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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.
Fluid Volume Deficit (FVD)
Hypovolemia





Weight loss
Restlessness
Dry mucous
membranes
Increased respirations
Decreased urine
output





Thirst
Flushed skin
Poor skin turgor
Systolic drop 1015mmHg
Sunken eyes
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
Fluid Volume Excess (FVE)
Hypervolemia

Weight gain

Puffy eyelids

Edema

Distended neck veins

Abnormal lung
sounds

Tachycardia

Increased BP and
pulse pressure.

Increased urine
output
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)
Clinical Manifestations:
Anorexia, muscle cramps,
exhaustion.
Poor skin turgor, dry mucosa/skin
Confusion, headache
Fluid
restriction:800ml/day
Sodium: Hypernatremia
At Risk
Loss of water
Nursing Care
Gain of sodium
I&O
No added salt diet
Monitor meds high in Na
Clinical Manifestations
Thirst, dry mouth
Restlessness,
disorientation
Edema
Increased BP
If IV hypotonic solution
used -- want gradual
decrease in serum Na
9prevent cerebral edema
Potassium: Hypokalemia
At Risk
Nursing Care
Vomiting/gastric suctioning
ECG for flattened T-wave
Alcoholics/cirrhosis
ID cause
Anorexia nervosa
Diet – high K
Non-K sparing diuretics
Teaching – use of diuretics,
laxatives
IV K replacement
Clinical Manifestations
Muscle weakness, fatigue, anorexia,
N&V, leg cramps, dysrrythmia
Potassium: Hyperkalemia
At Risk
Nursing Care
Kidney disease
Verify high serum
levels
Addison’s disease
Extreme tissue trauma
K replacement
Clinical Manifestation
Ventricular dysrrhythmia, muscle weakness,
peaked t-wavwes, respiratory paralysis
Restrict K foods
Teaching re K
supplements
Calcium:Hypocalcemia
At Risk
Nursing Care
Renal failure
Seizure precautions
Postmenopausal
Airway status
Low Vit D consumption
Nutritional intake and
supplements
Antacids, caffeine
Hypoparathyroidism
Clinical manifestations
Tetany, seizures,
depression,impaired memory,
confusion
Limit alcohol and
caffeine
Calcium: Hypercalcemia
Nursing care
At Risk
Increase activity
Hyperparathyriodism
Bone/mineral loss
during inactivity
Thiazide diuretics
Encourage fluids
Encourage fluids Na
– favour Ca
excretion
Safety/comfort
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
Compensatory Stage

BP normal

Increased HR

Vasoconstriction

Increased contractility

Fight or flight

Blood shunted to
heart and brain.
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 in
Irreversible 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:
 Colloids:
 Blood
electrolyte solution
plasma proteins
components
Risks of Fluid Replacement

Cardiovascular
overload

Pulmonary edema
Fluid Replacement: Nursing Care





Monitor I& O
Mental status
Skin perfusion
Vital signs
Lung sound
Overall Management of Shock

Vasoactive medication
 to improve
hemodynamic stability.
 Myocardial contract
 Myocradial resistence
 vasoconstriction

Nutritional support
 Meet
needs of
increased met.
 Often parenteral
feeding
Hypovolemic Shock

Decreased
intravascular volume
due to fluid loss
Nursing Care in
Hypovolemic Shock



Prevention
Fluid and blood
administration
Monitor for cardiac
overload and
pulmonary edema





Monitor vital signs
I&O
Temperature
Lung sounds
Cardiac rhythm and
rate.
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
Nursing Care in Septic Shock

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
Neurogenic 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 in
Anaphylactic Shock

Systemic antigenantibody reaction



Prevention: assess
for allergies and
observe response to
new medications/
blood administration
Remove causative
agent
Support cardiac and
pulmonary systems