Question

Fluid, Electrolyte, and Acid-Base Balance

A new graduate nurse is assigned to work with a preceptor in the Emergency Department. It is a very busy day and it seems as if every patient, regardless of chief complaint, has an issue with fluid, electrolyte, and/or acid-base balance.

Patient 1:

The first patient the nurse sees is a 37-year-old landscaper who is brought to the ED after collapsing on a job at the local country club. He is slightly confused but is able to state that he feels dizzy and weak. His skin is flushed, dry, and with poor turgor. He has dry, sticky mucous membranes. The preceptor identifies a nursing diagnosis of deficient fluid volume.

1. Describe how each of the following would change (increase or decrease) and the rationale for the change in the presence of deficient fluid volume:

Heart rate

Blood pressure

Serum hematocrit

Urinary output

Urine specific gravity

BUN

Weight

                       

Parameter	Expected Change	Rationale
Heart rate
Blood pressure
Serum hematocrit
Urinary output
Urine specific gravity
BUN
Weight

The ED provider orders IV fluids for this patient. The preceptor initiates an IV site and starts the fluids. The fluid order is to start 1000 mL of NS as ordered at 150 mL/hr. The infusion tubing has a drop factor of 15 gtt/mL.

2. This infusion will run by gravity rather than an infusion pump. How many drops per minute should the nurse time the infusion at to ensure the correct hourly rate?

3. A few minutes later, when the IV flow is checked, the nurse finds that it is not dripping. List at least 5 things the nurse should do to troubleshoot the IV flow.

The nurse is able to restore the IV flow. After 30 minutes of the infusion, the patient states, "My arm where the needle is feels funny."

4. What are the nurse’s priority actions? What further data should the nurse collect from the patient?

5. The patient is discharged after adequate hydration. Discharge teaching includes ways to prevent this from happening again on the job. What key points should the nurse include in the individualized teaching applicable to the job site?

Patient 2:

The next patient is a 76-year-old patient who presents with a chief complaint: "I can't sleep at night—I can't lie down, I get so out of breath." She is sitting in high Fowler's position on the exam table. She has a history of heart problems. She is diagnosed with acute exacerbation of congestive heart failure, and the preceptor identifies a nursing diagnosis of Fluid Volume Excess.

The physician gives the following orders:

NS at 125 mL/hr, Use infusion pump

Furosemide (Lasix) 80 mg IV now

Potassium citrate (K-Lyte) 10 mEq orally now and q4h × 2 doses

O₂ 2–5 LPM to keep O₂ sat greater than 92%

1. Which order should the nurse question? Why?

2. What is the term should the nurse use to document the patient's chief complaint regarding her breathing?

3. Besides the respiratory difficulty exhibited by the patient, what specific manifestations of fluid volume excess would the nurse look for on assessment?

4. What assessments and outcome data will the nurse use to determine if the interventions to reduce the fluid volume excess have been effective?

The patient was diuresed and is ready for discharge. Discharge orders include a low-sodium (2000 mg/day) diet and a fluid restriction of 1500 mL/day.

5. Describe discharge teaching necessary to help her manage her fluid restriction of 1500 cc per day.

Patient 3:

A young woman is brought to the Emergency Department by a neighbor who noticed her sitting, confused, on her front steps. The patient is a 24-year-old female and unable to give a valid history at this time. Admission data include the following:

Neurological: Confused

Pulmonary: Respirations 28 breaths/min and shallow, lungs clear

Cardiovascular: Irregular rapid pulse, palpitations

Gastrointestinal: Hypoactive bowel sounds

Musculoskeletal: Muscle weakness, cramps, fatigue

1. The preceptor identifies a nursing diagnosis of risk for decreased cardiac output related to electrolyte imbalance. What is the electrolyte imbalance that is being presented by this patient?

In light of the patient's confusion and the severity of the other symptoms, the ED provider orders a STAT BMP and the electrolyte imbalance is confirmed. Orders are given for replacement therapy to begin immediately.

2. What is a BMP and how will this test give the provider give the provider information about the patient’s electrolyte status? What is the normal range for the electrolyte the ED staff suspects may be out of balance?

3. What medication will the nurse anticipate to be ordered to correct this electrolyte problem and by what route should it be given? What are nursing responsibilities specific to the administration of this medication?

Due to a bed shortage, the patient remains in the ED for treatment for the next 12 hours. At that time her confusion has cleared and her apical pulse is now regular though still somewhat tachycardic at 102 beats/min. She tells the nurse she had been using her grandmother's "water pills" to help her lose weight.

4. What is the significance of this information?

5. It is decided to discharge her home with instructions regarding dietary intake to ensure good serum levels of the compromised electrolyte. What foods should be included in these instructions?

Patient 4:

The next patient to arrive is an 85 year old woman who was brought to the ED following three days of nausea, vomiting and diarrhea.

1. What electrolyte imbalances might the nurse expect to be present? What fluid imbalance is most likely present?

2. What are the nurse’s priority assessments to determine the presence of a fluid imbalance?

3. Given the patient’s symptoms, age, and the fluid imbalance that is likely present, what safety factors must the nurse consider when planning and delegating nursing care?

4. What acid/base imbalances might the nurse expect to be present and why?

5. Why are older adults particularly at risk for developing dehydration?

6. If IV fluids are ordered, what special precautions must be taken due to the patient’s age?

Patient 5:

A 24-year-old with diabetic ketoacidosis is admitted to the ED and his blood glucose on arrival was 780.   He has been started on an insulin drip and has received one amp of bicarb. The nurse will be doing finger stick blood sugars every hour.

ABG results are:

pH= 7.31

PaCO2= 25 mm/Hg

HCO3=12 mmol/l

1. The graduate nurse asks the preceptor to help with interpretation of the blood gases. How should the preceptor interpret these values and explain the reasons for the changes?

Patient 6:

A 75-year-old man with a long history of severe acute chronic obstructive pulmonary disease (COPD) is admitted to ED with fever, confusion and significant respiratory distress. He lives alone but his neighbor says he has been unwell for a week and has deteriorated over the previous 4 days. There is a long history of heavy smoking.

ABG results are:

pH 7.21

pCO2 70 mmHg

pO2 75 mmHg

HCO3 27 mmol/l

1. Again, the graduate nurse asks the preceptor to help with interpretation of the blood gases. How should the preceptor interpret these values and explain the reasons for the abnormal values?

Patient 7:

The last patient the nurse sees today presents to the ED with a complaint of chest tightness, tingling in the hands, and headache. He has noticeable trembling of the hands. He states, "I swear I think I am having a heart attack!" His vital signs are BP 162/88 – 104 – 32 and afebrile. The ED provider orders laboratory work including cardiac panel, chemistry panel, CBC, and arterial blood gases (ABGs). The provider tells the nurse "I think he is having an anxiety attack."

1. What would the nurse anticipate the ABG results to be if this diagnosis is correct? What disorder would be present and what are the possible increased or decreased values?

2. What interventions would the nurse use to assist the patient to compensate for this acid-base disorder?

Answer 1

Question 1

Parameter:

Heart rate: 90-120 bt/min

Rational: heart rate will be higher side due to dehydration, when there fluid deficiency demand will increase from body it leads to tachycardia

Blood pressure: 90/60 to 110/70  

Rational: due to lack of fluid blood pressure will be lower side

Hematocrit : 55% to 65%

Rational: Hematocrit is the ratio of the volume of red blood cells to the total volume of blood. when you become dehydrated, total blood volume decreases while the number of RBC packed in it stays the same. you are not bleeding and losing cells they are just being packed tighter.

Urine output 0.5cc/kg/hr or less than that

Rational: Dehydration is most common cause of decreased urine output. Typically, dehydration occurs

Urine specific gravity: >1.035

Rational: Urine specific gravity will increases an excess of ADH cause A specific gravity greater than 1.035 with frank dehydration.

Blood urea Nitrogen BUN: >20mg/dl

Rational: there is lack of fluid volume to excrete to waste products