Adult Care Nursing I / Theory

Faculty of Nursing
First Semester
2021-2022

1
Course Information
Course Title: Adult Care Nursing I / Theory
Course Number: 150702241
Prerequisites: Fundamentals of Nursing Theory & Clinical

Credit Hours: 4 Credit hours

Number of Lectures Two lectures
/week:

Lecture duration: 2 hours

Prof. Ali Ammouri

Dr. Mona Abed (Course coordinator)
Dr. Ala Ashour
Course Instructors: Dr. Ali Alshraifeen
Dr. Majdi Rababa
Dr. Mu’ath Tanash

Office hours:
Syllabus : Required text Book

Brunner and Suddarth's Textbook

of Medical-Surgical Nursing (10 -
14th edition)
Syllabus : Course contents

1. Fluids and Electrolytes:​ Balance and Disturbances (e.g: Hypovolemia, Na+ imbalance, ABGs …)
2. Peri/ Pre/ Intra/ Post/Opreative Nursing Care
3. Assessment and Management of Respiratory Disorders (e.g: Tonsilitis, Pneumonia, TB, …
4. Assessment and Management of Cardiovascular Disorders (e.g Dysrhythmias, ECG …)
5. Assessment and Management Blood Disorders (e.g Anemia, Bleeding …)
6. Assessment and Management Gastric and Duodenal Disorders (e.g Gastritis, Peptic &Duodenal
Ulcer …)

7. Assessment and Management Intestinal and Rectal Disorders (e.g Appendicitis, Hemorrhoids …)
8. Assessment and Management of Hepatic Dysfunction (e.g Jaundice, Hepatitis …)
9. Assessment and management of Diabetes Mellitus
 Adult Care Nursing I / Theory

Faculty of Nursing
First Semester
2021-2022

Lecture 1:
Fluid and Electrolytes: Balance
and Disturbance
 Fluid and Electrolytes
Objectives:

 Plan effective care of patients with the following

imbalances:
• Fluid Volume Deficit (FVD)
• Fluid Volume Excess (FVE)
• Hyponatremia and Hypernatremia
• Hypokalemia and Hyperkalemia.
• Hypocalcemia and Hypercalcemia
 Fluid and Electrolytes
Objectives:
• Compare metabolic acidosis and alkalosis with regard to
causes, clinical manifestations, diagnosis, and
management.
• Compare respiratory acidosis and alkalosis with regard
to causes,clinical manifestations, diagnosis, and
management.
• Interpret arterial blood gas measurements.
 Body Fluid Composition & Role

• Water
– Transport of nutrients & wastes to & from cells
– Medium for metabolic reactions
– Acts as solvent for electrolytes & nonelectrolytes
– Regulation of body temperature
– Facilitates digestion & elimination
– Lubricates joints & other body tissues
• Electrolytes
– Water balance regulation
– Acid–base balance
– Enzyme reactions
– Neuromuscular activity
 Fluid and Electrolyte Balance

• Necessary for life, and homeostasis.

• Nurses need to understand the physiology of fluid

and electrolyte balance and acid–base balance to
anticipate, identify, and respond to possible
imbalances.

• Nursing role: help prevent and treat fluid &

electrolyte disturbances.
 Body Fluid

• Approximately 60% of typical adult’s weight is fluid

(water and electrolytes).
– Varies with Age (Younger >Older), Body size
(Obese < Thin), Gender ( Men >Women).
- The skeleton has low water content.
- Muscle, skin, and blood contain the highest amounts
of water.
• Amount of water necessary to maintain health
– 1.500 milliliters -2.500 milliliters (Average)
 Body Fluid

• Body fluid is located in:

• Intracellular Fluid (ICF) (fluids in the cells)- 2/3
(primarily in the skeletal muscle mass).
• Extracellular Fluid (ECF) out side the cells- 1/3
– Intravascular (fluid within the blood vessels), 3L
Plasma and 3L erythrocytes, leukocytes, and
thrombocytes.
– Interstitial (surrounds the cell), 11 to 12 L. E.g.:
Lymph fluid.
– Transcellular: 1L. E.g.: cerebrospinal, pericardial
fluid, synovial, intraocular, pleural fluids, digestive
secretions.
Systemic Routes of Gains and Losses

• Gain
 Water & electrolytes are
gained in various ways:
• Dietary intake of fluid,
food
• Enteral feeding
(Nasogastric tube
(NGT))
• Parenteral fluids (IV)
Routes of Gains and Losses …

• Loss
– Kidney: normally filter 180L of plasma every day in
adults and excrete (urine output) 1 to 2L daily.
– General rule is that the output is approximately 1
mL of urine per kilogram of body weight per hour (1
mL/kg/h) in all age groups.
– Skin loss: sensible, insensible losses (Sweating:
500ml/day)
– Lungs: 300ml/day through exhalation
– GI tract: 100 to 200ml/day
 Calculation of Fluid Balance
 1 L=1 kg of body weight
 Acute change of body weight indicates fluid volume loss or
gain.
 Fluid Balance = difference between total intake and total
output.
 E.g., Total intake=2000ml, total output is 3000ml . Balance
= 2000 – 3000 = -1000 ml
 Negative Balance means output > intake
 E.g., Total intake = 1.5 L, total output is 0.5 L. balance = 1.5
L - 0.5 L = 1 L (1000 ml)
 Positive Balance means intake > output
• Quality and Safety Nursing Alert: When fluid balance is
critical, all routes of systemic gain and loss must be recorded
and all volumes compared. Organs of fluid loss include the
kidneys, skin, lungs, and GI tract.
 Regulation of Fluids and Electrolytes
 Kidneys
 Regulation of ECF volume and osmolality by selective
retention and excretion of body fluids
 Regulation of normal electrolyte levels in the ECF by
selective electrolyte retention and excretion
 Regulation of pH of the ECF by retention of hydrogen ions
 Excretion of metabolic wastes and toxic substances
 Acute change of body weight indicates fluid volume loss
or gain.
 Heart and Blood Vessel
 Failure of pumping action of heart interferes with renal
perfusion and thus with water and electrolyte regulation.
 Lung Functions
 Abnormal conditions, such as hyperpnea increases water
loss, lungs have major role in acid–base balance
 Regulation of Fluids and Electrolytes

 Parathyroid Functions
 The parathyroid glands, regulate Ca and po4 by Parathyroid
hormone (PTH).
 PTH influences bone reabsorption, ca absorption from the
intestines, and calcium reabsorption from the renal tubules.
 Adrenal Functions
 Increase secretion of aldosterone causes sodium retention
(and thus water retention) and potassium loss. A decreased
secretion of aldosterone causes sodium and water loss and
potassium retention.
 Cortisol, secreted in large quantities (or given as
corticosteroid therapy), it can also produce sodium and
fluid retention.
 Regulation of Fluids and Electrolytes

 Pituitary Functions
 The hypothalamus manufactures ADH, which is stored in
the posterior pituitary gland
 ADH maintains osmotic pressure of the cells by
controlling the retention or excretion of water by the
kidneys and by regulating blood volume
 Others
 Renin–Angiotensin–Aldosterone System, Antidiuretic
Hormone and Thirst, baroreceptors
 Fluid Volume Imbalances

 Fluid Volume Deficit (FVD), Hypovolemia

• Occurs when loss of extra cellular fluid (ECF)
exceeds the intake of the fluid.
• Water & Electrolytes are lost in same proportion as
they exist in normal body fluids, thus the ratio of
serum electrolyte to water remains the same.
• FVD may occur alone or in combination with other
imbalances.
• Dehydration is loss of water alone, with increased
serum sodium level.
Fluid Volume Deficit , Causes

– Abnormal fluid loss from vomiting, diarrhea, GI

suctioning, fever, sweating
– Decreased intake, inability to gain access to fluid
– Third-space fluid shift”third spacing”: movement
of fluid from the vascular system to other body
spaces (e.g; edema formation in burns, ascites
with liver dysfunction)
– Others, Diabetes insipidus (decreased ability to
concentrate urine), adrenal insufficiency,
osmotic diuresis, burns, hemorrhage, coma.
Fluid Volume Deficit
• Manifestations: rapid weight loss, decreased skin turgor,
oliguria, concentrated urine, capillary filling time prolonged,
postural hypotension, rapid weak pulse, cool clammy pale skin
due to vasoconstriction, tiredness, thirst, nausea, muscle
weakness, cramps, dizziness, delirium, & sunken eyes.
• Assessment & Diagnostic Findings:
1. Health history & physical examination
2. Laboratory data: increased hematocrit & hemoglobin.increased
serum and urine osmolality, elevated BUN and creatinine, increased
urine specific gravity,
3. Serum electrolyte changes may occur: Potassium and Sodium
levels can be reduced or elevated.
1. Decreased K with GI and renal losses.
2. Increased K with adrenal insufficiency.
3. Decreased Na occurs with increased thirst and ADH release.
4. Increased Na with insensible losses and diabetes insipidus.
 Fluid Volume Deficit, Medical Management
• Provide fluids to meet body needs.
– Oral fluids (preferred)
– IV solutions (In acute & sever fluid losses)
• Isotonic electrolyte solutions (e.g; Lactated
Ringers solution, 0.9% sodium chloride) the
first line choice to treat the hypotensive
patients with FVD.
• When patients becomes normotensive,
hypotonic electrolyte solution (e.g; 0.45%
sodium chloride) used to provide both
electrolytes and water for renal excretion of
metabolic wastes.
• Rate of IVF administration depends on
severity of loss and patient’s repose
 Fluid Volume Deficit , Nursing Management

– Assess and monitor for symptoms: skin and

tongue turgor by pinching the skin, mucosa,
urine output, mental status
– Assess and monitor I&O, daily weight, vital
signs (observes for a weak, rapid pulse &
orthostatic hypotension)
– Administration of oral fluids
– Oral care
– Administration of parenteral (IV) or enteral
fluids
• Prevention of FVD
– Measures to minimize fluid loss (e.g., in case of
diarrhea: antidiarrhea med., encourage fluid
intake…)
Fluid Volume Excess (FVE)- Hypervolemia

• Due to fluid overload (expansion of ECF), or diminished

function of homeostatic mechanisms.
• Caused by abnormal retention of water and sodium.
• Risk factors: heart failure, renal failure, cirrhosis of liver
• Contributing factors: excessive dietary sodium or
sodium-containing IV solutions
• Manifestations: edema, distended neck veins, abnormal
lung sounds (crackles), tachycardia, increased blood
pressure, pulse pressure and CVP, increased weight,
increased urine output, shortness of breath and wheezing
• DX tests: low HCT, CXR: pulmonary congestion
• Medical Management: directed at cause, restriction of
fluids and sodium, administration of diuretics, dialysis.
Fluid Volume Excess—Nursing Management

• I&O and daily weights; assess lung sounds, edema,

other symptoms
• Monitor responses to medications—diuretics
• Promote adherence to fluid restrictions, patient
teaching related to sodium and fluid restrictions
• Monitor, avoid sources of excessive sodium,
including medications and water supply.
• Promote rest: bed rest favors diuresis of fluid.
• Semi-Fowler’s position for orthopnea
• Skin care, positioning/turning to prevent skin
breakdown (edematous tissue is prone to skin
breakdown)
 Electrolyte Imbalances
Electrolyte Decrease Increase

Sodium (Na+) hyponatremia hypernatremia

Potassium (K+) hypokalemia hyperkalemia

Calcium (Ca++) hypocalcemia hypercalcemia

Magnesium (Mg++) hypomagnesemia hypermagnesemia

Phosphorus (HPO4–) hypophosphatemia hyperphosphatemia

Chloride (Cl-) hypochloremia hyperchloremia

Normal range of electrolyte
 Sodium
• Sodium (Na+) is the most abundant electrolyte in the
ECF; (135 to 145 mEq/L )
• Is the primary determinant of ECF volume
• Sodium also functions in establishing the electrochemical
state necessary for muscle contraction and the
transmission of nerve impulses
• Sodium is regulated by ADH, thirst, and the renin–
angiotensin–aldosterone system.
 Sodium Deficit (Hyponatremia)
• Serum sodium less than 135 mEq/L
• Causes: adrenal insufficiency (Aldosterone), water
intoxication, SIADH (Syndrome of inappropriate secretion
of antidiuretic hormone) or losses by vomiting, diarrhea,
sweating, diuretics.
• Manifestations: poor skin turgor, dry mucosa, headache,
decreased salivation, decreased blood pressure, nausea,
vomiting, abdominal cramping, neurologic changes
(seizures, delirium, coma).
• Medical Management: treating the underlying cause, water
restriction, sodium replacement (sodium by mouth,
nasogastric tube, or a parenteral route, Lactated Ringers
or isotonic saline 0.9%)
• Nursing Management: assessment and prevention,
dietary sodium and fluid intake, identify and monitor at-
risk patients, effects of medications (e.g.,diuretics)
Sodium Deficit (Hyponatremia)
 Hypernatremia

• Serum sodium greater than 145 mEq/L

• Causes: patients with no response to thirst (elderly,
coma), excess water loss, excess sodium administration,
diabetes insipidus, heat stroke, hypertonic IV solutions
• Manifestations: thirst; elevated temperature; dry,
swollen tongue; sticky mucosa; neurologic symptoms
(hallucinations); restlessness; weakness, pulmonary
edema, high BP.
• Medical Management: hypotonic electrolyte solution or
D5W
• Nursing Management: assessment and prevention,
assess for OTC medications sources of sodium, offer and
encourage fluids to meet patient needs, provide sufficient
water with tube feedings.
 Potassium (K+)
• Potassium (K+) is the major intracellular electrolyte
• Its concentration ranges from 3.5 to 5 mEq/L
• 80% of the potassium excreted daily leaves the body by
way of the kidneys
• Important in neuromuscular function & influences both
skeletal and cardiac muscle activity.
• Alterations in its concentration change myocardial
irritability and rhythm.
 Hypokalemia
• Serum potassium (K+) below-normal (<3.5 mEq/L), may
occur with normal potassium stores.
• When alkalosis is present, a temporary shift of serum
potassium into the cells occurs.
• Causes: GI losses (vomiting, gastric suction, diarrhea),
medications (Potassium losing diuretics [Thiazides, loop
diuretics], Corticosteroids), alkalosis, hyperaldosterism
(increase renal potassium wasting), poor dietary intake,
persistent insulin hypersecretion, (e.g. patients receiving
highcarbohydrate parenteral nutrition (Insulin promotes
K+ entry into skeletal muscle)
• Sever hypokalemia can cause death through cardiac or
respiratory arrest.
 Hypokalemia

• Manifestations: fatigue, anorexia, nausea, vomiting,

dysrhythmias, muscle weakness and cramps, paresthesias,
polyuria, glucose intolerance, decreased muscle strength, ECG
changes.
• Medical Management: increased dietary potassium (Fruits-
bananas, melon & vegetables, legumes, whole grains, milk,
meat), oral potassium replacement, IV potassium chloride
(KCl) for severe deficit.
• Nursing Management: assessment, severe hypokalemia is
life-threatening, monitor ECG and ABGs, dietary potassium,
nursing care related to IV potassium administration- after
adequate urine output has been established, monitor ECG.
• Patients receiving digitalis who are at risk for potassium
deficiency (e.g diuretcs) should be monitored closely for signs
of digitalis toxicity, because hypokalemia potentiates the action
of digitalis.
Hypokalemia
 Hyperkalemia

• Serum potassium (K+) greater than 5.0 mEq/L

• Causes: usually treatment related (rapid
administration), impaired renal function,
hypoaldosteronism, tissue trauma, acidosis-K+ moves
out of the cells & into ECF.
• Manifestations: cardiac changes and dysrhythmias,
muscle weakness with potential respiratory impairment,
paresthesias, anxiety, GI manifestations, ECG changes
• Medical Management: monitor ECG, limitation of dietary
potassium, cation-exchange resin (Kayexalate), IV
sodium bicarbonate, IV calcium gluconate, regular
insulin and hypertonic dextrose IV, -2 agonists,
dialysis.
 Hyperkalemia

• Nursing Management: Assessment of serum

potassium levels, mix IVs containing K+ well,
monitor medication affects, dietary potassium
restriction/dietary teaching for patients at risk,
monitors I & O, ECG.
• Hemolysis of blood specimen or drawing of blood
above IV site may result in false laboratory result.
• Salt substitutes, medications may contain potassium
• Potassium-sparing diuretics may cause elevation of
potassium - Should not be used in patients with
renal dysfunction.
•
• 38
 Calcium

• More than 99% of the body’s calcium (Ca++) is

located in the skeletal system;
• The small amount of calcium located outside the bone
circulates in the serum, partly bound to protein and
partly ionized.
• Calcium plays a major role in:
– transmitting nerve impulses and helps regulate
muscle contraction and relaxation, including
cardiac muscle.
– instrumental in activating enzymes that stimulate
many essential chemical reactions in the body
– Blood coagulation.
 Calcium
• Ca++ is absorbed from foods in the presence of normal
gastric acidity and vitamin D.
• The serum Ca++ level is controlled by PTH and
calcitonin.
• As ionized serum Ca++ decreases, the parathyroid
glands secrete PTH. This, in turn, increases Ca++
absorption from the GI tract, increases Ca++
reabsorption from the renal tubule, and releases
calcium from the bone.
• The increase in Ca++ ion concentration suppresses PTH
secretion.
• When Ca++ increases excessively, the thyroid gland
secretes calcitonin, which inhibits Ca++ reabsorption
from bone and decreases the Ca++ concentration.
 Hypocalcemia

• Serum Ca++ level less than 8.6 mg/dL, must be

considered in conjunction with serum albumin level
• Causes: hypoparathyroidism, malabsorption,
pancreatitis, alkalosis, massive transfusion of
citrated blood, renal failure, medications, other-
inadequate vitamin D consumption & Magnesium
deficiency.
• Manifestations: Tetany, numbness, paresthesias,
Trousseau’s sign, Chovstek's sign, seizures,
respiratory symptoms of dyspnea and
laryngospasm, abnormal clotting, anxiety, prolonged
QT interval on ECG
Hypocalcemia (cont’d)
Chovstek's sign
Watch the video

Trousseau’s Sign
 Hypocalcemia (cont’d)

• Medical Management: IV of calcium gluconate,

calcium and vitamin D supplements (increase Ca
absorption); diet (milk products, green, leafy
vegetables, canned salmon, sardines)
• Nursing Management: assessment, severe
hypocalcemia is life-threatening, weight-bearing
exercises to decrease bone calcium loss, patient
teaching related to diet and medications, seizure
precaution, and nursing care related to IV calcium
administration.
 Hypercalcemia

• Serum Ca++ level greater than10.2 mg/dL

• Causes: malignancy and hyperparathyroidism (increase release
of Ca++ & increased intestinal & renal absorption of Ca++), bone
mineral loss related to immobility, thiazide diuretics.
• Manifestations: muscle weakness, incoordination, anorexia,
constipation, nausea and vomiting, abdominal and bone pain,
polyuria, thirst, ECG changes, dysrhythmias (heart blocks)
• Medical Management: treat underlying cause, fluids,
restricting dietary Ca++ intake, furosemide, phosphates,
calcitonin, biphosphonates
• Nursing Management: assessment, hypercalcemic crisis has
high mortality, encourage ambulation, fluids of 3 to 4 L/d,
provide fluids containing sodium unless contraindicated, fiber
for constipation, ensure safety, ECG.