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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