Introduction
The common clinical syndrome that results from inadequate tissue perfusion, creating an imbalance between the delivery of oxygen and nutrients needed to support cellular function, need to understand the physiology of fluid and electrolyte imbalance and acid base balance to anticipate, role in the management of pain as experts in assessment, drug administration and patient education. Let’s we are see in details about these kind of conditions like as fluid and electrolyte imbalance, shock and pain.
1. Fluid and Electrolyte Imbalance
Fluid and electrolyte imbalance is dependent upon dynamic processes that are crucial for life and homeostasis. Potential and actual disorders of fluid and electrolyte balance occur in every setting, with every disorder, and with a variety of changes that affect healthy people (e.g.,increased fluid and sodium loss with strenuous exercises and high environmental temperature, inadequate intake of fluid and electrolyte) as well as those who are ill.
Fluid Balance:
Fluid volume deficit:
Hypovolemia
Fluid volume deficit (FVD) when the loss of extracellular fluid volume exceeds the intake of fluid.
Clinical Manifestation (Sign and Symptoms):
- Weight Loss
- Thirst
- Orthostatic changes in
- Pulse rate and bp
- Weak, rapid pulse
- Decrease the urine output
- Dry mucus membrane
Treatment /Intervention (Fluid management)
- Diet therapy – mild to moderate dehydration. Correct with oral fluid replacement .
- Oral rehydration therapy – Solutions containing glucose and electrolytes.
- IV therapy – type of fluid ordered depends on the type of dehydration and the clients cardiovascular status.
Fluid volume excess
Clinical Manifestation (signs and symptoms)
- Increase BP
- Bounding pulse
- Venous distension
- Pulmonary edema
Treatment /Intervention (FVE)
- Drug therapy – Diuretics may be ordered if renal failure is not the cause.
- Restriction of sodium and saline intake
- I/O
- Weight
Electrolyte Imbalance
Hypokalemia (<3.5mEq/L):
Pathophysiology – Decrease in K+ causes decreased excitability of cells, therefore cells are less responsive to normal stimuli.
Interventions:
- Assess and identify those at risk
- Encourage potassium rich foods
- K+ replacement (IV or PO)
- Monitor lab values
- D/c potassium – wasting diuericts
- Treat underlying cause
Hyperkalemia (>5.0mEq/L):
Pathophysiology: An increased excitability of cells.
Interventions:
- Need to restore normal K+ balance
- Infuse glucose and insulin
- Cardiac Monitoring
Hyponatremia (<135mEq/L):
Contributing factors
- Excessive diaphoresis
- Wound Drainage
- NPO
- CHF
- Low salt diet
- Renal disease
- Diuretics
Interventions /Treatment:
- Restore Na levels to normal and prevent further decreases in Na.
- Increase oral sodium intake and restrict oral fluid intake intake.
Hypernatremia (>145mEq/L):
Contributing Factors
- Hyper aldosteronism
- Renal failure
- Corticosteroids
- Increase in oral Na intake
Interventions /Treatment
- Drug therapy (45%NSS)
- Diet therapy – mild (ensure water intake)
Hypocalcemia (<9.0mg/dl):
Contributing Factors
- Decreased oral intake
- Lactose intolerance
- Decrease vitamin D intake
- Diarrhea
Interventions /Treatment:
- Drug therapy (ca supplements, vitamin D)
- Diet Therapy (high calcium diet)
- prevention of injury (seizure precautions)
Hypercalcemia (>10.5mg/dl):
Contributing Factors
- Excessive calcium intake
- Excessive vitamin D intake
- Renal failure
- Malignancy
Interventions /Treatment
- Eliminate the calcium administration
- Drug therapy
- Diuretics
- Cardiac Monitoring
Hypophosphatemia(<2.5mg/dl):
Contributing Factors
- Malnutrition
- Starvation
- Hypercalcemia
- Renal Failure
- Uncontrolled DM
Interventions
- Treat underlying cause
- Oral replacement with vitamin D
- IV phosphorus(severe)
- Diet Therapy (foods high in oral phosphate)
Hyperphosphatemia(>4.5mg/L):
- Causes few direct problems with body function. Care is directed to Hypocalcemia
- Rarely occurs
Hypomagnesemia(<1.4mEq/L)
Contributing Factors
- Malnutrition
- Starvation
- Diuretics
- Aminoglycoside
- antibiotics
- Hyperglycemia
- Insulin
- administration
Interventions
- Eliminate Contributing drugs
- IV mgso4
- Diet Therapy
Hypermagnesemia (>2.0mEq/L)
Contributing Factors
- Increased the mg intake
- Decrease Renal
- Excretion
Interventions
- Eliminate Contributing
- Drugs
- Administer diuretic
- Diet restrictions
2. Shock
Shock is a life – threatening condition that results from inadequate tissue perfusion. Many conditions may cause shock ; irrespective of the cause, tissue hypoperfusion prevent adequate oxygen delivery to cells, leading to cell dysfunction and death. The progression of shock is neither linear nor predictable, and shock states, especially septic shock, comprise an area of aggressive clinical research. Rapid assessment with early recognition and response to shock states is essential to the patient’s recovery.
Stages of Shock
Shock progresses along a continum and can be identified as early or late, depending on the signs and symptoms and the overall severity of organ dysfunction. A convenient way to understand the physiologic responses and subsequent clinical signs and symptoms of shock is to divide the continum into separate stages : Compensatory (stage 1),progressive (stage 2),and irreversible (stage 3).the survival. Current research and evidence – based practice focuses on assessing patients at greatest risk for shock and implementing early and aggressive interventions to reverse tissue hypoxia.
a) Compensatory stage :
In the Compensatory stage of shock, the BP remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. This results from stimulation of the sympathetic nervous system and subsequent release of catecholamines. Patients display the often-described “fight or flight” response.
b) Progressive stage :
In the second stage of shock, the mechanisms that regulate BP can no longer compensate, and the MAP falls below normal limits. Patients are clinically hypotensive ; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline.
c) Irreversible Stage :
The irreversible (or refractory) stage of shock represents the point along the shock continum at which organ damage is so severe that the patients does not respond to treatment and cannot survive. Despite treatment, BP remains low. Renal and liver dysfunction, compounded by the release of biochemical mediators, creats an acute metabolic acidosis. Anaerobic metabolism contributes to a worsening lactic acidosis. Reserves of ATP are almost totally depleted, and mechanism for storing new supplies of energy have been destroyed. Multiple organ dysfunction progressing to complete organ failure has occurred, and death is imminent.
Types of Shock
a) Hypovolemic Shock : The most common type of shock, is characterised by decreased intravascular volume. Body fluid is contained in the intracellular and extracellular compartments: Intracellular fluid accounts for about two – thirds of the total body water. The extracellular body fluid is found in one of two compartments :intravascular or interstitial. The volume of interstitial fluid is about three to four times that of intravascular fluid.. Hypovolemic Shock occurs when three is a reduction in intravascular volume by 15%to 30%,which represents an approximate loss of 750 to 1500 mL of blood in a 70 kg person.
b) Cardiogenic Shock : Cardiogenic shock occurs when the heart’s ability to cantract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and the tissues. The causes of Cardiogenic shock are known as either coronary or noncoronary. Coronary Cardiogenic shock is more common than noncoronary Cardiogenic shock and is seen most often in patients with acute MI resulting in damage to a significant portion of the left ventricular myocardium.
c) Distributive Shock : Distributive shock occurs when intravascular volume pools in peripheral blood vessels. This abnormal displacement of intravascular volume causes a relative Hypovolemia because not enough blood returns to the heart, which leads to inadequate tissue perfusion. The ability of the blood vessels to constrict helps return the blood to the heart. The vascular tone is determined both by central regulatory mechanisms,as in BP regulation, and by local regulatory mechanisms, such as tissue demands for oxygen and nutrients. Therefore, distributive shock can be caused by either a loss of sympathetic tone or a release of biochemical mediators from the cells that causes vasodilation.
d) Sepsis and Septic shock :The most common type of distributive shock, is caused by widespread infection or Sepsis. According to the Third international Consensus Definitions for Sepsis and Septic Shock Task Force, Sepsis is “life threatening organ dysfunction causes by a dysregulated host response to infection,”and Septic shock is” a subset of Sepsis in which underlying circulatory and cellular metabolism abnormalities are profound enough to substantially increase mortality”
The incidence of Sepsis can be reduced by using strict infection control practices, beginning with through hand hygiene techniques. Other Interventions include implementing programs to prevent central line infection, ensuring early removal of invasive devices that are no longer necessary.
Pathophysiology :
a) Cellular Changes : In shock, the cells lack an adequate blood supply and are deprived of oxygen and nutrients ; therefore they must produce energy through anaerobic metabolism. The results in low – energy yields from nutrients and an acidotic intracellular environment. Because of these changes, normal cell function ceases. The cell swells and the cell membrane becomes more permeable, allowing electrolytes and fluids to seep out of and into the cell.
b) Vascular Response: Local regulatory mechanisms, referred to as autoregulation, stimulate vasodilation or vasoconstriction in response to biochemical mediators released by the cell, communicating the need for oxygen and nutrients. A biochemical mediator is a substance released by a cell, or immune cells such as macrophages; the substance triggers an action at a cell site or travels in the bloodstream to a distant site, where it triggers action.
Blood pressure regulation :
Three major components of the circulatory system
- Blood volume, the cardiac pump, and the vasculature
- Must respond effectively to complex neural, chemical, and hormonal feedback systems to maintain an adequate blood pressure (BP) and peruse body tissues, BP is regulated through a complex interaction of neural, chemical
- Hormonal feedback systems affecting both cardiac output and peripheral resistance.
The relationship is expressed in the following equation :
Mean arterial BP = Cardiac output x peripheral resistance
Clinical Manifestation : Despite a normal BP, the patient shows numerous clinical signs indicating inadequate organ perfusion. The result of adequate perfusion is anaerobic metabolism and a bulid up lactic acid, producing metabolic acidosis. The respiratory rate increases in response to the need to increase oxygen to the cells and in compensation for metabolic acidosis.
Medical Management : Medical treatment is directed toward identifying the cause of the shock, correcting the underlying disorder so that shock does not progress, and supporting those physiologic process that thus far have responded successfully to the threat. Because compensation cannot be maintained indefinitely, measures such as fluid replacement and medication therapy must be initiated to maintain an adequate BP and reestablish and maintain adequate tissue perfusion.
3: Pain
The management of pain as experts in assessment, drug administration, and patient education. They are uniquely positioned to assume this role as the member of the health care team most consistently at the patient’s bedside.
Definition : Pain is defined as ” an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”
Types of pain : Pain can be classified in many ways, and clear distinctions are not always possible. Pain often is described as being of two types.
a) Acute Pain : Acute pain differs from chronic pain primarily in its duration. For example, tissue damage as a result of surgery, trauma, or burns produces acute pain, which is expected to have a relatively short duration and resolve with normal healing.
b) Chronic Pain : Chronic pain is sub classified as being of cancer or noncancer origin and can be time limited or persist throughout the course of a person’s life. Examples of non cancer pain include peripheral neuropathy from diabetes, back or neck pain after injury, and osteoarthritis pain from joint degeneration.Some conditions can produce both acute and chronic pain. For example, some patients with cancer have continuous chronic pain and also experience acute exacerbations of
Pain Periodically
Called breakthrough pain (BTP) – or endure acute pain from repetitive painful procedures during cancer treatment.
Pain Assessments : The highly subjective nature of pain causes challenges in assessment and management ; however, the patients self report is the undisputed standard for assessing the existence and intensity of pain.
Source: researchgate
Reassessing pain: Following initiation of the pain management plan, pain is reassessed and documented on a regular basis to evaluate the effectiveness of treatment. At a minimum, pain should be reassessed with each new report of pain and before and after the administration of analgesic agents. The frequency of reassessment depends on the stability of the patient’s pain and is guided by institutional policy. For example, in the postanesthesia care unit, reassessment may be necessary as often as every 10 minutes when pain is unstable during opioid titration but may be done every 4 to 8 hours in patients with unsatisfactory and stable pain 24 hours after surgery.
Pain Management : Achieving optimal pain relief is best viewed on a continum, with the primary objective being to provide both effective and safe analgesia. The quality of pain control should be addressed whenever patient care is passed on from one clinician to another, such as at change of shift and transfer from one clinical area to another. Optimal pain relief is the responsibility of every member of the health care team and begins with titration of the analgesic agent, followed by continued prompt assessment and analgesic agent administration during the course of care to safely achieve pain intensities that allow patients to meet their functional goals with relative ease.
Although in may not always be possible to achieve a patient’s pain intensity goal within the short time the patient is in an area like the PACU or emergency department, this goal provides direction for ongoing analgesic care. Important information to provide during transfer report is the patient’s comfort – function goal, how close the patient is to be achieving it, what has been done thus far to achieve it, and how well the patient has tolerated administration of the analgesic agent. There is growing interest among both clinicians and researchers on linking pain management to functional goals. Pain management interventions should improve and not inhibit progress toward healing and rehabilitation.
Pharmacologic management of pain :
Multimodal Analgesia
Pain is a complex phenomenon involving multiple underlying mechanisms and as such, requires more than one analgesic agent to manage it safely and effectively. The recommended approach for the treatment of all types of pain in all age groups is called Multimodal analgesia. A Multimodal regimen combines drugs with different underlying mechanisms, which allows lower doses of doses of each of the drugs in the treatment plan, reducing the potential for each to produce adverse effects. Furthermore, Multimodal analgesia can result in comparable or greater pain relief than can be achieved with any single analgesic agent.
Conclusion : Impaired concentration of electrolyte contribute greatly to the development of changes in the water balance. And with a variety of changes that affect healthy people (e.g, increased fluid and sodium loss with strenuous exercise and high environmental temperature, inadequate intake of fluid and electrolyte) as well as those who are ill.
Therefore, a casualty in shock requires immediate emergency treatment to prevent the permanent organ or tissue damage. However when the patient is having a this kind of shock disorder immediately transfer to the medical check up.
Pain Management is referred to the patient including pharmacological therapy, medical therapy and physiological counseling. All the medical team like doctors, nurses have to know about how to relieve a pain for all patients in their care.
– Posted By: Anita Ghosh
