Case Study: Acid-base Balance and Electrolytes Essay Paper
CASE STUDY:
A nurse is taking care of an 85-year-old woman in a hospital-based skilled nursing facility. In the 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:
Blood Chemistries Case Study: Acid-base Balance and Electrolytes Essay Paper
• Na: 147
• Cl: 110
• K: 4.0
Arterial Blood Gases
• pH: 7.33
• PCO2: 48
• HCO3: 27
• PO2: 96
Urinalysis
• Urine Specific Gravity: 1.040
Address the following:
1. Identify each of the abnormal laboratory findings in the above results. Specify how they differ from a normal range and identify what condition each abnormality indicates.
2. What specific electrolyte disturbance does the patient have?
3. What clinical manifestations would the nurse expect to see with this electrolyte abnormality presented above?
4. If the patient had an increase in her potassium level, for what clinical manifestations would the nurse monitor?
5. What blood gas abnormality is seen in this patient? Discuss the rationale for your answer.
6. What are the three major mechanisms of pH regulation?
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.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Rubric:
• Identification of the abnormal laboratory findings is accurate, supplemented by a detailed and thorough identification of the conditions each abnormality indicates.
• Identification of the electrolyte disturbance is correct.
• Identification of electrolyte abnormality clinical manifestations is accurate, supported by thorough and detailed insight.
• Identification of increased potassium level clinical manifestations is accurate, supported by detailed and thorough insight.
• Assessment of blood gas abnormality is accurate, supported by a detailed and thorough discussion of the patient’s condition.
• The three major mechanisms of pH regulation are accurately identified, and the properties of each mechanism are briefly described. Case Study: Acid-base Balance and Electrolytes Essay Paper
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From the laboratory values given, the sodium level is increased at 147mEq/L. The normal values of potassium range from 135-144mEq/L. Elevated levels of sodium denote a condition called hypernatremia. The pH of blood is reduced to 7.33. The normal values range from 7.35 to 7.45. Blood pH levels below the lower limit of the normal values indicate acidosis, as in this patient’s case. The PCO2 is also elevated at 48. The normal values range from 35-45mmHg. An elevated PCO2 is a diagnostic finding of hypercapnia. This means that the patient doesn’t have an adequate exchange of air and is retaining CO2. The normal values for urine-specific gravity are 1.016 – 1.022. The values obtained from this patient indicate that she has an elevated urine specific gravity at 1.040. This is a sign of more solute in urine, which may result from dehydration (McCance & Huether, 2019). All other laboratory values are within the normal range.
The only electrolyte imbalance the patient has is Hypernatremia. It is a hyperosmolar state due to a decrease in the amount of water in the body relative to sodium content. It is common in elderly patients with restricted water access or increased fluid loss (Wörnle,2021). The clinical manifestations that may be expected include confusion, lethargy, abnormal speech, irritability, seizures, abnormal jerks, and general cognitive dysfunction. This is due to effects on the nervous system, which results in neuronal shrinkage. Hypernatremia is also characterized by dehydration, and the patient may have symptoms that are synonymous with volume depletion. Symptoms of volume depletion include orthostatic hypotension, oliguria, dry skin, dry mucosal surfaces such as the oral mucosa, abnormal skin turgor, and tachycardia. Generalized weakness is also another clinical symptom that may be seen in the patient (Wörnle,2021). Case Study: Acid-base Balance and Electrolytes Essay Paper
Potassium levels are considered elevated if the values are above 5.0mEq/L in adults. This condition is referred to as hyperkalemia. The clinical manifestations of hyperkalemia vary according to the concentration levels of potassium. Levels higher than 7 mEq/L can present with neurologic and hemodynamic complications. Levels above 8.5 mEq/L can be fatal as it can cause cardiac arrest or respiratory paralysis (Palmer & Clegg, 2017). Symptoms of hyperkalemia are usually nonspecific. The most common symptoms are weakness and fatigue. Symptoms are usually related to muscular and cardiac dysfunction. Patients will present with dyspnea, palpitations, chest pain, and muscle paralysis. Examination of the patient may reveal bradycardia which may be due to heart block. The patient may also have a faster respiratory rate due to weakness of the respiratory muscles. An ECG is vital in monitoring patients with hyperkalemia. An ECG may reveal arrhythmias. The T-wave may also be peaked with a narrow base. Another ECG finding is the shortening of the QT interval and depression of the ST segment. Other ECG findings include small or absent P wave, wide QRS, prolonged PR interval, and augmented R wave (Palmer & Clegg, 2017). The fluid status of the patient should also be monitored. This includes tracking both the input and output. The electrolyte levels should be monitored regularly to assess for worsening of hyperkalemia. Excess electrolytes are excreted via the kidney. Monitoring kidney function is therefore vital. Arterial and venous blood gas should also be monitored for signs of acidosis.
The blood gas abnormality seen in this patient is respiratory acidosis. Respiratory acidosis results from alveolar hypoventilation, which causes an acid-base balance disturbance. CO2 is produced, and because of poor ventilation, most of it is retained in the body. This results in an increase in PCO2, i.e., hypercapnia. The normal range for PCO2 is 35-45 mmHg. An increased PCO2 lowers the ratio of bicarbonate (HCO3–) to PCO2. The net effect is a reduction in pH hence acidosis (Seiler et al., 2019). The pH level of this patient is 7.33. This falls below the normal range for pH, which is 7.35-7.45. The etiology of respiratory acidosis is multifactorial, ranging from CNS depression which causes hypoventilation, to lung diseases such as COPD, pulmonary edema, and pneumonia. Other factors include obesity, obstructive sleep apnea, hypermetabolic states such as thyroid crisis and sepsis. Treatment of respiratory acidosis in this patient includes improving ventilation.
The pH of blood measures the level of acidity or alkalinity. The normal pH ranges from 7.35 to 7.45. This pH is maintained at this level by a number of systems that kick in to compensate for any imbalances. These systems include the renal system, the respiratory system, and the cellular ion exchange system. The following equation governs the regulation of body pH: CO2 + H2OÛ H2CO3 Û H+ + HCO3 (McCance & Huether, 2019). An imbalance in any of the equation parameters prompts the systems to kick in. The respiratory system controls CO2 levels in the body. A decrease in pH triggers hyperventilation, leading to the expulsion of more CO2 and thus a reduction in H+ formation. This increases the blood pH back to normal. This mechanism acts inversely when the pH is high. Response from the respiratory mechanism is almost immediate to pH changes. The renal system responds to changes in the H+ levels. More H+ reduces the Ph of blood. This prompts the kidney to excrete more H+ in urine to restore the pH balance. HCO3, on the other hand, is reabsorbed by the kidneys to increase the pH of the blood. Response from the renal mechanism is slow and may take days to kick in. The cellular ion-exchange mechanism acts by exchanging H+ with another positively charged ion such as K+. This reduces the amount of H+ in blood. This system may cause hyperkalemia or hypokalemia (McCance & Huether, 2019). Case Study: Acid-base Balance and Electrolytes Essay Paper
References
Chong, W. H., Saha, B. K., & Medarov, B. I. (2021). Comparing Central Venous Blood Gas to Arterial Blood Gas and Determining Its Utility in Critically Ill Patients: Narrative Review. Anesthesia and Analgesia, 133(2), 374–378. https://doi.org/10.1213/ANE.0000000000005501
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in adults and children. St. Louis, MO: Elsevier Inc
Palmer, B. F., & Clegg, D. J. (2017). Diagnosis and treatment of hyperkalemia. Cleveland Clinic Journal of Medicine, 84(12), 934–942. https://doi.org/10.3949/ccjm.84a.17056
Seiler, F., Trudzinski, F. C., Kredel, M., Lotz, C., Lepper, P. M., & Muellenbach, R. M. (2019). Update: akute hyperkapnische respiratorische Insuffizienz [Update: acute hypercapnic respiratory failure]. Medizinische Klinik, Intensivmedizin und Notfallmedizin, 114(3), 234–239. https://doi.org/10.1007/s00063-017-0318-5
Wörnle M. (2021). Hypernatriämie [Hypernatremia]. MMW Fortschritte der Medizin, 163(20), 56–57. https://doi.org/10.1007/s15006-021-0457-8 Case Study: Acid-base Balance and Electrolytes Essay Paper
