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VCE Lessons 2-4.docx - Your Handytech » Maintenance Mode

  1. 1. Josh Neagle<br />NUR 301<br />Instructor: Ann Sossong<br />VCE Lesson 2, exercise 1<br />1. Identify and describe the two major fluid compartments in the body.<br />1. Water compartment: 2/3 of the body is water. In this compartment, water can move freely across the cell membrane, and intracellular ion composition is dramatically different from extracellular ion composition. In this compartment, water moves by ions that exert an osmotic pressure so water can go in and out of the cell.<br />2. Extracellular fluid compartment: contains interstitial and vascular fluids. Fluid entering and exiting the body must go through plasma before entering the cells. This plasma of the vascular space exchanges with interstitial space. This is determined by the balance of hydrostatic pressure and the osmotic pressure generated by the plasma proteins. <br />2. Compare and contrast the causes and clinical manifestations of various types of fluid imbalances by completing the table below and on the next page.<br />Fluid ImbalanceCausesClinical Manifestations<br />Dehydration Lack of fluid intake, Excess fluid loss,Loss of weight, <br />(Extra Cellular Fluid Age, Renal Impairment, Diuretic Use.Changes in I&O,<br />Volume Deficit)Changes in Vital<br />Signs, Dry MucousMembranes, Dry skin,Loss of Skin Turgor.<br />Cellular DehydrationLack of fluid intake, Excess fluid loss,Fever, confusion, <br />(Intracellular Fluid Age, Renal Impairment, Diuretic Use. Cerebral hemorrhage,<br />Volume Deficit)Coma, thirst, oliguria.<br />Fluid Overload:Failure to excrete fluids, infusion of Tachycardia, CHF, <br />Hypervolemiatoo much fluids, or infusion of fluids tooanascarca, ascites,<br />(Extra Cellular Fluidfast, CHF, ARF, Barbituate and Narcotic use.peripheral edema.<br />Volume Excess)<br />Water Intoxicationwater excess, sodium deficit, excessive alterations in mental<br />(Intracellular Fluid infusion of .45% NS, or 5% dextrose, status, pupillary <br />Volume Excess)compulsive fluid intake. changes, vital signs changes.<br />Third Space Fluidsincreased hydrostatic pressure, crushpallor, cold limbs, <br />(Extra Cellular Fluidinjuries, major tissue trauma, major weak and rapid pulse,<br />Volume Excess)surgery, extensive burns, acid-base hypotension, oliguria, <br />imbalance, bowel obstruction, sepsis.decreased levels of <br />conciousness.<br />3. Describe pathophysiology related to extracellular fluid volume deficit.<br />When the serum level of Na is low, there is less sodium available to move across the excitable membrane, resulting in delayed membrane depolarization. As the concentration of sodium decreases in the extra cellular fluid, the fluid becomes hypo-osmolar. Water moves into the cell to the area of greater concentration. Water is then lost from the extracellular space, causing a deficit and fluid loss in the blood stream. <br />4. Identify and describe three types of extracellular fluid volume deficits.<br />1. Hypovolemic hyponatremia- Na loss is greater than water loss. Na is lost from diuretic use, diabetic glycouria, aldosterone deficiency, intrinsic renal disease. Also caused by extra renal loss of Na from vomiting, diarrhea, increased sweating, and burns.<br />2. Envolemic hyponatermia: greater increase in TBa than in total body Na. Caused by edematous disorders resulting in Na deficits: CHF, cirrhosis of liver, nephrotic syndrome, acute renal failure, and polydipsia. <br />VCE Lesson 3, exercise 1<br />1. Cells use electrolytes for what two main purposes?<br />1. To conduct electrical impulses (nerve impulses, muscle contractions) to other cells..<br />2. To maintain voltages across cell membranes.<br />2. Describe the effect of potassium imbalance on the action potential.<br />Decreased potassium levels in the extracellular space will require a greater than normal stimulus for depolarization of the membrane in order to initiate an action potential. Almost all of the manifestations that occur with hypokalemmia result from slowed neuron excitability and its consequent effect on muscle function. <br />3. Identify risk factors for hypokalemia.<br />- Inadequate K+ intake<br />- People who are debilitated, confused, restrained, or lacking access to dietary sources, malnourished, anorexic, or bulemic.<br />- When loss of K+ is greater than intake.<br />- Surgical pt's when cortisol levels increase.<br />- People taking thiazide, loop and osmotic diuretics, cathartics, steroids, aminoglycosides, ibuprofen, and bicarbonate.<br />- Cushings syndrome, diuretic phase of renal failure, hyperaldosteronism, liver disease, cancer, wounds, Bartter syndrome, chronic electrolyte wasting syndrome. <br />4. Describe clinical manifestations associated with hypokalemia.<br />Abnormal EKG findings<br />- Disturbances with the GI, respiratory, muscle, and renal systems,<br />- Slowed muscle contraction leads to anorexia, and constipation, and abdominal distention.<br />- slowed skeletal contraction leads to muscle weakness and leg cramps.<br />- Decrease in conduction with nerve impulses leads to fatigue, parasthesias, hyporeflexia, and irritability.<br />- Depressed and prolonged St segment of ECG, depressed and inverted T wave, prominent U wave<br />- Increased risk for ventricular fibrillation and cardiac arrest.<br />- Shallow respirations, SOB, apnea, and respiratory arrest<br />- Slowed nerve conduction= dysphasia, confusion, depression, convulsions, and coma<br />- Urinary retention from smooth muscle slowing.<br />5. Identify causes and/or risks for hyperkalemia.<br />- Excess infusion on KCl or PO KCl<br />- decrease in kidney function<br />- GI tract and skin cannot excrete enough to compensate for hypokalemia<br />- Conditions that destroy cells such as fast growing cancers<br />- burns, crush injuries, severe infections<br />- After the use of stored blood, open heart surgery or surgery where perfusion pump is used.<br />- meds such as cyclosporine, sulfa combinations, heparin<br />- therapy with K sparing diuretics <br />6. Describe the clinical manifestations associated with hyperkalemia.<br />- Mild to moderate hyperkalemia causes nerve muscle irritability = paresthesia, tachycardia, intestinal colic, and diarrhea<br />- impaired cardiac conduction, ventricular contraction, hypotension, cardiac arrest, convulsion, flaccid paralysis, respiratory muscle paralysis<br />- ECG abnormalities<br />- Increase BUN and creatinine if PCO2 is low<br />VCE Lesson 3, exercise 2<br />1. What was Piya Jordan's initial potassium level at 2200?<br />Piya Jordan's potassium level on monday at 2200 was 3.3. This is just low of what is considered to be the normal range for potassium labs. (Normal range is 3.5-5.0)<br />2. What would be the most likely cause of hypokalemia in this patient?<br />The most likely cause in this patient could be the potential electrolyte imbalances related to digoxin toxicity, or her severe fluid retention (shown by her 2000 mL intake and only 700 mL output) could be the cause of her hypokalemia.<br />3. What did the physician order to treat this electrolyte imbalance? Is this action appropriate?<br />The physician has ordered KCl (20 mEq) in 250 mL of NS to infuse over 2 hours. Due to Piya's severe dehydration and electrolyte imbalance, this is an appropriate action.<br />4. Are the dilution and rate ordered by the physician safe to administer to Piya Jordan? Explain your answer.<br />The dilution ordered by the physician is one that is not listed as available by the drug guide, which would warrant a call to the physician himself or to the pharmacy. However, the rate ordered is correct, as the indicated dosage for adults is 5-10 mEq/hr. Prior to this however, a nurse would be taking labs to get accurate and up to date readings on serum potassium and chloride levels. <br />5. What should be assessed prior to the administration of the KCl?<br />Some things that should be always assessed before the administration of KCL would be the serum electrolyte levels, specifically those about to be infused in solution. Also, things such as hydration status, their medication profile (for compatibilities, contraindications, cautions, etc. ). In this case, Piya Jordan is on Digoxin (Lanoxin), which is a medication for CHF. With this medication comes the possibility of digoxin toxicity with hypokalemia. Therefore, what should be added to the list of things to assess prior to this medication administration would be serum digoxin levels. <br />6. What precautions should be taken when administered the above IV solution of potassium?<br />Some of the precautions were listed above, but added to this would be to watch the IV closely for phlebitis as the IV is infusing. This is characterized by hardness of the vein, streaking over the skin, swelling, and pain. Other considerations would be several lab values (see answer above), muscular contractility, age, and other medications being taken.<br />7. What was Piya Jordan's potassium level Tuesday at 0630? Was the physician's order for potassium effective? Is there any cause for concern?<br />Piya's potassium level on Tuesday at 0630 was 3.8, which now elevates her potassium status to WNL. This indicates that the physician's order was effective, however there was a very sudden rise in her potassium labs. This could have some adverse reactions in the pt, and should be watched closely. <br />8. Complete a physical assessment on Piya Jordan, specifically looking for the clinical manifestations of hypokalemia,. Document your findings in the chart below, and on the next page and underline those that correlate with hypokalemia. <br />Areas AssessedFindings on Physical Exam<br />Cardiovascular- No murmurs, rubs, or clicks.<br />No JVD noted.<br />S1 and S2 auscultated, apical rhythm irregular with atrial fibrilation noted on telemetry monitor.<br />Respiratory- Regular and even respiratory effort. Bilateral breath sounds clear and equal with decreased aeration in both lower lobes. No cough, no adventitious lung sounds, no accessory muscle use. <br />Neuromuscular- Glasgow Coma scale rating of 15, cranial nerves intact with no apparent deficits. Pt oriented to person only, w/ slurred and slow speech. Mildly confused, agitated, and restless. Perceptual ability impaired. <br />Gastrointestinal- Pt has absent bowel sounds, abd. tender w/ pain to palpation. No anal fissures or hemorrhoids, no flatus passed r/t absent bowel sounds.<br />Renal- Indwelling Foley catheter in place, draining clear yellow urine in sufficient quantities.<br />9. What is the potassium level that was drawn on Wednesday at 0630?<br />The potassium level that was drawn on Wednesday at 0630 reads 3.4, which is lower than the previous reading.<br />10. Explain the etiology for this recurrence of hypokalemia.<br />The recurrence of this hypokalemia is strongly related to the amount of fluid that Piya was retaining at the start of her hospital stay. The fluid was being retained as her body was trying to spare potassium and continue with normal muscle contraction, etc. When the physician ordered a 20 mEq infusion of Potassium Chloride, the expected finding was an immediate increase in her electrolyte levels, specifically potassium. The recurrence of this episode of hypokalemia is because Piya had what was to be considered a normal amount of potassium, her body was now releasing fluid via her indwelling foly catheter. Now that Piya is losing retained fluids, her potassium levels drop once more, and must be compensated as such.<br />VCE Lesson 4, exercise 1<br />1. Prior to caring for a client with multiple electrolytes imbalances, it is imperitive that first review and reinforce general concepts related to specific electrolytes. Using the text book, complete the table below by providing information related to specific calcium, phosphorus, and sodium imbalances. <br />Electrolyte ImbalanceDiagnostic Lab ValueEtiology and Risk Factors<br />HypercalcemiaHigher than or equal to malignancy, hyperpara- <br />5.5 mEq/L or 11 mg/dL.thyroidism,thiazide diuretic <br />therapy.<br />HypophosphatemiaLess than 1.2 mEq/L or 2.8 malnourishment, carbohydratemg/dL.overload, alcoholism.<br />HyponaturemiaLess than 135 mEq/L.CHF, ARF, dehydration, nausea, vomiting.<br />VCE Lesson 4, exercise 2<br />1. Record Pablo Rodriguez's serum chemistry results in the table below. Identify abnormal values by marking as H (for high), and L (for low).<br />Lab TestResults Tuesday 2000Results Wednesday 0730<br />Sodium133 L134 L<br />Potassium3.83.6<br />Calcium10.5 9.5<br />Phosphorus2.2 L2.3 L<br />Magnesiumnone1.9 L<br />Glucose110 H98<br />BUN9 5 <br />Hematocrit28 L26 L<br />2. What would be the most likely cause for the hyponaturemia noted in Pablo Rodriguez on admission?<br />The most likey cause of his hyponaturemia would be his diagnosis of a malignant neoplasm, as well as his secondary diagnosis of nausea and vomiting. The root cause of this is fluid loss, which means that sodium is lost with the water that is lost with his emesis. <br />3. What did the physician order to treat his electrolyte imbalance?<br />The physician ordered a complete chemistry profile in order to get values associated with Pablo's condition, and following these orders was a PO capsule of Neutra-Phos. In addition to these orders, an IV bolus of Lactated Ringer's was ordered to aid in the treatment of this balance. <br />4. What was Pablo Rodriguez's sodium level for wednesday at 0730? Was the physician's ordered treatment effective? Can you anticipate or suggest any change in orders?<br />Pablo's sodium level on wednesday at 0730 was 134, which is still low. However, the sodium level has risen since his admission, and therefore indicates some success based upon the physician's order. Some changes that may be put in place would be a secondary IV solution that would raise his sodium levels further, or increase the drip rate of his existing solutions. <br />5. Hyponaturemia can be associated with both hypovolemia (actual sodium loss) and hypervolemia (dilutional). Based on Pablo Rodriguez's presentation to the emergency department, what type of hyponaturemia do you think he is experiencing? Explain.<br />I think that Pablo is suffering from Hypovolemic Hyponaturemia, as his presentation carried several symptoms that are associated with this type. One of them being his c/o small hard stools. This is a symptom that happens when there is not enough water in the stool. As well as his presentation of dehydration and constipation.<br />6. Shift Totals Tuesday 0705 Tuesday 1505Tuesday 2305Wednesday 0705<br />Intake- 1501283<br />Output-100925<br />7. Based on the above I&O totals after the client received IV replacement therapy, what factors may be contributing to the persistent hyponaturemia? Explain your answer.<br />Although the correct data that was requested here was not published properly, there are several factors that could be contributing to the persistent hyponaturemia that the client is experiencing here. One of these is the malignancy that he is being treated for. Malignancies have been noted in the medical surgical textbook to have adverse effects on electrolyte levels, and general chemistry as well. The chemotherapy is also a process that can significantly dehydrate a client, thought it is something that can be ruled out since his last dose was about a month ago.<br />