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CHAPTER18—FLUI DSAND ELECTROL YTES Tabl eAc t i vi t y 1 .

El e c t r ol yt e

Nor malVa l ueRange

Sodi um

a . 1 2514 5mEq/L

Pot a s s i um

b. 3 . 5 5. 0mEq/L

Chl or i de

c . 9 6106mEq/L

Cal c i um

d. 4 . 5 5 . 6mEq/dL

Phos phor us

e . 2. 44. 1mEq/dL

Ma gne s i um

f .

Bi c a r bona t e

g. 2 224mEq/L

1 . 5 2. 5mEq/L

CLI NI CALAPPLI CATI ON OFMATH AND CONVERSI ON 2 .Ans we r : 2l i t e r s . Onel i t e rofflui de qua l s2. 2pounds( 1kg) ;t he r e f or e ,awe i ghtl os sof2 . 2poundswi l l r e fle c tl os sofonel i t e rofflui d. 1 50–1 45. 5=4 . 5pounds 2 . 2pounds×4. 5pounds=2. 045r ounde dt o2 1l i t e r i t e r s xl 3 .Ans we r : 4l i t e r s .Onel i t e rofflui de qua l s2 . 2pounds( 1kg) ; t he r e f or e , awe i ghtga i nof2 . 2poundswi l l r e fle c tga i nofonel i t e rofflui d. 2 142 05=9pounds 2 . 2pounds×9pounds=4 . 09r ounde dt o4 1l i t e r i t e r s xl 4 .Ans we r :I nt ake : 14 30mL; Out put :1 500 mL I nt a ke : 420 +3 0 0+5 10 +200 =14 30 mL Out put :30 0 +4 50 +5 0 0+2 50=1 500 mL 5 .Ans we r :1 850 mL 5 00mL+600 mL+30 0mL+2 50mL+200 mL=1 8 50mL The4 00mLt ha twa si mme di a t e l yc ol l e c t e di nt hec a nni s t e rwasnotdi s c a r de d[ orr e c or de dont he flows hee t ]a tt het i meofobs e r va t i on; t her e f or e ,i tbe c a mepar toft het o t alvol ume( 600 mL)t ha tt he nur s eobs e r ve di nt hec anni s t e ra tt hee ndoft hes hi f t . ( Not et os t ude nt :Thi sma ys e e ml i kea" t r i c k" ques t i on,butt hi st ypeofs c enar i oi snota t ypi c a lofwha tc oul doc c uri nt hec l i ni c als e t t i ng.Re membe rt ome as ur e ,r ec or da ndt he ndi s c ar dout put ,s ot ha tt heflui dt ot a l sa tt hee ndoft hes hi f tar ea cc ur a t e . ) 6 . Ans we r :I nt a ke : 211 0mL;Out put : 1 8 65 mL I nt a ke : 125 mL/hr×8hr =1 00 0mL+2 40 mL+20 0mL+2 70mL+400 mL=2 11 0 Out put :40 0mL+4 50 mL+70 0mL+3 0 0mL+1 5mL=18 65 Mul t i pl eChoi c e 7 . Ans we r4: Pot a s s i um i se xc r e t e dt hr ought heur i ne ; t he r e f or e ,i nc r e a s i ngur i neout puthe l pst hebody r i di t s e l fofe x c e s spot as s i um.I Vc a l c i um i sgi ve nt opa t i e nt swi t hhypoc a l c e mi a . Fl ui dr es t r i c t i ons

a r eus e df orpa t i e nt swi t hhypona t r e mi a .Foodshi ghi npot a s s i um ar egi ve nwhe nt hepa t i e nthas hypokal e mi a . 8 . Ans we r1:Re s pi r a t or ys t a t usi st hemos ti mpor t antbec a us et hepa t i e nti ss ho wi ngs i gnsofhypoc a l c e mi a( pa r a t hyr oi dgl andsc a nbedama ge ddur i ngt hyr oi ds ur ge r ya ndl os sofpa r a t hyr oi dhor mone i nt e r f e r eswi t ht heabs or pt i ona ndut i l i za t i onofc a l c i um) . Lar ynge a ls pas msc oul doc c urandc a us e r e s pi r a t or yar r es t .Addi t i onalr e s pi r a t or yas s e s s me ntwoul dbet oobs e r vef ors t r i dor ,dys pne aor c r owi ngs ounds . Chvos t e ks i gn( c ont r a c t i onoff a c i almus c l e s )ma ya l s obeobs e r ve ddur i ng hypoc a l c emi a . 9 . Ans we r2:Al loft he s epa t i e nt sha ver i s kf orde hydr a t i on,butobe s epopul a t i ons , ol de ra dul t sand i nf a nt sha vegr e a t e rr i s kbe c a us eofr e duc e dflui dsr es e r ve s .The7 2ye a rol dobe s ema l ehast wor i s k f a c t or s .I naddi t i on,f e ve rc a us e si ns e ns i bl eflui dl os sanda nor e xi a( l os sofappe t i t e )ma yc a us et he pa t i e ntt or e f us eor a lf oodsa ndflui ds . 1 0. Ans we r1,2 ,4, 5:Thenur s ewoul das s i s tt hene i ghborbyhe l pi nghe rt or e a dl a be l s . Condi me nt s , manyc anne df oods , f r oz enf oodsa ndpr epar edi t e msf r e que nt l yha v eahi ghs a l tc ont e nt . 1 1.Ans we r1 :Thenur s emus tkno wt ha tt hepa t i e nti spr oduc i ngur i nebe f or ea dmi ni s t e r i ngpot a s s i um. I fnot ,t hepa t i e ntwi l lbea tr i s kf orhype r kal e mi a . 1 2. Ans we r2:Poorflui di nt akeandi mmobi l i t ywi l lc ont r i but et oc ons t i pa t i on. 1 3. Ans we r2:As s e s s me ntfindi ngsandl a bor a t or yda t as ugge s tmet a bol i ca c i dos i s .Pa t i e nt swi t hdi a be t e s a r ea tr i s kf ordi a be t i ck et oac i dos i s . 1 4. Ans we r4:Opt i on4i nc l ude st hebi gge s tvar i e t yoff oodst ha tc ont a i npot as s i um.SeeBox18 3f oraddi t i onali nf or ma t i on 1 5. Ans we r3:I Vpot a s s i um i sa l wa ysgi ve nonani nf us i onpump: pot as s i um i sNEVERgi ve nI Vpus h a ndt ypi c a l l yt hepha r mac ywi l ldi l ut et hepot a s s i um i nanI Vs ol ut i on. 1 6. Ans we r4:Thepa t i e ntwi t hl ow c a l c i um c oul dha veal ar ynge als pas m,s oat r a c he os t omyt r a ya nda r e s us c i t a t i onba gs houl dbea va i l abl ea tt hebe ds i de . 1 7.Ans we r1 :Thepa t i e nti ss howi ngs i gnsofde hydr a t i on.Thenur s ewoul das s e s sf orot he r s i gns /s ympt oms :fla tnec kve i ns ,or t hos t a t i chypot e ns i on, s pe c i ficgr a vi t yofur i ne ,da r kur i ne ,and e l e va t e dt e mpe r a t ur e . 1 8. Ans we r1: Dai r ypr oduc t sa r et hebes ts our c eofc al c i um.Cal c i um i sal s of oundi ns omegr e e nl e a f y ve ge t abl e s , butt he s es our c e sa r eha r de rf ort hebodyt ous e . 1 9. Ans we r2: Whe nmet abol i cac i dos i soc c ur s , oneoft hec ompe ns a t or yme c ha ni s msi sani nc r e as e d r e s pi r a t or yr a t et or i dt hebodyofc a r bondi oxi de .Re movi ngc ar bondi oxi def r om t hebl oodl owe r s t hec a r boni ca c i dl e ve landr ai s e spH t oc r e a t eamor eal kal i nee nvi r onment .Di a phor e s i si snote xpec t e d, be c aus et hepa t i e nti sde hydr a t e d.Ur i neout puti sl i ke l yt obede c r e as e dbe c a us eofflui d de fic i tf r om di a r r he a .Thehe ar tr a t ei sl i ke l yt obei nc r e as e dal s obe c a us eofde h ydr a t i ons e c onda r y t odi ar r he a . 2 0. Ans we r3: Nor malphi s7 . 3 5;t hus ,a c i dos i si si de nt i fie d. PaC gr e a t e rt han45i st ypi c a lofc hr oni c 2O obs t r uc t i vepul mona r ydi s e as e . 2 1. Ans we r3: Br e a t hi ngi nt oapa pe rba ghe l pst hef a t he rt o“ r e br e a t he ”s omeoft hec a r bondi oxi det ha t hei sl os i ngbe c aus ehei shyper ve nt i l a t i ng. Thi swi l lhe l pc or r e c tt hebl oodpH.Pa nt i ngwi l lc ont r i but et or e s pi r a t or yal ka l os i s . 2 2. Ans we r1: As pi r i ni sc he mi c a l l ya c e t yl s a l i c yl i cac i d.Thi smedi c a t i onwi l lr e s ul ti ne x c e s s i vea c i di n t hebody ,r e s ul t i ngi nme t abol i cac i dos i s .Re s pi r a t or yal ka l os i si sa l s ol i k e l yast hebodya t t e mpt st o c ompe ns a t ef ort heac i dove r l oad. 2 3. Ans we r1: Suc t i oni ngr e move sac i dsf r om t hes t omac ha ndt hi si sr efle c t e di nane l e va t edpH whi c h i ndi c a t esa l ka l os i s . ThePaCO2i snor malorma ybes l i ght l ye l e va t edi ft hebodyi sa t t e mpt i ngt or e t a i n se l e va t e dbe c a us et heki dne ysar ea t t e mpt i ngt oe x c r et ebi c ar bonCO2andi nc r ea s eac i d.TheHCO3–i a t e ,butt heki dne ysa r es l owe rt ha nt heot herr e s pons es ys t e ms . 2 4. Ans we r2: We i ghi ngt hepa t i e ntda i l yi st hebe s tme t hodt ot r a c kt r e ndsofflui dga i norl os s .I ti se s s e nt i a lt ha tt hepa t i e ntbewe i ghedt hes a met i mee ve r yda ywi t ht hes a meamountofc l o t hi ng.As s e s s i ngbl oodpr e s s ur eandpul s ec anr e fle c tc ha nge si ni nt r a va s c ul a rvol ume( i . e . ,he mor r ha ge ) .I V flui di nt akepr ovi de si ns uffic i e nti nf or ma t i on.La bor a t or yva l uesa r ei nt e nde dt or e fle c tbodye l eme nt ss uc hase l e c t r ol yt e s , pr ot e i ns ,orc e l ls t r uc t ur e s . The r e f or e ,l ooki nga tl abor a t or yval uesi nc ont e xtoft hepa t i e nt ’ sc ondi t i onc a nc ont r i but et ounde r s t a ndi ngt hepa t hol ogyofflui ds t a t us ,butt hi s

i snott hebe s tme t hodt ot r ac kt r e ndsofflui di nc r e as eorde c r e a s e . 2 5. Ans we r1: Hyper na t r emi a( s odi um l e ve l so ve r145mEq/L)c a us e si nt r a c e l l ul a rde hydr a t i ona sflui d i spul l e df r om t hec e l l s .Hypo t oni cs ol ut i onsmovei nt ot hec e l l s ,c a us i ngt hem t oenl ar ge . The pr ovi de rc oul dpr e s c r i beahype r t oni cs ol ut i onwhi c hpul l sflui df r om t hec e l l si ft hepa t i e nthadhypona t r e mi a . I s ot oni cs ol ut i onse x pa ndt hebody’ sflui dvol umewi t houtc a us i ngaflui ds hi f tf r om onec ompa r t me ntt oa not heranda r egi ve nwhe nt hei nt r a va s c ul a rv ol umei sl ow ( i . e . ,he mor r ha ge ) . 2 6. Ans we r3: I s ot oni cs ol ut i onse xpa ndt hebody’ sflui dvol umewi t houtc a us i ngaflui ds hi f tf r om one c ompa r t me ntt oanot he r .The s es ol ut i onsa r et hemos tc ommonl yus e dwhent hee l e c t r ol yt eba l anc e i snott hei s s ue ,butflui dr e pl ac e me nti sne e de d.Hypot oni cs ol ut i onsmov ei nt ot hec e l l s , c aus i ng t he mt oe nl a r ge . Hyper t oni cs ol ut i onspul lflui df r om t hec e l l s . 2 7. Ans we r1, 2,3 ,4: El e c t r ol yt e ss er vei nbodymet abol i s m,wa t e rande l e c t r ol yt eba l anc e ,andr e gul at i ona ndf or ma t i onofhydr oc hl or i cac i d.Tr ans por t a t i onofnut r i e nt sandwa s t esr e l i e sont heflui d c ompone nt . 2 8. Ans we r4: Fr e s hve ge t a bl esc ont a i nmi ni ma la mount sofs odi um. Mi ni mi z i ngore l i mi na t i ngt abl e s a l ti se nc our a ge d.Che es eandc a nnedve ge t abl e sar ehi ghi ns odi um.Ea t i ngouti snotne c e s s ar i l y di s c our a ge d,butt henur s es houl dr e vi e wt heme nuwi t ht hepa t i e ntt omakes ur et ha ts e l ec t i onsa r e r e as ona bl e . 2 9. Ans we r4: Pa t i e nt swhot a kel oopdi ur e t i c smus tbec aut i one da boutt hes i gnsofl ow pot as s i um a nd a dvi s e daboutf oodst ha tpr o vi depot as s i um. Pa t i e nt swi t hs mal lbowe lobs t r uc t i onar emor ea tr i s k f orhypona t r emi a .Renalf ai l ur eof t e nr e s ul t si nhype r kal e mi a.Ex c e s s i vea l c oholc ons umpt i oni sa s s oc i a t e dwi t hhypoc a l c e mi aandh ypoma gne s e mi a . 3 0. Ans we r2: Thenur s ewoul ds e ar c hf ora ddi t i ona ls i gnsofflui dove r l oa d: dys pne a; ar api d,we a k pul s e ;c ough;di s or i e nt a t i on;i nc r e a s e dorde c r e a s e dbl oodpr e s s ur e ; c r a c kl e s ;a ndpi t t i nge de ma . I f o ve r l oa di ss us pe c t e d, s l ow t hei nf us i ona ndc ont a c tt heRN andpr ovi de r .We i ghtga i ni sus ual l ya goodi ndi c a t ororflui dove r l oad; ho we v er ,be c aus et hepa t i e nti sha vi ngs udde nons e tr e s pi r a t or y s ympt oms , t hi si ndi c a t ori snotasus e f ul . 3 1. Ans we r1: Hi ghl e ve l sofpot a s s i um ( nor ma lr ange3. 55 . 0mEq/L)c aus ec ar di acdys r hyt hmi asand c a r di aca r r es t .Thenur s ewoul di mme di a t e l ybe gi nt omoni t ort hehe ar t .Foodsandflui dswi t h pot as s i um woul dbewi t hhe l d.Che c ki ngf orme di c a t i onst ha ti nflue nc epot as s i um l e ve lwoul dbe a ppr opr i a t eonc et hei mme di a t eda nge rha sbe e nr es ol ve d.I Vc a l c i um gl uc ona t ei sgi vent opa t i e nt s whoha vehype r ka l e mi a ,s ot henur s ewoul de ns ur et ha tt hi si sa va i l abl e ,butt heme di c a t i onc a nnot begi ve nunt i lt hepr ovi de rpr e s c r i be si t . 3 2. Ans we r2: Thepa t i e nt ’ sc al c i um l e ve li sl ow, andt hi si nc r e as e she rr i s kf orbonewe akne s sa ndot he r pr obl e msa s s oc i a t edwi t hos t e opor os i s . Theot herva l ue sar ewi t hi nnor ma ll i mi t s . 3 3. Ans we r1: Al umi num hydr o xi de( Amphoj e l )i sgi ve nt opa t i ent swi t hhi ghphos phor usl e ve l s .The nor ma lr angei s2 . 4 4 . 1mEq/dL;t he r e f or e , t heva l ues ho wst he r a pyha sc or r e c t edt hei mba l anc et o t henor malr ange . Theot he rl e v e l sa r ea l s owi t hi nnor ma ll i mi t s . 3 4. Ans we r1: Al loft he s el e ve l sa r eont hel owe re ndoft henor malr angeands houl dbeobs e r ve df or c ont i nue ddownwar dt r ends ; howe ve r , be c a us et hepa t i enthads ur ge r yont hepa r a t hyr oi dgl a nds , t henur s es houl dbec onc e r neda boutt hec a l c i um l e ve li npa r t i c ul ar .Los sofpa r a t hyr oi dhor mone ( par a t hor mone )i nt e r f e r eswi t ht hea bs or pt i ona ndut i l i za t i onofc a l c i um.Ca l c i um l e ve l sbe l ow 4 . 5 mEq/dLc a nr e s ul ti nt e t anyandl a r ynge a ls pa s mst ha tc oul dbl oc kt heai r wa y . 3 5. Ans we r2: Thebl oodbuffe rr e s pondsi naf r ac t i onofas e c ondi nana t t e mptt oc or r e c ta c i dba s ei mba l anc e . Whe nt ha ts ys t em i se xhaus t e d,t hel ungsa r et hes e c ondl i neofde f e ns ea ndr e s pi r a t or yr a t e i nc r e a s e st oc ompe ns a t ef orme t a bol i ca c i dos i s . Theki dne ysa r et het hi r dl i neofde f e ns ebutwi l l t a kehour sorda yst oc or r e c tt hei mba l anc e . I ndi a bet i cket oa i dos i s ,ur i nar yout puti sus ual l yde c r e as e dbe c a us et hepa t i e nti si nas t a t eofde hydr a t i ona ndt hepa t i e nti sge ner al l yt a c hyc a r di c .I fal l s ys t e msf ai l ,t hepH wi l lde c r e as e . 3 6. Ans we r3: Re s pi r a t or ya l ka l os i sc anber e l a t e dt or a pi dr es pi r a t or yr a t e s .Thenur s ewoul dc hec kt he ve nt i l a t ors e t t i ngst oe ns ur et ha tt he yma t c ht heor de r s . I ft heve nt i l a t ors e t t i ngsar ei nc or r e c t ,t he nur s ewoul dr e s e tt he m.TheRN a ndpr ovi de rs houl dbeno t i fie da boutt hebl oodga sr e s ul t sand a nya c t i ont ha twast a ke n. Ex c e s s i ves e c r e t i onsoramuc uspl ugar emor el i ke l yt oc a us er e s pi r a t or y a c i dos i s .Us i ngt heba gva l ve ma s kwoul dbeappr opr i a t easat e mpor a r yme a s ur ei ft henur s ede t e r mi ne st ha tt heve nt i l a t ori sma l f unc t i oni ng.

Cr i t i c a lThi nki ngAc t i vi t i es 3 7. a . Ol de radul t sha v ec ha nge si nt he i rbodyflui damount ,r educ e dki dne yf unc t i on, andma y ha vei nc r e as e ds odi um i nt he i rdi e tandde c r e as e dflui di nt a ke . Thes ei ndi vi dual sar ea tgr e a t e r r i s kf orde hydr a t i ona ndpos t ur a lhypot e ns i on. b . Se r um pot a s s i um of3 . 4mEq/Li sl o w( nor ma lr ange3. 55 . 0mEq/L) .Thepa t i e ntwi l lne edr epl ac e me ntpot a s s i um.Thepa t i e nts houl dbec l os e l ymoni t or e df ors i gnsofhypokal emi aa nd l a bor a t or yva l ue ss houl dbec l os e l ymoni t or e ddur i ngt her e pl a c e me ntt he r a py . c . Thef ol l owi ngf ac t or sc ont r i but et ohypokal e mi a:vomi t i ng,di ar r he a ,anddi ur e t i c s . d. Re f e rt oBox184. Commons i gnsands ympt omsofhypokal e mi ai nc l udemus c l ewe a knes s ,l e g c r amps , naus e a ,vomi t i ng,andr e duc e dga s t r oi nt e s t i nalf unc t i on.I nt e r ve nt i onsi nc l udeme as ur i ngi nt a keandout put( I &O) ,moni t or i ngpa t i ent sondi go xi nanddi ur e t i c s ,moni t or i ngc ar di a c s t a t us , c he c ki ngl abor a t or yr e s ul t s ,a ndadmi ni s t e r i ngs uppl e ment s( di et ,me di c a t i ons ,I V) . e . Thenor malr angeofs odi um i s1 25 145mEq/L. The r e f or e , t hepa t i e nthasas odi um l e v e lt ha ti s s t i l lwi t hi nt henor malr a nge ;howe ve r , t heva l uei sont hel ow e nda ndt hepa t i e nti sl os i ng s odi um be c a us eofvomi t i nganddi a r r he a . Thepr o vi de ri sl i ke l yt opr e s c r i bei nt r a ve nouss ol ut i on t ha tpr o vi dess odi um s uc hasnor ma ls a l i neor45 %s a l i ne . Thenur s es houl dmoni t orl abor a t or y va l ue sandbeal e r tf ors i gnsofhypona t r e mi a . f . Re f e rt oBo x1 81 .Commons i gnsands ympt omsofhypona t r e mi ai nc l udehe ada c he ,f a t i gue ,a nd pos t ur alhypot e ns i on. I nt e r ve nt i onsi nc l udeme as ur i ngI &O, r epl a c i ngs odi um andflui ds ,a nd moni t or i ngflui dl os s es . g . Out puti nc l ude sur i ne ,di a r r he a , nas oga s t r i cs uc t i on, dr a i na ge ,ande me s i s . 3 8. a . Thenur s ea nt i c i pa t e st ha tt hepa t i e ntne edst r e a t me ntf orr e s pi r a t or yac i dos i s . b . Re f e rt oBo x1 81 0. Si gnsands ympt omsofr e s pi r a t or ya c i dos i si nc l udel e t har gy , di s or i e nt a t i on, he ada c he ,de c r e a s e dl e ve lofc ons c i ous ne s s , dys pne a , t a c h yc ar di a ,a ndi nc r e as e dbl oodpr e s s ur e . c . Tr e a t me ntf orr e s pi r a t or yac i dos i si nc l ude si nt e r mi t t e ntpos i t i vepr e s s ur ebr e a t hi ng( I PPB) , l owflo w ox yge n,a nt i bi ot i c s( f orunde r l yi ngi nf e c t i ons , i fpr e s e nt ) ,br onc hodi l a t or s , hydr a t i on,and c or r e c t i onoft heunde r l yi ngpr obl e m....