Transcript
A nurse is taking care of an 85-year-old woman in a hospital based skilled nursing facility. In report, the nurse is told the patient has not been breathing well for the past 2 days. She has been lethargic, her skin is warm and dry, and she has a decreased urine output. The following laboratory findings were returned from the laboratory immediately after morning report:
Na: 147 135-145 mmol/L
Cl 110 95-105 mmol/L
K 4.0 3.5-5 mmol/L
Blood Gases:
pH 7.33 pH 7.36 - 7.44
PCO2 34 36 - 44 mm Hg
HCO3 27 22 - 26 mEq/L
Po2 96
Urine:
Urine Specific Gravity 1.040 normal range: 1.003-1.030
The specific gravity of urine is dependent on the hydration status of the animal and the ability of the kidney to respond appropriately in order to dilute or concentrate urine over that of plasma.
Causes of Abnormally High Levels
•Dehydration, marked proteinuria, and marked glucosuria
•Concentrated urine is commonly seen in horses fed a high percentage of hay and those living in hot environments (Science Direct, 2017).
Address the following:
Identify each of the abnormal laboratory findings in the above results.
Hypernatremia is a serum sodium concentration > 145 mEq/L. It implies a deficit of total body water relative to total body sodium caused by water intake being less than water losses (Merck Manuals, 2018).
Hyperchloremia is an electrolyte imbalance and is indicated by a high level of chloride in the blood. The normal adult value for chloride is 97-107 mEq/L.
What specific electrolyte disturbance does the patient have?
Hypernatremia reflects a deficit of total body water (TBW) relative to total body sodium content. Because total body sodium content is reflected by extracellular fluid (ECF) volume status, hypernatremia must be considered along with status of the ECF volume:
Hypovolemia
Euvolemia
Hypervolemia
Note that the ECF volume is not the same as effective plasma volume. For example, decreased effective plasma volume may occur with decreased ECF volume (as with diuretic use or hemorrhagic shock), but it may also occur with an increased ECF volume (eg, in heart failure, hypoalbuminemia, or capillary leak syndrome) (Merck Manuals, 2018).
Chloride is an important electrolyte and works to ensure that your body's metabolism is working correctly. Your kidneys control the levels of chloride in your blood. Therefore, when there is a disturbance in your blood chloride levels, it is often related to your kidneys. Chloride helps keep the acid and base balance in the body (MedicalnewsToday, 2017).
What clinical manifestations would the nurse expect to see with this electrolyte abnormality presented above?
According to Merck Manuals 2018, the major signs of hypernatremia result from CNS dysfunction due to brain cell shrinkage. Confusion, neuromuscular excitability, hyperreflexia, seizures, or coma may result. Cerebrovascular damage with subcortical or subarachnoid hemorrhage and venous thromboses have been described in children who died of severe hypernatremia.
In chronic hypernatremia, osmotically active substances are generated in CNS cells (idiogenic osmoles) and increase intracellular osmolality. Therefore, the degree of brain cell dehydration and resultant CNS symptoms are less severe in chronic than in acute hypernatremia.
When hypernatremia occurs with abnormal total body sodium, the typical symptoms of volume depletion or volume overload are present. Patients with renal concentrating defects typically excrete a large volume of hypotonic urine. When losses are extrarenal, the route of water loss is often evident (eg, vomiting, diarrhea, excessive sweating), and the urinary sodium concentration is low (Merck Manuals, 2018).
According to Medical News Today 2017, chloride helps the body maintain its fluid balance. It also helps make the digestive enzymes that help the body metabolize food. Changes in chloride levels can harm these functions. When chloride levels are moderately high, a person may not notice any symptoms. Long-term hyperchloremia, however, can cause a range of symptoms.
Those include:
fluid retention
high blood pressure
muscle weakness, spasms, or twitches
irregular heart rate
confusion, difficulty concentrating, and personality changes
numbness or tingling
seizures and convulsions (MedicalnewsToday, 2017).
If the patient had an increase in her potassium level, what clinical manifestations would the nurse monitor for?
According to Tanya Feke 2018, without potassium, we could not live. The electrolyte is responsible for a number of essential life functions. Not only is potassium responsible for regulating water balance in the body, it keeps the heart pumping, the muscles contracting, the gut digesting, and your nerves firing.
That said, too much of a good thing can be harmful. High potassium, medically known as hyperkalemia, is a common laboratory finding. The diagnosis is made when levels in the blood are greater than 5.0 mEq/L. interestingly, most people do not get any symptoms from it. When they do, those symptoms are often mild and nonspecific, including common complaints like fatigue and generalized weakness (Tanya Feke, 2918).
When blood levels of potassium are too high, contractions of the heart may not be forceful enough to pump enough blood out of the heart to the brain and other organs. The heart rate can also slowdown from the delayed firing of action potentials. In that way, abnormal heart rhythms can also develop. Depending on the arrhythmia, this could be a life-threatening situation.
Cardiac symptoms of hyperkalemia can include:
Slow heart rate
Palpitations and cardiac arrhythmia
Chest pain
Cardiac arrest (Tanya Feke, 2918).
What blood gas abnormality is seen in this patient? Please discuss the rationale for your answer.
What are the three major mechanisms of pH regulation?
There are three mechanisms which diminish pH changes in body fluid: buffers; respiratory; renal.
3.2. THE BUFFER SYSTEMS OF THE BODY
(a) Proteins are the most important buffers in the body. They are mainly intracellular and include haemoglobin. The plasma proteins are buffers but the absolute amount is small compared to intracellular protein. Protein molecules possess basic and acidic groups which act as H+ acceptors or donors respectively if H+ is added or removed.
(b) Phosphate buffer (H2PO4- : HP042-) is mainly intracellular. The pK of this sytem is 6.8 so that it is moderately efficient at physiological pH's. The concentration of phosphate is low in the extracellular fluid but the phosphate buffer system is an important urinary buffer.
(c) H2CO2 : HCO3- is not an important true buffer system because normal blood pH (7.4) is so far from its pK (6.1). H2CO3 and HCO3- are involved in pH control but they are not acting as a buffer system as defined in Section 2.4. (AMUE, 2015).
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
References
Hyperchloremia (high chloride): Symptoms, causes, and treatments. (2017, October 24). Retrieved from https://www.medicalnewstoday.com/articles/319801.php
Hypernatremia - Endocrine and Metabolic Disorders - Merck Manuals Professional Edition. (n.d.). Retrieved from https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/hypernatremia
pH of the Blood - 3 - Control mechanisms - M J Bookallil. (n.d.). Retrieved from http://www.anaesthesia.med.usyd.edu.au/resources/lectures/acidbase_mjb/control.html
Tanya Feke, MD. (2018, March 26). Signs and Symptoms of Hyperkalemia (High Potassium). Retrieved from https://www.verywellhealth.com/signs-and-symptoms-of-hyperkalemia-4160468
Urine Specific Gravity - an overview | ScienceDirect Topics. (n.d.). Retrieved from https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/urine-specific-gravity
