SYSTEM IMBALANCES Prepared by Ella Smelyanskaya, RN, BSN (2017)Fluid & Electrolyte i {Balance ob ost important nutrient for life. « Water= primary body fluid. Adult weight is 55-60% water. = Loss of 10% body fluid = 8% weight loss SERIOUS = Loss of 20% body fluid = 15% weight loss FATAL » Fluid gained each day should = fluid lost each day (2 -3L/day average) = What is the minimum output per hour necessary to maintain renal function? 30ml/hr_._| Functions of Body Fluid = Medium for transport = Needed for cellular metabolism # Solvent for electrolytes and other constituents = Helps maintain body temperature = Helps digestion and elimination = Acts as a lubricant Mechanisms of Fluid Gain and Loss Gain Loss = Fluid intake 1500ml = “Sensible” = Food intake 1000mI ae eereroal . Seen of nutrients Sweat 100m! (1OmI of H20 ser 100 Keal) | |» “Insensible” Not visible. SKin (evaporation) SOOM! Lungs 400ml | Feces 200m! |}Regulation of Fluids Hypothalmus —thirst receptors (osmoreceptors) continuosly monitor serum osmolarity (concentration). If it rises, thirst mechanism is triggered. +Vasopressin (AKA ADH )- increasing H20 reabsorption Pituitary regulation- posterior pituitary releases ADH (antidiuretic hormone) in response to increasing serum osmolarity. Causes renal tubules to retain H20. = Thirst is a late sign of water deficit “Regulation of Fluids (continued ) » Renal regulation- Nephron receptors sense decreased pressure (low osmolarity) and kidney secretes RENIN. Renin - Angiotensin I — Angiotensin II « Angiotensin II causes Na and H20 retention by kidneys AND..... = Stimulates Adrenal Cortex to secrete Aldosterone which causes kidneys to excrete K and retain Na and H20.he Geriatric Client -normal physiological aging results in decreased thirst mechanism decreased # of sweat glands decreased renal function -there also may be decreased mobility and/or cognitive function which impacts their ability to get adequate fluid intake. Variations in Body Fluids a Elderly: Have lower % of total body fluid than younger adults =» Women: Have lower % total body fluid than men Muscle tissue has more H20 content THAN adipose tissueFluid Compartments | ‘Intracellular | Extracellular Fluid fluid (ICF) = Fluid outside the cell. id inci = 1/3 of body's H20 . nie inside the tions tone ialioes cel = 3 types: = Most (2/3) of Interstitial- fluid the body’s H20 | around/between cells Pa Intravascular- (plasma is in the ICF. Haid Hocd vescas Transcellular —CSF, | Synovial fluid etc Consider this.... eo : » Age variations exist in regards to H20 content of fluid compartments = Infants = 60% of H20 is found in ECF 40% of H20 is found in ICF = What might this mean in regards to fluid loss for an infant? — Reverse of adults! Infant MORE PRONE to fluid Loss!luid Balance = Dynamic process = Balance between body fluids and electrolytes = Attraction between ions (electrolytes) and water (fluids) causes fluids to move across membranes and leave their compartments. | Solvent (H20) Movement = Cell membranes are semipermeable allowing water to pass through » Osmosis- major way fluids transported Water shifts from low solute concentration to high solute concentration to reach homeostasis (balance).Osmolarity Concentration of particles in solution The greater the concentration (Osmolarity) of a solution, the greater the pulling force (Osmotic pressure) Normal serum (blood) osmolarity = 280-295 mostne A solution that has HIGH osmolarity is one that is > serum osmolarity = HYPERTONIC solution A solution that has LOW osmolarity is one that is < serum osmolarity = HYPOTONIC solution A solution that has equal osmolarity as serum = ISOTONIC solution Hypertonic Fluids = Hypertonic fluids have a higher concentration of particles (high osmolality) than ICF = This higher osmotic pressure shifts fluid from the cells into the ECF = Therefore Cells placed in a hypertonic solution will shrinkPe | ‘Hypertonic Fluids = Used to temporarily treat hypovolemia « Used to expand vascular volume « Fosters normal BP and good urinary output (often used post operatively) ~. = Monitor for hypervolemia ! pt Not used for renal or cardiac disease. THINK — Why not? = D5% 0.45% NS = D5% NS =» D5% LR Pulmonary Edema 4 Hypotonic Fluids = Hypotonic fluids have less concentration of particles (low osmolality) than ICF = This low osmotic pressure shifts fluid from ECF into cells = Cells placed in a hypotonic solution will swellHypotonic Fluids Used to “dilute” plasma particularly in hypernatremia = Treats cellular dehydration = Do not use for pts with increased ICP risk or third spacing risk S = 0.45%NS = 0.33%NS ., |, Isotonic Fluid = Isotonic fluids have the same concentration of particles (osmolality) as ICF (275-295 mOsm/L) = Osmotic pressure is therefore the same inside & outside the cells = Cells neither shrink nor swell in an isotonic solution, they stay the same: | Isotonic Fluid = Expands both intracellular and extracellular volume = Used commonly for: excessive vomiting,diarrhea = 0.9% Normal saline T =» DSW ; = Ringer's Lactate | Consider this.... = When tissue injury occurs, proteins pathologically leak from the intravascular space into the intersititial space. Termed: Third spacing = This explains _ EDEMA as a sign of the inflammatory process. 10Solute Movement - | _Diffusion tet = Movement of solutes from high concentration to low concentration = It is a PASSIVE movement DOWN the concentration gradiant. (requires no energy) = Many body processes use diffusion. Example: 02 and CO2 exchange » Rate is affected by: concentration gradiant, permeability-surface area-thickness of membranes, and size of particles. (Fick’s Law) Solute Movement —other mechanisms « Active transport- requires energy (ATP) to move from low concentration to high concentration (uphill) Example: Na / K pump = May be enhanced by carrier molecules with binding sites on cell membrane Example: Glucose (Insulin promotes the insertion of binding sites for Glucose on cell membranes).Filtration = Solvent AND solute movement = Passage from an area of High Pressure to an area of Low Pressure Termed: Hydrostatic Pressure = Example: Arterioles have higher pressure than ICF Fluid, oxygen and nutrients move into cells Venules have lower pressure than ICF Fluid, carbon dioxide and wastes move out of cells Fluid volume deficit FVD . |4(Hypovolemia) » Loss of both H20 and electrolytes from ECF. = Causes include: Increased output, Hemorrhage, vomiting, diarrhea, burns, OR «= Fluid shift out of vascular space ( “third spacing” ) into interstitial spaces 12Dehydration « Isotonic dehydration = H20 & electrolyte loss in equal amounts; diarrhea and vomiting = Hypertonic dehydration = H20 loss greater than electrolyte loss; excessive perspiration, diabetes insipidus Assessment FVD - Hypovolemia Cardiovascular: = Diminished peripheral pulses; quality 1+(thready) = Decreased BP & orthostatic hypotension = Increased HR = Flat neck & hand veins in dependent position = Elevated Hematocrit (Hct) Gastrointestinal: = Thirst = Decreased motility; diminished bowel sounds, possible constipation 13Assessment fyb - Hypovolemia (continued) Ta Neuromuscular: Integumentary: = Decreased CNS activity = Dry mouth & skin (lethargy to coma) » Poor turgor (tenting) = Possible fever = Pitting edema = Skeletal muscle weakness» Sunken eyeballs = Hyperactive DTR Renal: » Decreased output = Increased spec grav of urine = Weight loss » Hypernatremia Respiratory: = Increased rate and depth Interventions for FVD - Hypovolemia a = Prevent further fluid loss = Oral rehydration therapy = IV therapy = Medications; antiemetics, antidiarrheals = Monitor CV, Resp, Renal, GI status = Monitor electrolytes — possible supplement rx = MONITOR WEIGHT and I &O 14NCLEX Practice a Intravenous fluids are ordered for your client who is experiencing diarrhea and vomiting for the past 2 days. Which IV solution would the nurse expect to see prescribed? DsNS 0.45%NS Ds1/2NS RL <= a b, c 4. Fluid Volume Excess Be la FVE - Hypervolemia = Fluid overload is an excess of body fluid - overhydration = Excess fluid volume in the intravascular area-hypervolemia » Excess fluid volume in interstitial spaces edema: al Fluid Volume Excess & uJ = Causes: = Increased Na/H20 retention = Excessive intake of Na (PO or IV) = Excessive intake of H20 ( PO or IV) (Water intoxication) = Syndrome of inappropriate antidiuretic hormone (SIADH) «= Renal failure, congestive heart failure Assessment LFVE - Hypervolemia S | (GI: Elevated pulse; 4+ Increased motility bounding, elevated BP, Stomach cramps distended neck & han Nausea & Vomiting veins, ventricular gallop (S3) Hyponatremia Rena R Weight gain esp: BP eo, Moist Decreased spec grav of Crackles,Tachypnea | | Neuromuscular: Integumentary: Altered LOC, headache, Periorbital edema skeletal muscle twitching Pitting or Non-pitting edema | 16Interventions FVE - Hypervolemia ‘Restore normal fluid balance, prevent further overload = Drug therapy; diuretics = Diet therapy; decrease Na & fluids = Monitor intake and output (I & O) = Monitor weights = Monitor electrolytes = Monitor CV, Resp, Renal systems 1 Electrolytes = Work with fluids to keep the body healthy and in balance = They are solutes that are found in various concentrations and measured in terms of milliequivalent (mEq) units = Can be negatively charged (anions) or Positively charged (cations) = For homeostasis body needs: Total body ANIONS = Total body CATIONS 17~ Cations Anions Positively charged Negatively charged + Sodium Na+ |J= Chloride Cl- » Potassium K+ = Phosphate PO4- » Calcium Ca++ + Magnesium Mg++ = Bicarbonate HCO3- = Regulate water distribution = Muscle contraction = Nerve impulse transmission = Blood clotting = Regulate enzyme reactions (ATP) = Regulate acid-base balance 18Sodium Na+ c— 5-145mEq/L = Major Cation = Chief electrolyte of the ECF = Regulates volume of body fluids » Needed for nerve impulse & muscle fiber transmission (Na/K pump) = Regulated by kidneys/ hormones yponatremia = Serum Na+ <135mEq/L = Results from excess of water or loss of Na+ = Water shifts from ECF into cells = S/S: abd cramps, confusion, N/V, H/A, pitting edema over sternum = Tx: Diet/IV therapy/fluid restrictions 19Lets think about ... Hyponatremia = What are some medical conditions that may cause a dilutional hyponatremia? CHF Renal Failure SIADH ( Cancer, pituitary trauma ) Addisons Disease ( hypoaldosteronism & Na loss ) What are some conditions that might cause actual loss of sodium from the body? Gi losses = nasogastric suctioning, vomiting, darthea Certain diuretic therapies Permanent neurological damage can occur when serum Na levels fall below 110 mEa/L.. Why? Hypotonic environment swells cells, increasing ICP ~ brain damage Serum Na+> 145mEq/L. = Results from Na+ gained in excess of H2O OR Water is lost in excess of Na+ » Water shifts from cells to ECF = S/S: thirst, dry mucous membranes & lips, oliguria, increased temp & pulse, flushed skin,confusion = Tx: IV therapy/diet 20Let’s think about. q Hypernatremia = What are some medical conditions that may cause elevated serum Na? Renal failure Diabetes Insp idus Diabetes Melitus (hyperglycemic dehydration) Cushings syndrome (hyperaldosteronism) What are some other patient populations at risk for hypernatremia? Elderly ( decreased thirst mechanism ) Patient's receiving: -tube feedings -corticosteroid drugs -certain diuretic therapies Seizures, coma, death my result if hypernatremia is left untreated. Why? Cells loose fluid inta the ECE causina irreversible cell damane Critical Thinking jt Hypo / Hyper Natremia a For the client experiencing FVD and hypernatremia | excessive intake of water, d/t excessive water loss, which IV solution would you |_| which IV solution would expect the physician to you expect the physician order? to order? For the client experiencing FVE & hyponatremia d/t D5NS. =— a D5 %2NS NS » DSRL DSW « DSW Ya NS 4 %2NS <== 21. otassium = K+ is = 3.5-5.0 mEq/L «= Chief electrolyte of ICF = Major mineral in all cellular fluids » Aids in muscle contraction, nerve & electrical impulse conduction, regulates enzyme activity, regulates IC H20 content, assists in acid-base balance = Regulated by kidneys/ hormones = Inversely proportional to Na Hypokalemia = Serum level < 3.5mEq/L = Results from decreased intake, loss via GI/Renal & potassium depleting diuretics « Life threatening-all body systems affected = S/S muscle weakness & leg cramps, decreased GI motility, cardiac arrhythmias = Tx: diet/supplements/IV therapy 22Lets think about ... la Hypokalemia a hoe = What are some medical conditions that may cause 2 hypokalemia? Renal Disease / CHF (dilutional) Metabolic Alkalosis Cushings Disease ( Na retention leads to K loss ) What are some conditions that might cause actual loss of potassium from the ody? I losses — nasogastric ductioning, vomiting, diarrhea Certain diuretic therapies Inadequate intake — ( body cannot conserve K, need PO intake) Cardiac arrest may occur when serum K levels fall below 2.5, mEq/L. Why? Increased cardiac muscle irritability leads to PACS and PVCs, then AF (Hyperkalemia = Serum level >5 mEq/L = Results from excessive intake, trauma, crush injuries, burns, renal failure = S/S muscle weakness, cardiac changes, N/V, parathesias of face/fingers/tongue = Tx:diet/meds/IV therapy/ possible dialysis 23Lets think about ... Hyperkalemia What are some medical conditions that may cause hyperkalemia? Renal Disease=most common cause Burns and other major tissue trauma Metabolic Acidosis Addison's Disease ( Na loss leads to K retention ) What are some conditions that might cause potassium levels to rise in the body? Certain diuretic therapies Excessive intake — ( inappropriate supplements) Cardiac arrest may occur when serum K levels rise above mEq/L. Why? Decreased electrical impulse conduction leads to bradycardia and eventual asystole. Critical Thinking Potassium IV additives Which of the following interventions will the nurse undertake when administering parenteral K additives? Monitor the IV site for phlebitis © Place on cardiac monitor if > 10 mEq @ Assure of adequate mixing of K in solution © Monitor for elevated K levels @ Monitor for decreased Na levels Administer potassium by slow IV ethod pe y ee 24= Most abundant in body but: 99% in teeth and bones = Needed for nerve transmission, vitamin B12 absorption, muscle contraction & blood clotting = Inverse relationship with Phosphorus = Vitamin D needed for Ca absorption Hypocalcemia . Serum Ca < 4.3mEq/L = Results from low intake, loop diuretics, parathyroid disorders, renal failure » S/S osteomalacia, EKG changes, numbness/tingling in fingers, muscle cramps / tetany, seizures, Chovstek Sign & Trousseau Sign = Tx: diet/IV therapy 25| {Chovstek | Trousseau | Lets think about ... Hypocalcemia » What are some medical conditions that may cause hypocalcemia? Hypoparathyroidism (low PTH levels = decreased release of Ca from bones) S/P thryoid surgery ( low Calcitonin = decreased release of Ca from bones) Acute pancreatitis Crohns Disease Hyperphosphatemia ( ESRF) What are some other conditions that might cause low Ca? GI losses — nasogastric suctioning, vomiting, diarrhea Long term immobilization Lactose intolerance If hypocalcemia is prolonged, the body will utilize stored Ca from bones. What complication might arise? Fractures / late sian 26Hypercalcem = Serum Ca > 5.3mEq/L = Results from hyperparathyroidism, some cancers, prolonged immobilization = S/S muscle weakness, renal calculi, fatigue, altered LOC, decreased GI motility, cardiac changes = Tx: medication/ IV therapy Lets think about ... Hypercalcemia What are some medical conditions that may cause hypercalcemia? Hyperparathyroidism (high PTH levels = increased release of Ca from bones) Paget's Disease Some Cancers ~ Multiple Myleoma Chronic Alcoholism ( with low serum phosphorus ) What are some other conditions that might cause low Ca? Excessive intake of Ca OR Vitamin D Excessive intake of OTC antacids If hypercalcemia is uncorrected, AV block and cardiac arrest may occur, 27.. |i Magnesium Mg2+ ot = 1,5-2.5mEq/L = Most located within ICF = Needed for activating enzymes, electrical activity, metabolism of carbs/proteins, DNA synthesis » Regulated by intestinal absorption and kidney ypomagnesemia Serum < 1.5mEq/L « Results from decreased intake, prolonged NPO status, chronic alcoholism & nasogastric suctioning = S/S: muscle weakness, cardiac changes, mental changes, hyperactive reflexes & other hypocalcemia S/S. = Tx: replacement IV therapy’ restore normal Ca levels ( Mg mimics Ca) seizure precautions 28Hypomagnesemia = Common in critically ill patients = Associated with high mortality rates = Increases cardiac irritability and ventricular dysrhythmias - especially in patients with recent MI = Maintenance of adequate serum Mg has been shown to reduce mortality rates post MI lypermagnesemia = Serum>2.5mEq/L » Results from renal failure, increased intake = S/S: flushing, lethargy, cardiac changes (decreased HR),decreased resp, loss of deep tendon reflexes = Tx: restrict intake diuretic rx 29ke = 95-105mEq/L » Most abundant anion in ECF = Combines with Na to form salts = Maintains water balance, acid-base balance, aids in digestion (hydrochoric acid) & osmotic Pressure (with Na and H20) » Regulated by kidneys = Follows Sodium (Na) _ |Chloride Cl _Hypochloremia = Serum level 96mEq/L = Results from prolonged vomiting & suctioning = S/S metabolic alkalosis, nerve excitability, muscle cramps, twitching, hypoventilation, decreased BP if severe = Tx: diet/IV therapy 30\g ay typerchloremia = Serum level > 106mEq/L Results from excessive intake or retention by kidneys — metabolic acidosis = S/S Arrhythmias, decreased cardiac output, muscle weakness, LOC changes, Kussmauls’s respirations = Tx: restore fluid & electrolyte balance : {Phosphate PO4- fe = 2.5-4.5mg/dl » Needed for acid-base balance,neurological & muscle function, energy transfer ATP & affects metabolism of carbs/proteins/lipids, B vitamin synthesis = Found in the bones = Regulated by intake and kidneys «= Inversely proportional to Calcium Therefore some regulation by PTH as well 31|. Hypophosphatemia = Serum level < 1.8mEq/L = Results from decreased intestinal absorption and increased excretion = S/S bone & muscle pain, mental changes, chest pain, resp. failure = Tx: Diet/ IV therapy ‘“Hyperphosphatemia Serum level> 2.6mEq/L Results from renal failure, low intake of calcium S/S: neuromuscular changes (retary EKG changes, parathesia-fingertips/mout! Tx: Diet; hypocalcemic interventions Medications: phosphate binding « The body can tolerate hyperphosphatemia fairly well BUT the accompanying hypocalcemia is a larger problem! 32= This means to maintain balance... to control by balancing the dietary intake of electrolytes with the renal excretion and reabsorption of electrolytes ‘Interventions for F/E balance = Assess patient carefully- note changes = Monitor 1& O (Intake & Output) = Monitor weight changes « Monitor urine = Monitor vs = Monitor lab results and dx test = Maintain proper IV therapy 33Volume/Time - IV Drop Rate Given a certain amount of liquid, a time period, and a drop factor (atts/mL.), what is the necessary IV flow rate in attsimin? Fomnuta ‘Volume (mL) | Time (min) Example: Calculate the WV flow rate for 1200 mL of NS to be infused in 6 hours, The infusion sels calibrated for a drop factor of 15 gtts/mt. Volume (mL) Time (min) Convert 6 hours fo minutes. + mine (xby 60) + 6x60 = 360 min 1200 ral 45 gusimt. = [50 ita] 360 min x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min) x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min) Example: Calculate the IV flow rate for 200 mL of 0.9% NaCI IV over 120 minutes. Infusion set has drop factor of 20 gtts/ml. Volume (mL) Fi tt: = Ri tts it Time (min) % DPP Factor (gtts/mL) = Y (Flow Rate in gtts/min) 200 mL 120 min x 20 gtts/mL =Osmosis Osmosis is the diffusion of water from an area of high concentration to an area of low concentration across a membrane. Cell membranes are completely permeable to water and the amount of water in the environment has a large effect on the survival of a cell. The picture shows a tube separated by =) a membrane and how the water moves from an area of high concentration to an area of low. The process of osmosis, showing the flow of water; in an attempt to equalize concentrations of a solute on both sides of the semipermeable membrane. (The water flows from the dilute solution pressure, ‘a more concentrated solution.) The level of the fluid column is maintained by osmot : concer vy eluant Isotonic solution Hypotonie sotution Hypertonic (normal) (dilute) (concentra e Solute e 8 ele ag 2c” 6 ° ohere « e fees : ° o 6 el? oo % a Lo @ ej ge gt ag” Normal rea Swollen/ruptured Shranke blood cell red blood cell blood: (Hemolysis) (Crenai Osmosis and red blood cells. Water moving through a red blood cell membrane in solutions with three different concentrations of solute. All these actions have the goal of equalizing the solute concentration on both sides of the cell membrane, Left: Isotonic (normal) solution has the same concentration as the cell, and the water moves into and out of the celll at the same rate, Center: Hypotonic (diluted) solution causes the cell to swell and eventually hemolyze (burst) because of the large amount of water moving into the cell. Right: Hypertonic (concentrated) solution draws water out of the cell, causing it to shrink.Diffusion Diffusion is the net movement of a substance (liquid or gas) from an area of higher concentration to one of lower concentration. A drop of dye in water is concentrated but then begins to disperse through out the water moving from an area of high toanareaoflow ™ 3 concentration. \ Ajo oveety sepeised nator [| 2] F DIFFUSION Semipermeable membrane —| B > High solute concentration Low solute concentration The process of diffusion, showing gas exchange in the alveoli. Oxygen is transported across the alveoler- capillary membrane from the alveoli of the lungs to the capillaries, to add oxygen to the unoxygenated blood returning from the body (systemic circulation). The carbon dioxide in the capillaries (area of greater concentration) moves into the alveoli (aree of lesser concentration). This simple diffusion is an example of passive transport.FLUID- ELECTROLYTES IMBALANCE. I 1. Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function? A. Assessing dietary intake B. Decreasing fluid intake C. Providing limited physical activity D. Turing, coughing, and deep breathing 2. A 12-year-old boy was admitted in thee hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the client? ‘A. Room temperature reduction B. Fluid restriction of 2,000 mi/day C. Axillary temperature measurements every 4 hours D. Antiemetic agent administration 3. Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization, Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury? A.“ do not have to see my doctor unless i have problems.” B.“I can stop taking my antibiotics once I am feeling better.” C. “If have redness, drainage, or fever, 1 should call my healthcare provider.” D. “I can retumn to my normal activities as soon as I go home.” 4. Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply. A. Clustering activities to allow uninterrupted periods of rest B. Maintaining correct body alignment at all times C. Monitoring intake and output, using a urometer if necessary D. Using a footboard or pillows to keep feet in correct position E. Performing active and passive range-of-motion exercises F. Weighing the client daily at the same time and in the same clothes 5. A 36-year-old male client is about to be discharged from the the hospital after 5 days duc to surgery. Which intervention should be included in the home health care nurse’s instructions about measures to prevent constipation? A. Discouraging the client from eating large amounts of roughage-containing foods in the diet. B. Encouraging the client to use laxatives routinely to ensure adequate bowel elimination C. Instructing the client to establish a bowel evacuation schedule that changes every day 1D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day. 6. Mr. MePartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale? A, Nutritional needs remain unchanged for the well-nourished adult, B. Age is an insignificant factor in cellular repair. C. The presence of infection may slow the healing process D, Tissue with inadequate blood supply may heal faster. 7. A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma, Which nursing intervention should be included for reducing pain due to cellular injury? A. Administering anti-inflammatory agents as prescribed B. Elevating the injured area to decrease venous return to the heart C. Keeping the skin clean and dry D. Applying warm packs initially to reduce edema 8. Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling? A. Inserting an indwelling Foley catheter B, Having the client perform Kegel exercises C. Keeping the skin clean and dry D. Using pads or diapers on the client 9, Jeron is admitted in the hospital due to bacterial pneumonia, He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client? A. Prevention of fluid volume excess B. Maintenance of adequate oxygenation C. Education about infection prevention D. Pain reduction 10. Mang Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care? A. Stress-reduction techniques B. Home environment evaluation C. Skin-care measures D. Participation in activities of daily living11. Mrs. dela Riva is in her first trimester of pregnancy, Sbe has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity? A. Monitoring intake and output accurately B. Instructing the client to cough and deep-breathe every 2 hours C. Keeping the linens dry and wrinkle free D. Using a foot board to maintain correct anatomic position 12, Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first? A. Massage the reddened are for a few minutes, B. Notify the physician immediately C. Arrange for a pressure-relieving device D. Tum the client to the right side for 2 hours 13, Pierro was noted to be displaying facial grimaces after murse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do? A. Administering the client's ordered pain medication immediately B. Using guided imagery instead of administering pain medication C. Using therapeutic conversation to try to discourage pain medication D. Attempting to rule out complications before administering pain medication 14. Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism? A. Maintenance of asepsis with indwelling catheter insertion B. Use of masks, gowns, and gloves when caring for clients with infection C. Correct handwashing technique D. Cleanup of blood spills with sodium hydrochloride \V/15. A patient with tented skin turgor, dry mucous membranes, and decreased urinary ontput is under nurse Mark’s care. Which nursing intervention should be included the care plan of Mark for his patient? ‘A. Administering 1.V. and oral fluids B. Clustering necessary activities throughout the day C. Assessing color, odor, and amount of sputum D. Monitoring serum albumin and total protein levels, 16, Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to 3hospitalization. Which foods should the nurse instruct the client to increase? A. Whole grains and nuts B. Milk products and green, leafy vegetables C. Pork products and canned vegetables D. Orange juice and bananas 17. Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation, Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis? A. Administering sodium chloride 1.V. B. Encouraging slow, deep breaths C. Preparing to administer sodium bicarbonate D. Administer low-flow oxygen therapy 18. Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client’s intake, A. 2,230 B. 2,740 C.2,470 D. 2,320 19. Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated? A. Positive Trousseau’s sign B. Positive Chvostek’s sign C. Tetany D. Paresthesia 20. Lab tests revealed that patient Z’s [Na‘] is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess? A, Tented skin turgor and thirst B. Muscle twitching and tetany C. Fruity breath and Kussmaui’s respirations D. Muscle weakness and paresthesia 21. Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client’s blood gas values through improved ventilation and oxygen 4therapy, which is the client’s primary stimulus for breathing? : A. High PCO2 B. Low PO2 C. Normal pH D. Normal bicarbonate (HCO3) 22. A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit? A. Assessing urinary intake and output B. Obtaining the client’s weight weekly at different times of the day C. Monitoring arterial blood gas (ABG) results D. Maintaining 1.V. therapy at the keep-vein-open rate 23. Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium? A. 14-year-old Elena who is taking diuretics B. 16-year-old John Joseph with ileostomy C. 16-year-old Gabriel with metabolic acidosis D. 18-year-old Albert who has renal disease 24, Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate? A. Instituting seizure precaution to prevent injury B. Instructing the client on the importance of preventing infection C. Avoiding the use of tight tourniquet when drawing blood D. Teaching the client the importance of early ambulation 25, Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid? A. Potassium B. Phosphate C. Chloride D. Sodium 26. Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate? A. Potassium supplements B. Kayexalate C. Calcium gluconate D. Sodium tablets 27. Which clinical manifestation would lead the nurse to suspect that a client is 5experiencing hypermagnesemia? : 2 A. Muscle pain and acute rhabdomyolysis B. Hot, flushed skin and diaphoresis C. Soft-tissue calcification and hyperreflexia D. Increased respiratory rate and depth 28, Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client? A. Sodium level - B, Magnesium level C. Potassium level D. Calcium level 29. Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial earbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement? A. Instructing the client to breathe slowly into a paper bag B. Administering low-flow oxygen C. Encouraging the client to cough and deep breathe D. Nothing, because these ABG values are within normal limits. 30. A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order? A. Potassium B, Sodium bicarbonate C. Serum sodium level D. BronchodilatorFLUID-ELECTROLYTE IMBALANCE I] 1, Lee Angela’s lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret this serum chloride Jevel as: A.high B.low C. within normal range D. high normal 2. Which of the following conditions is associated with elevated serum chloride levels? A. cystitis B. diabetes C. eclampsia D. hypertension 3. In the extracellular fluid, chloride is a major: A. compound B. ion C. anion D. cation 4, Nursing intervention for the patient with hyperphosphatemia include encouraging intake of: A. amphogel B. Fleets phospho-soda C. milk D. vitamin D 5. Etiologies associated with hypocalcemia may include all of the following except: A. renal failure B. inadequate intake calcium C. metastatic bone lesions D. vitamin D deficiency 6. Which of the following findings would the nurse expect to asses in hypercalcemia? A. prolonged QRS complex B. tetany C. petechiae D. urinary calculi 7. Which of the following is not an appropriate nursing intervention for a patientwith hypercalcemia? A. administering calcitonin B. administering calcium gluconate C. administering loop diuretics D. encouraging ambulation 8. A patient in which of the following disorders is at high risk to develop hypermagnesemia? A. insulin shock B. hyperadrenalism C. nausea and vomiting D. renal failure 9. Nursing interventions for a patient with hypermagnesemia include administering caleium gluconate to: A. increase calcium levels, B. antagonize the cardiac effects of magnesium C. lower calcium levels D. lower magnesium levels 10. For a patient with hypomagnesemia, which of the following medications may become toxic? A. Lasix B. Digoxin C. calcium gluconate D.CAPD 11. Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance? A. skin turgor B. intake and output C. osmotic pressure D. cardiac rate and rhythm 12. Insensible fluid Josses include: Avurine B. gastric drainage C. bleeding D. perspiration 13. Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretichormone (SIADH)? A. hypotonic solution B. hypertonic solution C. isotonic solution D. normotonic solution 14, Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances? A. hypokalemia B. hyperkalemia C. hyponatremia D. hypernatremia 15. When assessing a patient for signs of fluid overload, the nurse would expect to observe: A. bounding pulse B. flat neck veins C. poor skin turgor D, vesicular 16. The physician has ordered IV replacement of potassium for a patient with severe hypokalemia. The nurse would administer this: A. by rapid bolus B. diluted in 100 ce over 1 hour C. diluted in 10 cc over 10 minutes DIV push 17. Which of the following findings would the nurse explect to assess in a patient with hypokalemia? A. hypertension B. pH below 7.35 C. hypoglycemia D. hyporeflexia 18, Vien is receiving oral potassium supplements for his condition. How should the supplements be administered? A. undiluted B. diluted C. on an empty stomach D. at bedtime 19. Normal venous blood pH ranges from:A.6.8 to 7.2 B.7.31 107.41 C. 7.35 t0 7.45 D.7.0 to 8.0 20. Respiratory regulation of acids and bases involves: A. hydrogen B. hydroxide C. oxygen D. carbon dioxide 21. To determine if a patient’s respiratory system is functioning, the nurse would assess which of the following parameters: C. arterial blood gas D. pulse oximetry 22. Which of the following conditions is an equal decrease of extracellular uid (ECF) solute and water volume? A. hypotonic FVD B, isotonic FVD C. hypertonic FVD D. isotonic FVE 23. When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight loss begins to exceed: A.0.25 Ib B. 0.50 1b C.1ib D.1kg 24, Dietary recommendations for a patient with a hypotonic fluid excess should include: A, decreased sodium intake B. increased sodium intake C. increased fluid intake D. intake of potassium-rich foods 25. Osmotic pressure is created through the process of: A. osmosisB. diffusion C. filtvation D. capillary dynamics 26, A rise in arterial pressure causes the baroreceptors and stretch receptors to signal an inhibition of the sympathetic nervous system, resulting i A. decreased sodium reabsorption B. increased sodium reabsorption C. decreased urine output D. increased urine output 27. Normal serum sodium concentration ranges from: A. 120 10 125 mEq/L B. 125 to 130 mEq/l C. 136 to 145 mEq/L D. 140 to 148 mEq/L 28. When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include: A. water gain B. diuretic therapy C. diaphoresis D. all of the following 29, Nursing interventions for a patient with hyponatremia include: A. administering hypotonic IV fluids B. encouraging water intake C. restricting fluid intake D. restricting sodium intake 30. The nurse would analyze an arterial pH of 7.46 as indicating: A. acidosis B. alkalosis C. homeostasis, D. neutralityFLUID-ELECTROLYTE IMBALANCE III. 1.The net diffusion of water from one solution of water from one solution through a semipermeable membrane to another solution containing a lower concentration of water is termed: A. filtration B. diffusion C. osmosis D. brownian motion 2. When assessing a patient’s total body water percentage, the nurse is aware that all of the following factors influence this except: A.age B. fat tissue C. muscle mass D. gender 3. Orly Khan is suffering from fluid volume deficit (FVD), which of the following symptoms would the nurse expect to assess in the patient? A.rales B. bounding pulse C. tachycardia D, bulging neck veins 4. John Reid is admitted in the hospital and is currently receiving hypertonic fluids. Nursing management for the client includes monitoring for all of the following potential complications except: ‘A. water intoxication B, fluid volume excess (FVE) C. cellular dehydration D. cell shrinkage € an isotonic solution; which one of the n? 5. Mr. Wenceslao is scheduled to recei following is an example of such sol A.D10% W B. 0.45% saline C. 0.9% saline D. 3% normal saline W 6, Which of the following arterial blood gas (ABG) values indicates uncompensated metabolic alkalos A. pH 7.48, PaCO2 42, HCO3 30D. pH 7.48, PaCO2 34, HCO3 26 7. The body’s compensation of metabolic alkalosis involves: A. increasing the respiratory rate B, decreasing the respiratory rate C. increasing urine output D. decreasing urine output 8. When assessing a patient for metabolic alkalosis, the nurse would expect to find: A. low serum potassium B. changes in urine output C. hypotension D. increased CVP 9. Which of the following blood products should be infused rapidly? A, packed red blood cells (PRBC) B. fresh frozen plasma (FFP) C. platelets D. dextran 10. Which of the following statements provides the rationale for using a hypotonic solution for a patient with FVD? A.A hypotonic solution provides free water to help the kidneys eliminate the solute. B. A hypotonic solution supplies an excess of sodium and chloride ions. C. Excessive volumes are recommended in the early postoperative period D. A hypotonic solution is used to treat hyponatremia 11. Redd is receiving a blood transfusion. When mo would analyze an elevated body temperature as in joring the patient, the nurse ating: A. a normal physiologic process B. evidence of sepsis, C.a possible transfusion reaction D. an expected response to the transfusion 12. The process of endocrine regulation of electrolytes involves: A. sodium reabsorption and chloride excretion B. chloride reabsorption and sodium excretion C. potassium reabsorption and sodium excretion D. sodium reabsorption and potassium excretion 13. The chief anion in the intracellular fluid (ICF) is: A. phosphorusB. potassium C. sodium D. chloride 14, The major cation in the ICF is: A. potassium B. sodium C. phosphorus D. magnesium 15, Hypophosphatemia may result from which of the following diseases? A. liver cirthosis B. renal failure C. Paget’s disease D. alcoholism 16. A patient with which of the following disorders is at high risk for developing hyperphosphatemia? A. hyperkalemia B. hyponatremia C. hypocalcemia D. hyperglycemia 17. Normal calcium Jevels must be analyzed in relation to: A. sodium B. glucose C. protein D. fats 18. Calcium is absorbed in the GI tract under the influence of: A. vitamin D B. glucose c.HCI D. vitamin C 19. Which of the following diagnoses is most appropriate for a patient with hypo calcemia? A. constipation, bowel B. high risk for injury: bleeding C. airway clearance, ineffective D. high risk for injury: confusion 20. When serum calcium levels rise, which of the following hormones is secreted? 3A. aldosterone B. renin C. parathyroid hormone D. calcitonin 21. The presence of which of the following electrolytes contributes to acidosis? A. sodium B. potassium C. hydrogen D. chloride 22. The hungs participate in acid-base balance by: A. reabsorbing bicarbonate B. splitting carbonic acid in two C. using CO? to regulate hydrogen ions D. sending hydrogen ions to the renal tubules 23. The respiratory system regulates acid-base balance by: A. increasing mucus production B. changing the rate and depth of respirations C. forming bicarbonate D. reabsorbing bicarbonate 24. Which of the following is a gas component of the ABG measurement? A. carbon dioxide B. bicarbonate C. hydrogen D. pH 25. Chloride helps maintain acid-base balance by performing which of the following roles? A. participating in the chloride shift B. following sodium to maintain serum osmolarity C. maintaining the balance of cations in the ICF and ECF D. separating carbonic acid 26. Which of the following hormones helps regulate chloride reabsorption? A. antidiuretic hormone B. renin C. estrogen D, aldosterone27. Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia? 2 A. Muscle pain and acute rhabdomyolysis B. Hot, flushed skin and diaphoresis C. Soft-tissue calcification and hyperreflexia D, Increased respiratory rate and depth 28. Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client? A. Sodium level B. Magnesiuim level C. Potassium level D. Calcium level 29. Mr. Saleedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm He, partial pressure of arterial carbon dioxide of 49 mm He, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement? A. Instructing the client to breathe slowly into a paper bag B. Administering low-flow oxygen C. Encouraging the client to cough and deep breathe D. Nothing, because these ABG values are within normal limits. 30, A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order? A. Potassium B, Sodium bicarbonate C. Serum sodium level D. BronchodilatorAcid-Base Balance ‘The body's balance between acidity and alkalinity is referred to as acid- base balance, also called body pH. ‘The blood's acid-base balance is precisely controlled because even a ‘minor deviation from the normal range can severely affect many ‘organs. The body uses different mechanisms to control the blood's acid-base balance. ‘These mechanisms involve the Lungs Kidneys Buffer systems. ‘Adoctor evaluates a person's acid-base balance by measuring the plt and levels of earbon dioxide (an acid) and bicarbonate (a base) in the ‘blood. When an imbalance develops, you can detect it quickly by knowing how to assess your patient and interpret arterial blood gas (ABG) values Components of the ABG: * pH: This is a measure of the overall concentration of Hydrogen ions...it measures acid/base in the blood Normal range is 7.35 - 7.45 * PaCO2: This is the partial pressure of carbon dioxide dissolved in plasma. It measures ventilation (how well the body can get rid of C02)....it is the respiratory component of the ABG. Normal is 35-45 mm Hg 11/16/2016Components of the ABG: PaO2: The partial pressure of oxygen dissolved in plasma. The PaO2 measures oxygenation, and normal ranges are 80-100 mm Hg ALWAYS look at the PaO2 FIRST! Your pt may need urgent oxygenation. $a02: This is a measure of the % of oxygen that is attached to hemoglobin in red blood cells. Normal is > 95% in healthy humans (avg is 98% for a healthy pt). Hypoxemia = low 02 in blood Hypoxia = low 02 in tissues Regulation of Acids and Bases ‘The acid/base balance in the body is regulated by the respiratory system and the renal system. The respiratory system is responsible for altering CO2 levels in the body to balance pH. Chemo receptors sense pH changes and increase or decrease the respiratory rate and depth. This change occurs within minutes of pH alterations REMEMBER....on the ABG, the PaCO2 is an acid!!! The renal system will work to compensate a respiratory imbalance via the production of bicarbonate. The kidneys also reabsorb or excrete acids and bases and Is a major buffer system. However, the renal system takes hours or days to kick in and achieve compensation, In addition to acid and bicarb , the body also has phosphate buffers and protein buffers that act within seconds to protect tissues and cells from abnormal pH. C02 + H20 €9 H2CO3 €> H+ + HCO3- 11/16/2016Components of the ABG: * HCO3-: This is bicarbonate, a chemical buffer made in the kidneys to neutralize acids. It is the metabolic component of the ABG. Normal is 22-28 mEq/L. Base Excess: This is an indicator of the total buffer base of the body. It ranges from -2mEq to +2mEq If you have a LOT of base, the base excess level moves toward the positive side. If you don’t have a lot of base excess, it will move toward the negative side. When the pt is in acidosis, the level will be more negative. Normal Values and Acceptable Ranges of the ABG Elements pH-~--7.4 (7.35 to 7.45) Pa02- 90mmHg (80 to 100 mmHg) Sa02- 93 to 100% PaCO2-—-40mmHg (35 to 45 mmHg) HC03 ---24mEq/L_ (22 to 26mEq/L) 11/16/2016Definitions * Acidosis (acidemia) occurs when pH drops below 7.35 Alkalosis (alkalemia) occurs when the pH rises above 7.45 Aprimary respiratory problem is determined if the PaCO2 is less than 35mmig (alkalosis) or greater than 45 mmHg {acidosis ) A primary metabolic problem is when the HCO3 is less than 22mEq/L (a losis) or greater than 26mEq/L (alkalosis). Respiratory Acidosis (\/pH and 4*PaCO2) ABG: pH<7.35 PaCO2 > 45 mm Hg Mech: Hypoventilation Causes: drugs, head injury, lung disease, airway obstruction, respiratory muscle dysfxn, chest wall dysfixn. adache, fatigue flushed skin, Ieetabity Late: lethargy, confusion, somnolence “De Breathe morel Increase RR) Treat the cause (reverse nares prn with Narcan/Romazicon) Improve respiratory efforts (use 5, ‘mobility, positioning, bronchodilators, correct ventlator settings rate Continually reassess Goa Deerease C02 levels Provide adequate 02 Normal pH 11/16/2016Respiratory Alkalosis (‘pH and |, PaCO2) ABG: pH > 7.45, Paco? <35 mm He ‘+ Mech: Hyperventilation + Causes: stimulated respiratory system, arterial hypoxemia, increased metabolism, hepatic that is putting a lot of ‘ammonia in the system, mechanical ventilation + (problem with rate or volume), + CNS problems Signs: ntaly:anlety, Increased Iretablity of CNS and peripheral NS ‘De -Address the underlying cause (pain, anxiety) Help pt calm down and breathe slower -Lower the rate or volume on vent settings. Goal: Increase CO? levels Provide adequate 02 Normal pH ‘Metabolic Acidosis (\/pH and HCO3-) ABG: pH <7.45 HCO3-< 22 mEq/L + Mech: loss of base or gain of acid. + Causes: -Lose base: losses of bile, + pancreatic juices, small intestine + secretions containing bicarb + (fistulas, diarrhea). + -Gain acid: ketoacidosis, lactic * acidosis (occurs with sepsis), + drugs, poisons, TPN + -Renal failure (decreased secretion + of H+ ions, so more H+ retained Signs: CNS depression, HA, weakness, confusion -Later you'll have delirium then stupor Respiratory depression -Kussmaul respirations Te: “Treat the underlying problem -Replace bicarb -Monitor K+ (K+ will come out of the cell and go into the cell with fluctuations in acid) Goal: Increase bicarb levels Normal pH Normal serum electrolytes 11/16/2016Metabolic Alkalosis (‘pH and 4‘HCO3-) silty of central and ‘ABG: pH > 7.45 peripheral NS HCO3- > 28 mEq/L Mech: gain of base or loss of aci Causes -Excessive antacids (gain of base) -mineralocorticoids -G1 output (loss of aci Cramps “Tetany Disorientation - lethargy me -Remove source (decrease antacids) -Monitor electrolytes (K+) “Treat cause (vomiting) via vomiting and gastric + Goat: i + Lower bicarb levels sxn...intermittent sxn is eel better!) + Normal serum electrolytes 11/16/20168-Step Guide to ABG Analysis: Tic-Tac-Toe Method An arterial blood gas (ABG) is a blood test that measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood. Blood for an ABG test is taken from an artery whereas most other blood tests are done on a sample of blood taken from a vein. 1. Know the normal values Know the normal and abnormal ABG values when you review the lab reports. They're fairly easy to remember: for pH, the normal value is 7.35 to 7.45; 35-45 for paCO2, and 22-26 for HCOs. Remember also this diagram and note that paCO> is really inverted for the purpose of this method. Neutral 7.35 - 7.45 pH 45-35 Pato, (Respiratory) 22-26 2, Determine if pH is under acidosis or alkalosis Next thing to do is to determine the acidity or alkalinity of the blood through the value of pH. The pH level of a healthy human should be between 7.35 to 7.45. The human body is constantly striving to keep pH in balance. pH level below 7.35 is acidosi pH level above 7.45 is alkalosis 3. Determine if acid-base is respiratory or metabolic Next thing you need to determine is whether the acid base is Respiratory or Metabolic. paCO, = Respiratory HCO; = Metabolic4, Remember ROME Still, it all boils down to mnemonics. The mnemonic RO-ME. Respiratory Opposite When pH is up, PaCO, is down = Alkalosis When pH is down, PaCO; is up = Acidosis Metabolic Equal When pH is up, HCO, is up = Alkalosis, When pH is down, HCO; is down = Acidosis 5, Tie-Tac-Toe And yes, ABG problems can be solved work using the tic-tac-toe method. All you haye to do is make a blank chart similar to this: Acidic |Normal 6. Mark the Chart Using the lab result values, mark them on your tic-tac-toe. Let’s begin with this sample problem: PH: 7.26, paCOr: 32, HCOs: 18 Using the normal values reference chart in the first step, determine where the values should be under in the tic-tac-toe. In the given example, the solution is as follows: pH of 7.26 is LOW = ACID so place pH under Acid paCOz of 32 is LOW = BASE so place paCO> under Base HCO; of 18 is LOW = ACID so place HCOs under Acid Your chart should look like this:Therefore this ABG is RESPIRATORY ALKALOSIS, FULLY COMPENSATED. Try this problem next: pH 7.1, PaCOz 40, HCO3 18 pH is LOW = ACID 50 place pH under Acid PaCO) is NORMAL = NORMAL so place PaCO> under Normal HCO; is LOW = ACID so place HCO; under Acid In this case HCO; goes with pH. HCOs is considered Metabolic (shown in step 3), and both are under Acidic, so this example implies Metabolic Acidosis. The PaCO. is normal, When pH is ABNORMAL, and when either one of PaCO, or HCO is ABNORMAL, it indicates UNCOMPENSATION. Acidic | Normal Therefore this ABG is METABOLIC ACIDOSIS, UNCOMPENSATED.Acidic ipleek kyo :y0)s 7, Match it up In this step, determine at which column matches up with the pH. In the given example, HCO; goes with pH. HCOs is considered Metabolic (shown in step 3), and both are under Acid, so this example implies Metabolic Acidosis. 8. Determine compensation ‘The last step is to determine if the ABG is Compensated, Partially Compensated, or Uncompensated. Here’s the trick: If pH is NORMAL, PaCO) and HCO; are both ABNORMAL = Compensated If pH is ABNORMAL, PaCOs and HCOs are both ABNORMAL = Partially Compensated If pH is ABNORMAL, PaCOz or HCOs is "ABNORMAL = Uncompensated ‘Therefore this ABG is METABOLIC ACIDOSIS, PARTIALLY COMPENSATED . By applying the steps above, interpret the following ABGs: pH:7.44, PaCOz: 30, HCO: 21 pH is NORMAL = NORMAL so place pH under Normal PaCO; is LOW = BASE so place PaCO, under Base HCO; is LOW = ACID so place HCO; under Acid *Since the acidity of the blood is determined by the value of the pH, determine whether the normal pH is SLIGHTLY ACIDIC or SLIGHTLY BASIC. In this example, pH is NORMAL but SLIGHTLY BASIC therefore it is ALKALOSIS. In this case PaCO> goes with pH. PaCO, is considered Respiratory (shown in step 3), and both are under Basic, so this example implies Respiratory Alkalosis. The HCOs is also abnormal. When pH is NORMAL and PaCO, and HCO; are both ABNORMAL, it indicates FULL COMPENSATION.ACID- BASE Analysis NCLEX EXAM PARTI In acid-base balance the normal plasma PCO2 and bicarbonate levels are disturbed, Match the changes in these parameters given below with the disorders in the given choices. 1. Low plasma PaCO2 A. Metabolic Acidosis B, Respiratory Alkalosis C. Metabolic Alkalosis D. Respiratory Acidosis 2. High plasma PaCO2 A. Metabolic Acidosis B. Respiratory Alkalosis C. Metabolic Alkalosis D. Respiratory Acidosis 3. Decreased plasma bicarbonate (HCO3-) A. Metabolic Acidosis B. Respiratory Alkalosis C. Metabolic Alkalosis D. Respiratory Acidosis 4, Increased plasma bicarbonate (HCO3-) A, Metabolic Acidosis B. Respiratory Alkalosis C. Metabolic Alkalosis D. Respiratory Acidosis What two organs in the body serve as a compensatory function to maintain acid base balance? A. Kidneys and Lungs B. Lungs and Spleen C. Heart and Liver D. Gallbladder and Appendix 6. Arterial blood gas (ABG) measurement will give the information needed to determine if the primary disturbance of acid-base balance is respiratory or metabolic in nature. A. True B. False C. Both Carbonic Acid Excess and Deficit Only iD. Both Bicarbonate Excess and Deficit Only 1. The major effect of acidosis is overexcitement of the central nervous system. A. Te B. False C. Maybe D. Both Acidosis and Alkalosis result in overexcitement of the central nervous system. 8, Alkalosis is characterized by overexcitement of the nervous system, A. True B. False C. The major effect of Alkalosis is a depression of the central nervous system. D. Both Acidosis and Alkalosis result in overexcitement of the central nervous system. 9, The human body functions optimally in a state of homeostasis. ‘A. True B. False C. Maybe D. Homeostasis has nothing to do with metabolic balance. 10. Acids have no hydrogen ions and are able to bind in a solution. A. True B. False C. Acid is a substance that is not capable of donating hydrogen ions. D. Acids and bases have nothing to do with hydrogen ions. Match the acid-base status of the following blood samples to the disorders in the given choices. (PaCO2 values are in mm Hg and bicarbonate values in mmol/). LL. pH 7.57, PaCO2 22, HCO3- 17 A. Respiratory Acidosis, Partially Compensated B. Respiratory Alkalosis, Uncompensated C. Metabolic Acidosis, Partially Compensated D. Respiratory Alkalosis, Partially Compensated 12, pHi 7.39, PaCO2 44, HCO3- 26 A. Respiratory Acidosis B. Metabolic Acidosis, C. Respiratory Alkalosis D. Normal 13, pH 7.55, PaCO2 25, HCO3- 22A. Respiratory Acidosis, Partially Compensated B. Respiratory Alkalosis, Uncompensated C. Metabolic Alkalosis, Partially Compensated D. Metabolic Acidosis, Uncompensated 14, pH 7.17, PaCO2 48, HCO3- 36 A. Respiratory Acidosis, Uncompensated B. Metabolic Acidosis, Partially Compensated C. Respiratory Alkalosis, Partially Compensated D. Respiratory Acidosis, Partially Compensated 15. pH 7.34, PaCO2 24, HCO3- 20 A. Respiratory Acidosis, Partially Compensated B. Metabolic Acidosis, Partially Compensated C. Metabolic Acidosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated 16. pH 7.64, PaCO2 25, HCO3- 19 A. Respiratory Acidosis, Uncompensated B. Respiratory Alkalosis, Partially Compensated C. Respiratory Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated 17. pH 7.45, PaCO2 50, HCO3- 30 ‘A. Metabolic Alkalosis, Fully Compensated B. Respiratory Alkalosis, Fully Compensated C. Metabolic Alkalosis, Partially Compensated D. Respiratory Acidosis, Partially Compensated 18. pH 7.6, PaCO2 53, HCO3- 38 A. Metabolic Alkalosis, Partially Compensated B, Metabolic Alkalosis, Fully Compensated C. Respiratory Acidosis, Partially Compensated D. Respiratory Alkalosis, Fully Compensated 19. pH. 7.5, PaCO2 19, HCO3- 22 A. Respiratory Alkalosis, Partially Compensated B. Metabolic Alkalosis, Partially Compensated C. Respiratory Acidosis, Uncompensated D. Respiratory Alkalosis, Uncompensated 20. pH 7.4, PaCO2 59, HCO3- 35A. Respiratory Acidosis, Uncompensated B. Metabolic Alkalosis, Uncompensated C. Respiratory Acidosis, Fully Compensated D. Metabolic Alkalosis, Partially CompensatedABG Analysis NCLEX Exam PART /! L. George Kent is a 54 year old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum, He ‘has difficulty in communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has a tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm ‘Hg, HCO3 28 mmoV/L, and PaO2 60 mm Hg. How would you interpret this? A. Respiratory Acidosis, Uncompensated B, Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Acidosis, Partially Compensated 2. Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dchydrated—his eyes are sunken and mucous membranes are dry—and he has a two week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. ‘What is your assessment? - A. Respiratory Acidosis, Uncompensated B, Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis,-Uncompensated D. Metabolic Acidosis, Partially, Compensated 3. A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia, Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm He, and HCO3 25 mmol/L. What does this mean? A. Respiratory Alkalosis, Uncompensated B, Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated 4-Ricky’s grandmother is suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to ave dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base 1disorder is shown? A. Respiratory Alkalosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated 5, Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgieal pain. The client’s respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli! The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg and HCO3 24 mEq/L. What does this mean? A. Respiratory Alkalosis, Partially Compensated B. Respiratory Acidosis, Uncompensated C. Metabolic Alkalosis, Partially Compensated D. Metabolic Acidosis, Uncompensated 6. Baby Angela was rushed to the Emergency Room following her mother’s complaint that the infant has been irritable, difficult to breastfeed and has had diarrhea for the past 3 days. The infant's respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg and HCO3 19 mEq/L. What does this mean? A. Respiratory Alkalosis, Fully Compensated B. Metabolic Acidosis, Uncompensated C. Metabolic Acidosis, Fully Compensated D. Respiratory Acidosis, Uncompensated 7. Mr. Wales, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 ce in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment? ‘A. Metabolic Acidosis, Uncompensated B. Metabolic Alkalosis, Uncompensated C. Respiratory Alkalosis, Uncompensated D, Metabolic Alkalosis, Partially Compensated 8. Client Z is admitted to the hospital and is to undergo brain surgery. The client is very anxious and scared of the upcoming surgery. He begins to hyperventilate and becomes very dizzy. The client loses consciousness and the STAT ABGs reveal pH 27.61, PaCO2 22 mmHg and HCO3 25 mEq/L. What is the ABG interpretation based on the findings? ‘A. Metabolic Acidosis, Uncompensated B. Respiratory Alkalosis, Partially Compensated C. Respiratory Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated 9. Three-year-old Adrian is admitted to the hospital with a diagnosis of asthma and respiratory distress syndrome. The mother of the child reports to the nurse on duty that she bas witnessed slight tremors and bebavioral changes in her child over the past four days. The attending physician orders routine ABGs following an assessment of the ABCs. The ABG results are pH 7.35, PaCO2 72 mmHg and HCO3 38 mEq/L. What acid-base disorder is shown? A. Respiratory Acidosis, Uncompensated B. Respiratory Acidosis, Fully Compensated C. Respiratory Alkalosis, Fully Compensated D. Metabolic Alkalosis, Partially Compensated 10. Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials “911” because Anne is unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided? A. Metabolic Acidosis B. Metabolic Alkalosis C. Respiratory Acidosis D. Respiratory AlkalosisABG Analysis NCLEX Exam part Il. 1. Dave, a 6-year-old boy, was rushed to the hospital following her mother’s complaint that her son has been vomiting, nauseated and has overall weakness. After series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D: Metabolic Alkalosis 2. An old beggar was admitted to the emergency department due to shortness of breath, fever, and a productive cough. Upon examination, crackles and wheezes are noted in the lower lobes; he appears to be tachycardic and has a bounding pulse. Measurement of arterial blood gas shows pH 7.2, PaCO2 66 mm Hg, HCO3 27 mmol/L, and PaO2 65 mm Hg. As a knowledgeable nurse, you know that the normal value for pH is: A.7.20 B.7.30 Cc. 7.40 D.7.50 3. Liza’s mother is seen in the emergency department at a community hospital. She admits that her mother is taking many tablets of aspirin (salicylates) over the last 24-hour period because of a severe headache. Also, the mother complains of an inability to urinate. The nurse on duty took her vital signs and noted the following: Temp = 97.8 °F; apical pulse = 95; respiration = 32 and deep. Which primary acid- base imbalance is the gentleman at risk for if medical attention is not provided? A. Respiratory Acidosis B. Respiratory Alkalos C. Metabolic Acidosis D. Metabolic Alkalosis 4. A patient who is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation, The doctor diagnosed him of having dehydration. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm He, PaCQ2 22 mm Hg, and HCO3 14 mmol/L; other results are Na+ 120 mmol/L, K+ 2.5 mmol/L, and Cl- 95 mmol/L. As a knowledgeable nurse, you know that the normal value for PaCO2 is: A. 22mm Hg B. 36 mm HgC. 48 mm Hg D. 50 mm Hg 5. A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is at 34/minute, Which primary acid-base disturbance is the young man at risk for if medical attention is not provided? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis 6, An elderly client was admitted to hospital in a coma. Analysis of the arterial blood gave the following values: PCO2.16 mm Hg, HCO3- 5 mmol/L and pH 7.1. As a well-rounded nurse, you know that the normal value for HCO3 is: A. 20 mmol/L B. 24 mmol/L C. 29 mmol/L D. 31 mmol/L 7. In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the operation, the following values were acquired from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40 mmol/l. What is the underlying disorder? A. Respiratory Acidosis, B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis, 8. A mountaineer attempts an assault on a high mountain in the Andes and reaches an altitude of 5000 meters (16,400 ft) above sea level. What will happen to his arterial PCO2 and pH? A. Both will be lower than normal. B. The pH will rise and PCO2 will fall. C. Both will be higher than normal due to the physical exertion. D. The pH will fall and PCO2 will rise 9. A young woman is found comatose, having taken an unknown number of sleeping pills an unknown time before. An arterial blood sample yields the following values: pH 6.90, HCO3- 13 meq/liter and PaCO2 68 mmHg. This patient’s acid-base status is most accurately described as: A. Metabolic AcidosisB. Respiratory Acidosis C. Simultaneous Respiratory and Metabolic Acidosis, D. Respiratory Acidosis with Complete Renal Compensation 10, A mother is admitted in the emergency department following complaints of fever and chills. The nurse on duty took her vital signs and noted the following: Temp = 100 °F; apical pulse = 95; respiration = 20 and deep, Measurement of arterial blood gas shows pH 7.37, PaQ2 90 mm Hg, PaCO2 40 mm Hg, and HCO3 24 mmol/L. What is your assessment? A. Hyperthermia B. Hyperthermia and Respiratory Alkalosis C. Hypothermia D. Hypothermia and Respiratory AlkalosisFluid-Electrolyte Imbalance Part |. LA, 2-A, 3-C, 4-B,D,E; 5-D, 6-C,7-A, 8-B, 9-B, 10-B, 11-C, 12-D, 13- D, 14-C, 15-A, 16-D, 17-B, 18-C, 19-A, 20-A, 21-B, 22-A, 23-D, 24-D, 25- ,26-B, 27-B, 28-C, 29-C, 30-B. Part Il. 1-C, 2-C, 3-C, 4-A, 5-C, 6-D, 7-B, 8-D, 9-B, 10-B, 11-D, 12-D, 13-B, 14-A, 15-A, 16-B, 17-D, 18-B, 19-B, 20-D, 21-C, 22-B, 23-B, 24-B, 25-B, 26-D, 27-C, 28-D, 29-C, 30-B. PART Ill LC, 2-D, 3-C, 4-A, 5-C, 6-A, 7-B, 8-A, 9-C, 10-A, 11-C, 12-D, 13-A, 14-A, 15-D, 16-C, 17-C, 18-A, 19-B, 20-D, 21-C, 22-C, 23-B, 24-A, 25-A, 26-D, 27-B, 28-D, 29-C, 30-A. ABGs PART I.1-B,2-D, 3-A, 4-C, 5-A, 6-A, 7-B, 8-A, 9-A, 10-B, 11-D, 12-D, 13-B, 14-D, 15-B, 16-B,17-A, 18-A, 19-D, 20-C . PART Il. 1-B,2-D, 3-A, 4-C, 5-B, 6-C, 7-B, 8-C, 9-B, 10-C. PART Ill. 1-D, 2-C, 3-C, 4-B, 5-B, 6-B, 7-D, 8-B, 9-C, 10-A.