Fluid and Electrolyte Case Studies

1. Fluid and Electrolyte Case Studies Nursing 2904 Spring 2006 Carol Isaac MacKusick, MSN,RN, CNN

3. Donald R Assessment findings +3 pitting, generalized edema Abdomen distended, tight Orthopneic c/o SOB Pt states: “I have been stuck on the couch for the last two weeks” Investigation reveals that his dyspnea and fatigue have kept him bedridden

4. Donald R Mr. R’s age and poor physical condition place him at risk for: Hypertension Dehydration ARF CHF Dehydration – the older client is predisposed for Na losses as well as FVD r/t decreased muscle mass, smaller fat stores, and a reduction in percentage of body fluidsDehydration – the older client is predisposed for Na losses as well as FVD r/t decreased muscle mass, smaller fat stores, and a reduction in percentage of body fluids

5. Donald R Mr. R’s edema is an example of fluid located in which space? ICF Intravascular Interstitial Transcellular Transcellular – generally only 1% of body weight. Has thepotential to increase significantly when fluids becomes abnormally sequestered in body cavities and tissues (third spacing) Interstitial – 15% of body weight; interstitial fluid functions as a transport medium for movement of nutrients, gases, waste products, and other substances between the blood and body cells. Acts as a back up fluid reservoir. ICF – 40% of body wt; rich in nutrientsTranscellular – generally only 1% of body weight. Has thepotential to increase significantly when fluids becomes abnormally sequestered in body cavities and tissues (third spacing) Interstitial – 15% of body weight; interstitial fluid functions as a transport medium for movement of nutrients, gases, waste products, and other substances between the blood and body cells. Acts as a back up fluid reservoir. ICF – 40% of body wt; rich in nutrients

6. Donald R Assuming Mr. R’s abdominal distention is ascites, the shift of intravascular fluid into his peritoneal cavity is referred to as: Third spacing Congestive failure Edema peritonitis Third spacing Congestive failure – generally associated with heart disease Edema – generalized fluid volume overload, not necessarily in interstitial spaces Peritonitis – infection of abd cavityThird spacing Congestive failure – generally associated with heart disease Edema – generalized fluid volume overload, not necessarily in interstitial spaces Peritonitis – infection of abd cavity

7. Donald R As Mr. R’s BP decreases, the baroreceptors will trigger Renal vasodilatation Increased HR Suppression of ACTH release Peripheral vasoconstriction Peripheral vasoconstriction – to hold onto the fluids to maintain volume ACTH – adrenocorticotropic hormone – from renal and endocrine systemsPeripheral vasoconstriction – to hold onto the fluids to maintain volume ACTH – adrenocorticotropic hormone – from renal and endocrine systems

8. Donald R Mr. R’s urine output has been 25 ml / hour for the past two hours. His most current serum osmolality is 315 mOsm / L. He is c/o extreme thirst. Oliguria present – risk of ARF at this point in timeOliguria present – risk of ARF at this point in time

9. Donald R Based on the available data, his urine output and serum osmolality are most likely due to: Renal failure Peripheral edema Suppressed ADH release Intravascular fluid deficit Intravascular deficit – a high serum Mosm suggests FVD or hemoconcentration, meaning there is less fluid than solutes in the serum. Can be used as a need to determine need for IV fluids ADH – vasopressin. When serum mOsm is increased, ADH increases permeability of renal tubules, allowing for more water to be reabsorbedIntravascular deficit – a high serum Mosm suggests FVD or hemoconcentration, meaning there is less fluid than solutes in the serum. Can be used as a need to determine need for IV fluids ADH – vasopressin. When serum mOsm is increased, ADH increases permeability of renal tubules, allowing for more water to be reabsorbed

10. Donald R His thirst is activated by Hemodilution Release of aldosterone Increased osmolality ADH release Increased osmolalityIncreased osmolality

11. Donald R Mr. R has a serum albumin drawn. The results show a significantly low albumin level. Serum albumin – measurement of absorbed nutrients in blood; easily lost nutrient during acute illnessSerum albumin – measurement of absorbed nutrients in blood; easily lost nutrient during acute illness

12. Donald R A low serum albumin directly alters the movement of solutes in what way? Fluids escape out of the capillaries Fluids are drawn into the capillaries Fluids escape out of the interstitial spaces Fluids are drawn into the interstitial spaces Fluids escape out of the capillaries – pressure is exerted by plasma proteins as they flow through the capillary to draw fluid into the capillaryFluids escape out of the capillaries – pressure is exerted by plasma proteins as they flow through the capillary to draw fluid into the capillary

13. Donald R It is decided that Mr. R requires IV fluids

14. Donald R Which type of IV solution would be best for treating intravascular fluid deficit? Hypertonic solutions Isotonic solutions Hypotonic solutions Colloid solutions Isotonic solutions – ie – NS – same as normal serum statusIsotonic solutions – ie – NS – same as normal serum status

15. Donald R Mr. R receives an IV fluid to increase his intravascular volume and increase his arterial blood pressure. The best IV fluid to accomplish this goal is: 5% dextrose in NS 0.45% NS 5% dextrose in H2O 0.2% NS 5% DEXTROSE IN WATER – isotonic solution. Used when rapid expansion is needed. Most common reason is IVF deficit. 5% dextrose in NS – generally found as 5% dextrose in 0.45% NS – used for tx of water intoxication, hyponatremia - hypertonic 0.45% NS – hypotonic – used for ICF deficit; fluid shifts into IC compartment 0.2% NS – also hypotonic5% DEXTROSE IN WATER – isotonic solution. Used when rapid expansion is needed. Most common reason is IVF deficit. 5% dextrose in NS – generally found as 5% dextrose in 0.45% NS – used for tx of water intoxication, hyponatremia - hypertonic 0.45% NS – hypotonic – used for ICF deficit; fluid shifts into IC compartment 0.2% NS – also hypotonic

16. Donald R Mr. R has received a large volume of IV fluids. His serum electrolytes are now: Na 128 mEq/L Cl 90 mEq/L Total Ca 11.2 mg/dL K 5.2 mEq/L Mg 3.2 mg/dL Po4 2.0 mg/dL Na – low Cl – low Ca – high K – upper end of high nL Mg – high Po4 - lowNa – low Cl – low Ca – high K – upper end of high nL Mg – high Po4 - low

17. Donald R Mr. R’s Na can cause body water to shift from the Extracellular into intravascular compartment Interstitial into intravascular compartment Extracellular into intracellular compartment Intracellular into extracellular compartment ECF to ICFECF to ICF

18. Donald R Mr. R’s Ca level is 11.2 mg/dL. This level is most likely caused by his: Renal status Nutritional status Chloride status immobilization Immobilization – causes bone breakdownImmobilization – causes bone breakdown

19. Donald R Should Mr. R’s K level approach 7 mEq/L, you would be most concerned with CV changes Respiratory changes Neurological changes Renal damage CV changesCV changes

20. Donald R Why do you believe that Mr. R presents with hypomagnesemia? Hypercalcemia Chronic ETOH Starvation Acute pancreatitis All except high Ca hypoMg results from acute pancreatitis, starvation, ETOH abuse, burnsAll except high Ca hypoMg results from acute pancreatitis, starvation, ETOH abuse, burns

21. Donald R Mr. R’s hypophosphatemia can affect his musculoskeletal system in which of the following ways? Muscle spasm Joint pain Muscle weakness Muscle cramping Muscle weakness hypoPo4 causes causes weakness hyperPo4 causes weakness and cramping Joint pain is seen with hyperPo4Muscle weakness hypoPo4 causes causes weakness hyperPo4 causes weakness and cramping Joint pain is seen with hyperPo4