Question

You are assigned to care for a 65-year-old woman admitted last evening with a recent history of cellulitis and a 3-day history of persistent vomiting and diarrhea. She takes no medications at home, other than a daily multivitamin. Her weight on admission was 153 pounds. The patient states her original weight is 165 pounds (75 kg). The nurse notes that the patient’s mucous membranes and skin are dry. Vital signs are temperature 99.8° F, pulse 112, respirations 32, and blood pressure 100/76. Her urine output over the last 8 hours is 125 mL with a specific gravity of 1.033. Morning labs reveal serum K+ 3.5 mEq/L; Na+ 159 mEq/L; and Cl- 120 mEq/ L. Her hematocrit and BUN were elevated. Serum glucose was 163 mg/ dl. Her ABG results were: pH of 7.30, HCO₃ 17 mEq/L, PaCO2 of 28, PaO2 of 88.

1. The nurse assesses the patient’s body fluid state. Name four of her symptoms and laboratory findings that are suggestive of the fluid imbalance (dehydration).
2. Which type of hypernatremia is the patient experiencing (water loss or sodium gain)?
3. This patient’s symptoms are most likely a result of which acid-base imbalance? Explain the rationale for your response.
4. The bicarbonate level of 17 mEq/L is the result of which factor?
5. Which ABG finding indicates a worsening acid-base imbalance?
6. What priority nursing and collaborative interventions do you anticipate for this patient?

Answer 1

1. Symptoms of dehydration are :-

- Heart rate of 112 means tachycardia

- Respiratory rate of 32 means tachypnea

- mucous membrane and skin dry

- decreased urine output 125ml over 8hrs.

- hypotension (100/76mmhg )

Laboratory findings of dehydration are :-

- hypernatremia (159 mEq/l )

- decreased bicarbonate level (17mEq/l)

- increased urine specific gravity (1.033)

- increased BUN level

- increased chloride level ( 120mEq/l )

- hyperglycemia ( 163mg/gl )

2. Types of hypernatremia patient experiencing is due to water loss from the body .

3. Metabolic acidosis , because there is both decrease in the pH and HCO3 from the normal range( pH is 7.35 to 7.45 and HCO3 is 22 to 27 mEq/l ) which results in acidosis . Metabolic acidosis occurs when either increase in production of non volatile acid or excessive loss of bicarbonate from the body overwhelms mechanism of acid base hemostasis or when renal acidification is compromised .

4.History of 3 days diarrhea is the factor responsible for decreased level of bicarbonate ,because of loss of bicarbonate in diarrheal stools

5. Bicarbonate level of 17 mEq/l indicates a worsening acid base imbalance as there is huge loss of bicarbonate in diarrheal stool .

6. Priority Nursing and collaborative interventions are :-

Assess the vitals of the patient and do the neurological assessment .

1- Fluid replacement by IV fluids( isotonic solutions) like Ringer lactate , Normal saline etc

2- Correction of acid base imbalance by management of electrolyte levels in the body .

3- Monitoring intake and output

4- Prevention of skin break down, providing oral care and skin care , 2hrly position change etc .