Question

ELECTROLYTE IMBALANCES:

Several patients were admitted in the medical ward. Answer the following questions pertinent to the patients’ conditions.

PATIENT A–Presented in the emergency department with severe headache, irritability, and tremors after finishing a full marathon. Laboratory values reveal Serum sodium level of 130 mEq/L.

PATIENT B–Presented in the emergency department with severe body malaise, diminished bowel sounds, and ECG reveals an extra U-wave in the tracing after 8 bouts of watery diarrhea. Laboratory values further reveal a Serum potassium level of 3.0 mEq/L.

PATIENT C–A post thyroidectomy patient presented with severe muscle cramps and prolongation of QT-interval in the ECG and was referred to the medical consultant for co-management. Serum calcium level is 4.0 mEq/L.

PATIENT D–A patient receiving magnesium for the management of seizure disorder suddenly presented with depressed deep tendon reflex and becomes stuporous. Laboratory values reveal a Serum Magnesium level of 2.6 mg/dL.

1. Given the Patient B’s presentation, trace the pathophysiological cause of the decrease in serum potassium level.
2. What will be the emergency medication that should be readily available in managing the disorder apparent for Patient D?
3. Explain the relationship of thyroid surgery and the development of hypocalcemia in Patient C.
4. Explain the relationship of Patient A’s prior activity and the development of hyponatremia.
5. Explain the mechanism behind the development of prolonged QT –interval for Patient C.
6. Enumerate at least one (1) nursing diagnosis for Patient A, B, C, and D.

ACID-BASE IMBALANCES:

Multitude of patient’s conditions can predispose them to different acid-base imbalances. Several patients were admitted in the medical-surgical ward and are put under your care. Answer the following questions pertinent to the patients’ conditions.

PATIENT A–admitted in the medical ward 30 minutes ago with chief complaint of severe dizziness and vertigo accompanied by frequent vomiting. As the patient moves, vomiting follows which is now recorded to be 7-8 times from the time of admission. Diphenhydramine 1 ampule TIV and metoclopramide 1 ampule TIV as stat doses were given to the patient.

PATIENT B–a dialysis patient who have stopped attending his dialysis session was admitted in the ward due to changes in sensorium. Serum creatinine level is elevated as well as the Blood Urea Nitrogen (BUN). Shallow respiration is noted upon the assessment of the patient.

PATIENT C–a patient was rushed to the emergency department and later was admitted to the ward with chief complaint of shortness of breath, numbness and tingling around mouth and fingers, and lightheadedness after taking a major examination in school. The patient was offered a brown bag by the admitting nurse.

PATIENT D–A patient with emphysema as admitted in the ward due to difficulty of breathing. The patient appears reddish and is complaining of lightheadedness. The patient was immediately hooked to oxygen therapy at 2 Lpm. Choose from the following ABG results which will be consistent with the patient’s condition:

A.pH 7.50 PaC02 31 HCO3 17

B.pH 7.30 PaC02 30 HCO3 18

C.pH 7.48 PaC02 49HCO3 30

D.pH 7.32 PaC02 50 HCO3 28

1. Patient A: __
2. Patient B: __
3. Patient C: __
4. Patient D: __
5. Explain why Patient B presented with shallow respiration in relation to the patient’s condition.
6. Explain why Patient D experiences lightheadedness and why the patientappears reddish in relation to the patient’s condition.
7. Explain the purpose of offering brown bag to Patient C as an emergency management for the patient’s condition.
8. Create a drug study for the medication: METOCLOPROMIDE specifying the following:

• Drug classification
• Mechanism of action
• Indication (*for the case of the patient mentioned above)
• Contraindication
• Side effects
• Nursing Considerations

Answer 1

Electrolyte Imbalance:

1. Pathophysiological cause of the decrease in serum potassium level:

Normal serum potassium level is 3.5 to 5.5 mEq/L. Potassium is an intracellular cation and its concentration in extracellular fluid is low.Patient's with diarrhea develops loss of large amount of K⁺ due to fecal loss. If the patient already have low potassium levels before diarrhea, frequent episodes of diarrhea can cause severe hypokalemia leading generally to cardiac arhythmias,paralytic ileus and muscle weakness.

2.Normal magnesium level is 1.7 to 2.2 mg/dL. For patient D Magnesium level is 2.6mg/dl that indicates hypermagnesemia.Manifestations are flaccid paralysis of muscles, hyporeflexia,breathing difficulty,hypotension,bradycardia and lethargy. Delirium,Coma and cardiac arrest can happen at even more higher levels. Emergency drug to be infused in such case is Calcium gluconate as it can prevent cardiac complications. Diuretics like furosemide can also be administered to aid in magnesium excretion along with adequate IV fluids to prevent hypovolemia.

3. During a thyroid surgery if accidental removal or damage happens to one or more parathyroid glands, it can result in hypocalcemia. Parathyroid glands releases Parathyroid hormone which stimulates release of stored calcium from bones to blood stream. Normal serum calcium level is 4.3 to 5.3 mEq/L. The patient C has a calcium level of 4 mEq/l that indicates hypocalcemia.

4. Normal serum sodium level is 135 to 145 mEq/l. Patient A have a sodium level of 130 mEq/l which indicates hyponatremia. Following excessive physical activity Patient A might have consumed enormous amount of water to prevent dehydration. Along with this, there may be excessive loss of sodium chloride through sweat. Increased physical activity lead to non osmotic AVP (vasopressin) secretion[vasopressin causes water retention by kidneys that causes dilution of sodium,decreasing it's concencentration leading to hyponatremia]. All of these leads to significant sodium depletion and associated symptoms.

5. In hypocalcemia there will be prolonged QT interval related to lengthening of ST segment which is inversely propotional to the serum calcium level.

6. Nursing diagnosis:

Patient A: Sodium imbalance(hyponatremia) related to excessive physical activity as evidenced by headache,tremors and irritability,low lab values of Sodium 130mEq/l.

Patient B: Electrolyte imbalance(hypokalemia) related to excessive fluid loss through stools as evidenced by ECG changes,diminished bowel sounds and malaise.

Patient C:Calcium imbalance(hypocalcemia) related to thyroid surgery as evidenced by muscle cramps and ECG changes, prolonged QT interval

Patient D: Magnesium imbalance (hypermagnesemia) related to daily intake of magnesium containing medication as evidenced by hyporeflexia and high lab value of magnesium 2.6mg/dl.

Acid Base Imbalance

1.Patient A: Option C- pH 7.48 PaC02 49 HCO3 30 - Metabolic alkalosis

Patient B: Option B- pH 7.30 PaC02 30 HCO3 18 - Metabolic acidosis

Patient C: Option A - pH 7.50 PaC02 31 HCO3 17- Respiratory alkalosis

Patient D : Option D - pH 7.32 PaC02 50 HCO3 28 - Respiratory acidosis

2. Due to failing functions of Kidney patient may have buit up of toxic waste materials inside body, fluid retention increasing cardiac workload, hemodilution and anemia causing reduced RBC count[RBC contains hemoglobin that carries oxygen to cells] all these contributing to shallow breathing.

3. Emphysema causes increased air space in the lungs and destruction of the walls of the alveoli. Due to airflow limitation capillaries gets congested and patient will have a reddish appearance.Decreased oxygen rich blood supply to brain can lead to hypoxia,light headedness and CNS tissue damage.

4. Brown bag medicine review helps to evaluate the possibility of drug interaction causing current symptoms, by going through the medications that the patient takes daily and also review the method of intake. This helps to identify misunderstanding about drug regimen, malpractice and errors leading to complications.

5.METOCLOPROMIDE

Drug classification: Prokinetic agents

Mechanism of action: it provides an antiemetic effect by antagonizing Dopamine 2 (central and peripheral) and serotin receptors in the chemoreceptor trigger zone in the area postrema of the brain.

Indications: Nausea,Vomiting,delayed gastric emptying,

Contra indications: Pheochromocytoma,Parkinsons disease

Side effects: headache,confusion,sleeplessness,exhaustion

Nursing consideration:

Assess for contraindications

Administer 30 minutes before meals to aid in better absorption

Assess for GI symptoms (nausea,vomiting,constipation)

Advice to rinse mouth frequently to avoid dryness