,hypertonicdehydrationwithhypotonicfluidsolutions,andhypotonicdehydrationwithhypertonicfluidsolutions.FluidVolumeExcess體液過多Overhydrationorfluidoverload水中毒TypesIsotonicOverhydrationHypertonicOverhydrationHypotonicOverhydrationFluidVolumeExcess體液過多OverhydrationorfluidoverloadElevatedbloodpressureCVC(centralvenouspressure中心靜脈壓）↑Shallowrespiration淺呼吸IncreaseordecreaseurineoutputPale，CoolskinTABLE9-1AssessmentFindings:FluidVolumeDeficitandFluidVolumeInterventionsAdministerdiuretics;osmoticdiureticstypicallyareprescribedfirsttopreventsevereelectrolyteimbalances.Monitorelectrolytevalues,andpreparetoadministermedicationtotreatanimbalanceifpresent.Aclientwithacutekidneyinjuryorchronickidneydiseaseisathighriskforfluidvolumeexcess.PracticalquestionsThenurseisassignedtocareforagroupofclients.Onreviewoftheclients’medicalrecords,thenursedeterminesthatwhichclientismostlikelyatriskforafluidvolumedeficit?1.Aclientwithanileostomy2.Aclientwithheartfailure3.Aclientonlong-termcorticosteroidtherapy4.Aclientreceivingfrequentwoundirrigations1Thenursecaringforaclientwhohasbeenreceivingintravenous(IV)diureticssuspectsthattheclientisexperiencingafluidvolumedeficit.Whichassessmentfindingwouldthenursenoteinaclientwiththiscondition?1.Lungcongestion2.Decreasedhematocrit3.Increasedbloodpressure4.Decreasedcentralvenouspressure(CVP)4Thenurseisassignedtocareforagroupofclients.Onreviewoftheclients’medicalrecords,thenursedeterminesthatwhichclientisatriskforfluidvolumeexcess?1.Theclienttakingdiuretics2.Theclientwithkidneydisease3.Theclientwithanileostomy4.Theclientwhorequiresgastrointestinalsuctioning2Sodium鈉135-145mEq/LHypernatremia低鈉血癥

Hyponatremia高鈉血癥Na+HyponatremiaandhypernatremiaNormalserumsodiumlevelNa+:135-145mEq/LCommonfoodsources:Box9-2,p88CausesAssessment:Table9-2.p89InterventionNa+Commonfoodsources:Box9-2,p88Bacon熏肉Butter黃油Cannedfood罐頭食品Cheese奶酪Frankfurters灌腸Ketchup番茄醬Lunchmeat午餐肉Milk牛奶Mustard芥菜Processedfood加工食品Snackfood休閑食品Soysauce醬油Tablesalt食鹽Whiteandwhole-wheatbread白面包和全麥面包Na+Hyponatremia＜135mEq/L

低鈉血癥Causes:Diuretics利尿劑Wounddrainage,especiallygastrointestinalRenaldisease/failureAldosterone(醛固酮）↑Low-saltdietExcessiveingestionofhypotonicfluidsorirrigationwithhypotonicfluids過度攝入低滲的液體或沖洗低滲的液體Freshwaterdrowning淡水淹溺Syndromeofinappropriateantidiuretichormone(抗利尿激素)secretionHyperglycemia高血糖癥Congestiveheartfailure充血性心力衰竭Na+Hypernatremia>145mEq/LCauses:Corticosteroids皮質(zhì)類固醇Cushing’ssyndromeRenalfailureHyperaldosteronism高醛甾酮癥Oralsodiumingestion/sodium-containingIVfluidsDecreasedWaterintake:NothingbymouthIncreasedwaterloss:metabolism↑，fever,

hyperventilation換氣過度,infection,excessivediaphoresis,waterydiarrhea,diabetesinsipidus（尿崩癥）Na+AssessmentHyponatremiahypernatremiaShallow,ineffectiverespiratorymovement淺的，無效的呼吸運動Generalizedskeletalmuscleweakness全身骨骼肌肉無力Headache,seizures頭痛，癲癇發(fā)作Hyperactivebowelsounds腸鳴音亢進(jìn)Drymucousmembranes粘膜干燥Hypervolemia→pulmonaryedema肺水腫Extremethirst極度口渴Decreasedurinaryoutput尿量減少Na+InterventionMonitorcardio,renal……statusIftheclientistakinglithium,hyponatremiacancausediminishedlithium(鋰）excretion,resultingintoxicity!!→→→monitorthelithiumlevel!!!Thenurseisreviewinglaboratoryresultsandnotesthataclient’sserumsodiumlevelis150mEq/L.Thenursereportstheserumsodiumleveltothehealthcareprovider(HCP)andtheHCPprescribesdietaryinstructionsbasedonthesodiumlevel.Whichfooditemdoesthenurseinstructtheclienttoavoid?1.Peas2.Nuts3.Cauliflower4.Processedoatcereals4Thenursecaringforagroupofclientsreviewstheelectrolytelaboratoryresultsandnotesasodiumlevelof130mEq/Lononeclient’slaboratoryreport.Thenurseunderstandsthatwhichclientisathighestriskforthedevelopmentofasodiumvalueatthislevel?1.Theclientwhoistakingdiuretics2.Theclientwithhyperaldosteronism3.TheclientwithCushing’ssyndrome4.Theclientwhoistakingcorticosteroids1Thenurseiscaringforaclientwithheartfailurewhoisreceivinghighdosesofadiuretic.Onassessment,thenursenotesthattheclienthasflatneckveins,generalizedmuscleweakness,anddiminisheddeeptendonreflexes.Thenursesuspectshyponatremia.Whatadditionalsignswouldthenurseexpecttonoteinaclientwithhyponatremia?1.Muscletwitches2.Decreasedurinaryoutput3.Hyperactivebowelsounds4.Increasedspecificgravityoftheurine3PotassiumK+3.5-5.0mEq/LCommonfoodsourcesAvocado鱷梨BananasCantaloupe哈密瓜Carrots胡蘿卜FishMushroomsOrangesPotatoesPork,beef,vealRaisins葡萄干Spinach菠菜StrawberriesTomatoes

Hypokalemia-<3.5mEq/L低鉀血癥

Majorcause:Diuretics

(Potassium)

Hyperkalemia

->5.1mEq/L高鉀血癥Majorcause:Renalfailure；Addison’sdiseaseK+PotassiumisneveradministeredbyIVpush,intramuscular,orsubcutaneousroutes.嚴(yán)禁通過靜脈推注、肌肉注射或皮下補鉀。IVpotassiumisalwaysdilutedandadministeredusingandinfusiondevice.通過靜脈補鉀時必須稀釋?。。+ECTChangesinElectrolyteImbalancesElectrolyte

ECTchangesHypocalcemiaProlongedSTintervalProlongedQTintervalHypercalcemiaShortenedSTsegmentWidenedTwaveHypokalemia

STdepressionShallow,flat,orinvertedTwaveProminentUwaveHyperkalemiaTall,peakedTwavesFlatPwavesWidenedQRScomplexProlongedPRintervalHypomagnesemiaTallTwaves‘depressedSTsegmenthypermagnesemiaProlongedPRintervalWidenedQRScomplexesThenurseprovidesinstructionstoaclientwithalowpotassiumlevelaboutthefoodsthatarehighinpotassiumandtellstheclienttoconsumewhichfoods?Selectallthatapply.1.Peas2.Raisins3.Potatoes4.Cantaloupe5.Cauliflower6.Strawberries2/3/4/6Thenurseispreparingtocareforaclientwithapotassiumdeficit.Thenursereviewstheclient’srecordanddeterminesthattheclientwasatriskfordevelopingthepotassiumdeficitbecauseofwhichsituation?1.Sustainedtissuedamage2.Requiresnasogastricsuction3.HasahistoryofAddison’sdisease4.Istakingapotassium-retainingdiuretic2Thenursereviewsaclient’selectrolytelaboratoryreportandnotesthatthepotassiumlevelis2.5mEq/L.Whichpatternwouldthenursenoteontheelectrocardiogramasaresultofthelaboratoryvalue?1.Uwaves2.AbsentPwaves3.ElevatedTwaves4.ElevatedSTsegment1Thenursingstudentneedstoadministerpotassiumchlorideintravenouslyasprescribedtoaclientwithhypokalemia.Thenursinginstructordeterminesthatthestudentisunpreparedforthisprocedureifthestudentstatesthatwhichactionispartoftheplanforpreparationandadministrationofthepotassium?1.Obtaininganintravenous(IV)infusionpump2.Monitoringurineoutputduringadministration3.Preparingthemedicationforbolusadministration4.Ensuringthatthemedicationisdilutedintheappropriateamountofnormalsaline3Hypocalcium-<8.6mg/dLAssessmentfindings:Chvostek’ssign

Trousseau’ssign

(Calcium)Hypercalcium->10mg/dLAssessmentfindings:AbsentdeeptendonreflexCa2+HypocalcemiaandhypercalcemiaSerumcalciumlevel:8.6-10mg/dLCommonfoodsources:box9-5,p92CausesAssessment:Table9-5,p93InterventionCa2+CausesofhypocalcemiaLactoseintolerance乳糖不耐癥Malabsorption吸收不良syndromes:celiacsprue乳糜瀉orCrohn’sdisease克羅恩病End-stagerenaldiseaseRenalfailure,polyuricphaseDiarrheaSteatorrhea脂肪痢Wounddrainage,especiallygastrointestinalCa2+CausesofhypocalcemiaCont.Hyperproteinemia高蛋白血癥Alkalosis堿中毒Medicationssuchascalciumchelators螯合劑orbinders粘結(jié)劑Acutepancreatitis急性胰腺炎Hyperphosphatemia高磷酸鹽血癥ImmobilityRemovalordestructionoftheparathyroidglands甲狀旁腺Ca2+CausesofhypercalcemiaOralintakeofcalcium/vitaminD↑RenalfailureUseofthiazidediuretics噻嗪利尿劑Hyperparathyroidism甲狀旁腺機能亢進(jìn)Hyperthyroidism甲狀腺機能亢進(jìn)Malignancy惡性（腫瘤等）Glucocorticoids糖皮質(zhì)激素Adrenalinsufficiency腎上腺機能不全Ca2+InterventionsVitaminDHypo:initiateseizureprecautionsMonitorforhypercalcemiaPathologicalfractureMovetheclientcarefullyandslowlyAssisttheclientwithambulationCa2+Thenurseisassessingaclientwithasuspecteddiagnosisofhypocalcemia.Whichclinicalmanifestationwouldthenurseexpecttonoteintheclient?1.Twitching2.Hypoactivebowelsounds3.NegativeTrousseau’ssign4.Hypoactivedeeptendonreflexes.Thenursecaringforaclientwithhypocalcemiawouldexpecttonotewhichchangeontheelectrocardiogram(ECG)?1.WidenedTwave2.ProminentUwave3.ProlongedQTinterval4.ShortenedSTsegmentHypomagnesemia-<1.6mg/dLMg2+（magnesium）Hypermagnesemia->2.6mg/dLMg2+Hypophosphatemia-<2.7mg/dL

（calcium）

（phosphorus）Hyperphosphatemia->4.5mg/dLHypophosphatemiaandhyperphosphatemiaSerumphosphoruslevel:2.7-4.5mg/dLCommonfoodsources:box9-7,p95CausesAssessmentInterventionCausesofhypophosphatemiaIntake↓:maln