Fluid, Electrolyte, Acid/Base balance
Water, Electrolyte and Acid-base Balance: An Overview
Chapter 24 Water, Electrolyte, and Acid-Base Balance
1 2
Water and electrolyte balance
• Water balance • The amount of water gained each day equals the amount lost
Water and Electrolyte Balance
• Electrolyte balance • The ion gain each day equals the ion loss • Acid-base balance •
H+
gain is offset by their loss
On an average day, we will lose ~500 mg of Na+ in urine 3
4
1
Fluid, Electrolyte, Acid/Base balance
Fluids - Compartments
Fluids – function and constituents • Water losses are normally balanced by gains − Eating
• Intracellular fluid (ICF)
− Drinking
• The cytosol of cells
Lose greater than 20%
death
− Metabolic generation
• Makes up about two-thirds of the total body water
• Fluid functions − Transportation
• Extracellular fluid (ECF)
− Temperature regulation
• Major components include the interstitial fluid, plasma and lymph
− Lubrication − Chemical reactions
• Minor components include all other extracellular fluids
• Fluid constituents − Water 5
− Electrolytes
Electrolytes
6
Regulation of fluids and electrolytes
Cells and tissues do not directly transport water, so fluid balance actually reflects control of ion concentrations • Receptors respond to changes in • Plasma volume • Osmotic concentrations • All water moves passively in response to osmotic gradients • “water follows salt” 7
8
2
Fluid, Electrolyte, Acid/Base balance
Fluid Movement “water follows salt”
Fluid shifts
• Water movement between ECF and ICF • If ECF becomes hypertonic relative to ICF, water moves from ICF to ECF • If ECF becomes hypotonic relative to ICF, water moves from ECF into cells
9
10
Regulation of fluids and electrolytes
Water AND electrolyte concentration
• Fluid Deficiency
Relationship between water and electrolytes, specifically sodium
• Volume depletion (hypovolemia): Water and sodium are lost • Hemorrhage, severe burns, chronic vomiting, diarrhea, Addison’s disease (aldosterone hyposecretion)
• Fluid Deficiency - Dehydration
• Dehydration: more water lost than sodium leading to increased ECF osmolarity (hypertonic) • Not drinking, diabetes mellitus, diabetes insipidus (ADH hyposecretion), profuse sweating, diuretic overdose
• Fluid Excess
• Na+ in the ECF is abnormally high • Can lead to circulatory shock • Fluid Excess - Hypotonic Hydration
• Volume excess: Water and sodium are retained
• Hyponatremia
• Aldosterone hypersecretion, renal failure
• Hypotonic hydration (water intoxication, positive water balance, over hydration): more water than sodium is ingested/retained leading to decreased ECF osmolarity (hypotonic) • Drinking plain water to replace fluid loss, ADH hypersecretion,
• Hypernatremia
11
• Na+ concentration in the ECF is reduced • Improper hydration can be as deadly as dehydration
12
3
Fluid, Electrolyte, Acid/Base balance
74 year old man found unconscious
Regulation of fluids and electrolytes Nervous system and endocrine system work together • Nervous system • Hypothalamus monitors osmolarity • Stimulated by increased osmotic pressure
0 sec
• Triggers: • Increased thirst • Secretion of ADH
• Barorecptors monitor pressure
40 sec
Hypothalamus can respond to a 2% change in concentration
• blood - heart, carotid arteries • CSF – ventricles
• Endocrine System – regulatory hormones 14
13
15 sec
Regulation of fluids and electrolytes
Regulatory hormones (fluid deficiency)
Endocrine Regulatory Hormones 1. Antidiuretic hormone (ADH)
• Fluid Deficiency 1.
− Made: hypothalamus / posterior pituitary gland
Antidiuretic Hormone (ADH)
2. Aldosterone
− Released:
3. Renin
• blood osmolarity
4. Angiotensin II
• blood pressure
− Stimulates:
• Fluid Excess 1.
• water conservation (reabsorption in collecting duct)
Atrial Natriuretic Peptide (ANP)
2. Brain Natriuretic Peptide (BNP) 15
16
4
Fluid, Electrolyte, Acid/Base balance
Regulatory hormones (fluid deficiency)
Regulatory hormones (fluid deficiency)
2. Aldosterone − Made: adrenal cortex
3. Renin
− Released:
− Made: juxtaglomerular apparatus − Released:
• blood volume • plasma Na+
• Decreased renal blood flow • Decreased blood pressure
• plasma K+ • Angiotensin II
− Stimulates: release of angiotensin II
− Stimulates: • Na+ absorption and K+ secretion (kidney tubules) Uses sodium/potassium pumps 17
Regulatory hormones (fluid deficiency)
18
Regulatory hormones (fluid excess)
4. Angiotensin II − Made: inactive plasma protein converted to active form by enzymes in the lungs and liver − Released: • plasma volume • renin − Stimulates: • Thirst • Increased peripheral vasoconstriction increases blood pressure • Constricts afferent/efferent arterioles increases/conserves GFR, ensures filtration even with low BP. • Release of aldosterone • Release of ADH 19
• Natriuretic peptides (ANP and BNP) − Made: heart and ventricles − Released: stretch receptors respond to increased pressure/volume − Stimulate: • Decrease thirst • Block the release of ADH and aldosterone • BNP also blocks EP/NE peripheral vasodilation 20
5
Fluid, Electrolyte, Acid/Base balance
Electrolytes - Role
22
Electrolyte Balance
21
Deficiency
Problems with Electrolyte Balance
Electrolyte
Calcium (4.5-5.5 mEq/L)
• Disturbances – Hypo = deficiency
Chloride (95-105 mEq/L)
– Hyper = excess
Cause
Symptoms Hypocalcemia Numbness and tingling in fingers; hyperactive reflexes, muscle cramps, tetany, and convulsions; bone fractures, spasms of the laryngeal muscles Hypochloremia
Increased loss through hypoparathyroidism, decreased dietary intake, elevated phosphate levels
Increased chloride loss through excessive vomiting, aldosterone deficiency or diuretics; excessive water intake; congestive heart failure
Muscle spasms, metabolic alkalosis, shallow respirations, hypotension, tetany
Hypomagnesemia
• Usually result from sodium ion imbalances • Potassium imbalances are less common, but more dangerous
Magnesium (1.5-2.0 mEq/L)
Increased loss of in urine or feces; diuretics, alcoholism, malnutrition and diabetes mellitus
Phosphate (1.8-2.6 mEq/L)
Increased loss in urine, decreased intestinal absorption or increased utilization
• Sodium and potassium primary players because − Major contributors to osmotic concentrations in ECF and ICF − Directly affect functioning of all cells 23
Potassium (3.5-5.0 mEq/L)
Sodium (135-145 mEq/L)
Weakness, irritability, tetany, delirium, convulsions, confusion, anorexia, nausea, vomiting, paresthesia, and cardiac arrhythmias
Hypophosphatemia Confusion, seizures, and coma; muscle pain, numbness, and tingling of the fingers; uncoordination, memory loss, and lethargy Hypokalemia
Excessive loss through vomiting or diarrhea; hyperaldosteronism; kidney disease; or diuretics or decreased dietary intake
Muscle fatigue, flaccid paralysis, mental confusion, increased urine output, shallow respirations, flattened T wave in EKG
Hyponatremia Decreased dietary Muscular weakness, intake; increased dizziness, headache, loss through and hypotension; diarrhea, vomiting, tachycardia and aldosterone shock; mental deficiency or confusion, stupor, and diuretics, excessive coma water intake
Excess Symptoms Hypercalcemia
Cause
Hyperparathyroidism, excessive vitamin D intake
Lethargy, weakness, anorexia, nausea, vomiting, polyuria, itching, bone pain, depression, confusion, paresthesia, stupor, and coma
Hyperchloremia Dehydration, excessive intake, severe renal failure, hyperaldosteronism or acidosis
Lethargy, weakness, metabolic acidosis, and rapid, deep breathing
Electrolyte Balance For lab, focus on ECF levels
Hypermagnesemia Renal failure, increased intake (antacids), aldosterone deficiency, hypothyroidism
Hypotension, muscular weakness or paralysis, nausea, vomiting, and altered mental functioning
Hyperphosphatemia Decreased renal excretion (renal failure), increased dietary intake or increased release from damaged cells
Anorexia, nausea, vomiting, muscular weakness, hyperactive reflexes, tetany, and tachycardia
Hyperkalemia Excessive intake; renal failure; aldosterone deficiency; crushing injuries to tissues, transfusion, or hemolyzed blood
Irritability, nausea, vomiting, diarrhea, muscular weakness, can induce ventricular fibrillation
Hypernatremia
Dehydration, excessive dietary intake
Intense thirst, hypertension, edema, agitation and convulsions
24
6
Fluid, Electrolyte, Acid/Base balance
Sodium balance
Sodium Concentration: The Homeostatic Regulation of Normal Sodium Ion Concentrations in Body Fluids
• Rate of sodium uptake across digestive tract directly proportional to dietary intake • Sodium losses occur through urine and perspiration • Shifts in sodium balance result in expansion or contraction of ECF
25
Fluid Volume: The Integration of Fluid Volume Regulation and Sodium Ion Concentrations in Body Fluids
26
Edema and Na+ Imbalance
28
Sodium concentration changes lead to fluid volume/pressure changes
27
7
Fluid, Electrolyte, Acid/Base balance
Potassium balance
ECF Concentrations of other electrolytes Electrolyte
Potassium ion concentrations in ECF are low • Not as closely regulated as sodium • Potassium ion secretion at kidneys increases as • ECF concentrations rise • Aldosterone secreted • Potassium retention at kidneys occurs when pH falls • Sodium potassium pumps switch to using H+ ions instead of K+ • Hypokalemia: muscle weakness and paralysis 29 • Hyperkalemia: cardiac arrhythmia
Calcium (4.5-5.5 mEq/L)
Cause
Symptoms Hypocalcemia
Increased loss through hypoparathyroidism, decreased dietary intake, elevated phosphate levels
Numbness and tingling in fingers; hyperactive reflexes, muscle cramps, tetany, and convulsions; bone fractures, spasms of the laryngeal muscles
Hypochloremia
Chloride (95-105 mEq/L)
Increased chloride loss through excessive vomiting, aldosterone deficiency or diuretics; excessive water intake; congestive heart failure
Muscle spasms, metabolic alkalosis, shallow respirations, hypotension, tetany
Hypomagnesemia
Magnesium (1.5-2.0 mEq/L)
Increased loss of in urine or feces; diuretics, alcoholism, malnutrition and diabetes mellitus
Weakness, irritability, tetany, delirium, convulsions, confusion, anorexia, nausea, vomiting, paresthesia, and cardiac arrhythmias
Hypophosphatemia
Phosphate (1.8-2.6 mEq/L)
Confusion, seizures, and coma; muscle Increased loss in urine, pain, numbness, and decreased intestinal tingling of the fingers; absorption or increased uncoordination, utilization memory loss, and lethargy
Cause
Symptoms Hypercalcemia
Hyperparathyroidism, excessive vitamin D intake
Lethargy, weakness, anorexia, nausea, vomiting, polyuria, itching, bone pain, depression, confusion, paresthesia, stupor, and coma
Hyperchloremia Dehydration, excessive intake, severe renal Lethargy, weakness, failure, metabolic acidosis, and hyperaldosteronism or rapid, deep breathing acidosis Hypermagnesemia Renal failure, increased intake (antacids), aldosterone deficiency, hypothyroidism
Hypotension, muscular weakness or paralysis, nausea, vomiting, and altered mental functioning
Hyperphosphatemia Decreased renal excretion (renal failure), increased dietary intake or increased release from damaged cells
Anorexia, nausea, vomiting, muscular weakness, hyperactive reflexes, tetany, and tachycardia
30
Acid-base Balance
31
32
8
Fluid, Electrolyte, Acid/Base balance
Weak Acid H2CO3
Strong Acid HCL
H+ Cl-
H+
H+ Cl-
ClH+
ClH+
H+
H+ ClH+
H+ Cl- Cl
ClH+
HCO3-
H+ H+ HCO3 HCO3 H2CO3 H2CO3 HCO3HCO3 H+ H2CO3 H2CO3 H+ H2CO3
H- Cl-
Acids and Bases pH Scale
H+
33
34
Common Acids
The importance of pH control
• Carbonic acid is most important factor affecting pH of ECF
The pH of the ECF remains between 7.35 and 7.45
− CO2 reacts with water to form carbonic acid − Inverse relationship between pH and concentration of CO2 • Sulfuric acid and phosphoric acid − Generated during catabolism of amino acids • Organic acids
• Alteration outside these boundaries affects all body systems • If plasma levels fall below 7.35 (acidemia), acidosis results − CNS shut down: coma, heart failure, peripheral vasodilation (decreased blood pressure), coma • If plasma levels rise above 7.45 (alkalemia), alkalosis results − Random firing of CNS: spasms, convulsions, coma
− Metabolic byproducts such as lactic acid, ketone bodies 35
36
9
Fluid, Electrolyte, Acid/Base balance
Mechanisms of pH control
Mechanisms of pH control - Buffers • Buffers • Bicarbonate • intracellular • extracellular
• Buffers
• Phosphate
• Ion exchange with cells
• intracellular
• Compensation
• Proteins
• modify renal or respiratory function
• intracellular – more • some extracellular (plasma proteins)
• Hemoglobin 37
• intracellular
38
CO2
PO43- + H+ HPO42- + H+ H2PO4-
Hb
O2
H+ 39
RBC 40
10
Fluid, Electrolyte, Acid/Base balance
Mechanisms of pH control – ion exchanges Ion Exchanges: work with intracellular buffering systems to maintain plasma pH 1. Chloride shift •
hemoglobin buffer system •
•
H+ are buffered by hemoglobin
Cl- swapped for HCO3-
2. Potassium ion exchange • • •
Proteins Phosphate buffer system •
H2PO4- H+ + HPO42-
K+
swapped for H+
41
42
Maintenance of acid-base balance Compensation: change system function in response to pH
H+
• Respiratory Compensation • Lungs help regulate pH through carbonic acid bicarbonate buffer system • Changing respiratory rates changes PCO2 • Acute and chronic − Acute ex: lactic acidosis (seizure) , alcoholic ketoacidosis
H+ PO43- + H+ HPO42- + H+ H2PO4-
H+ H+ H+ K+ Blood
Tissue Cell
43
• Renal compensation • Kidneys help regulate pH by adjusting secretion and reabsorption of H+ and bicarbinate • Chronic (day or longer) 44 − Chronic ex: emphysema
11
Fluid, Electrolyte, Acid/Base balance
Respiratory Compensation
Renal Compensation
CO2 + H2O H2CO3 H+ + HCO3• Acidic = too much H+ • Increase respiratory rate • Basic = too little H+ • Decrease respiratory rate 45
46
Renal compensation continued
Disturbances of Acid-base Balance
47
48
12
Fluid, Electrolyte, Acid/Base balance
Acid-base balance maintained by
Acid-Base Disorders
Maintain tight control within range 7.35 – 7.45
• Respiratory acid base disorders • Result when abnormal respiratory function causes rise or fall in CO2 in ECF
• Buffer systems
• Metabolic acid-base disorders
• Ion exchange
• Generation of acids
• Compensation
− lactic acid (anaerobic respiration), ketone bodies (beta oxidation), phosphoric acid (nucleic acid catabolism), fatty acids (lipid catabolism), …
• Respiration • Renal function
• Anything affecting concentration of bicarbonate ions in ECF 49
Acid Base Disorders
50
Respiratory acidosis
• Acidosis decreased neurological function • Respiratory acidosis
• Results from excessive levels of CO2 in body fluids
• Renal compensation
• Hypoventilation
• Metabolic acidosis
−Ex: emphysema, asthma, CNS damage, pneumothorax
• Respiratory compensation • Renal compensation • Alkalosis spontaneous neural firing
• Cellular ion exchange increased plasma potassium
• Respiratory alkalosis • Renal compensation
• Renal compensation increase in plasma bicarbonate
• Metabolic alkalosis • Respiratory compensation • Renal compensation
51
Which conditions are acute and which are 52 chronic?
13
Fluid, Electrolyte, Acid/Base balance
Respiratory alkalosis
Metabolic acidosis Major causes are: • Increased production of acids − Lactic acid, ketone bodies
• Relatively rare condition
• Ingestion of acidic drugs
• Associated with hyperventilation
− Aspirin, penicillin, phenobarbital, vit C
− Ex: fever, panic attacks, anemia, CNS damage
• Bicarbonate loss due to chronic diarrhea or overuse of laxatives
• Renal compensation decrease in plasma bicarbonate
• Inability to excrete hydrogen ions at kidneys − Organ failure, glomerulonephritis, diuretics Cellular ion exchange increased plasma potassium Respiratory compensation decreased plasma CO2 (decreased bicarbonate) 53
Renal compensation increased plasma bicarbonate
Anion Gap: distinguish type of metabolic acidosis
Metabolic alkalosis
[Na] + [other cations] = [Cl] + [HCO3] + [other anions]
• Occurs when HCO3- concentrations become elevated
[Na] – ([Cl] + [HCO]) = [other anions] – [other cations]
54
• Caused by repeated vomiting
= anion gap = 8-16 mEq/L plasma • Increased anion gap increased unmeasured anions • Most commonly due to increased acids • lactic acid, ketoacids, phosphate, sulfate, salicylates, uremia • Normal or decreased anion gap decreased unmeasured anions
• Renal compensation decreased plasma bicarbonate
• Due to loss of bases (bicarbonate), very rare • Most commonly diarrhea
• Respiratory compensation increased plasma CO2
55
56
14
Fluid, Electrolyte, Acid/Base balance
Homeostasis in Infants
58
• More body water in ECF • Rate of fluid intake/output is 7X higher
High Risk: •
Infants
•
Elderly
• Higher metabolic rate • Produces more metabolic wastes • Kidneys cannot • Concentrate urine • Remove excess H+
FLUID, ELECTROLYTE AND ACID-BASE DISTURBANCES
• Greater water loss • Skin ( surface area / volume) • Lungs ( RR) 57
• Higher K+ and Cl- concentrations
Impaired Homeostasis in the Elderly • Decreased volume of intracellular fluid • Decreased total body K+ • Decreased respiratory and renal function
Clinical Diagnosis
• Slowing of exhaled CO2 • Decreased blood flow and GFR “Reach high, for stars lie hidden in your soul. Dream deep, for every dream precedes the goal.”
• Reduced sensitivity to ADH • Impaired ability to produce dilute urine 59
60
15
Fluid, Electrolyte, Acid/Base balance
Clinical Diagnosis
1. Check pH Low Acidosis
Normal Check electrolyte levels
1. Test pH Normal → look at electrolyte imbalance
High Alkalosis
2. Check PCO2
2. Check PCO2
Low Normal Metabolic Metabolic Acidosis acidosis with Respiratory Compensation
See electrolyte table Abnormal → look at acid base imbalance see next slide
High Respiratory Acidosis
High Normal Metabolic Metabolic alkalosis alkalosis with Respiratory Compensation
3. Check Bicarb
Low Respiratory Alkalosis
3. Check Bicarb
1. pH
High Chronic with renal compensation
Low / Normal Acute and/or no renal compensation
2. pCO2 3. Bicarb
4. If it is metabolic, check Anion Gap
4. Anion gap
High Due to generation/retention of acids
Low / Normal Due to loss of base
61
Deficiency Electrolyte
Case Studies
Calcium (4.5-5.5 mEq/L)
Chloride (95-105 mEq/L)
Cause
Symptoms Hypocalcemia Numbness and tingling in fingers; hyperactive reflexes, muscle cramps, tetany, and convulsions; bone fractures, spasms of the laryngeal muscles Hypochloremia
Increased loss through hypoparathyroidism, decreased dietary intake, elevated phosphate levels
Increased chloride loss through excessive vomiting, aldosterone deficiency or diuretics; excessive water intake; congestive heart failure
Muscle spasms, metabolic alkalosis, shallow respirations, hypotension, tetany
Hypomagnesemia Magnesium (1.5-2.0 mEq/L)
Increased loss of in urine or feces; diuretics, alcoholism, malnutrition and diabetes mellitus
Phosphate (1.8-2.6 mEq/L)
Increased loss in urine, decreased intestinal absorption or increased utilization
Potassium (3.5-5.0 mEq/L)
63
Sodium (135-145 mEq/L)
Weakness, irritability, tetany, delirium, convulsions, confusion, anorexia, nausea, vomiting, paresthesia, and cardiac arrhythmias
Hypophosphatemia Confusion, seizures, and coma; muscle pain, numbness, and tingling of the fingers; uncoordination, memory loss, and lethargy Hypokalemia
Excessive loss through vomiting or diarrhea; hyperaldosteronism; kidney disease; or diuretics or decreased dietary intake
High / Normal Acute and/or no renal compensation
Muscle fatigue, flaccid paralysis, mental confusion, increased urine output, shallow respirations, flattened T wave in EKG
Hyponatremia Decreased dietary Muscular weakness, intake; increased dizziness, headache, loss through and hypotension; diarrhea, vomiting, tachycardia and aldosterone shock; mental deficiency or confusion, stupor, and diuretics, excessive coma water intake
Excess Symptoms Hypercalcemia
Cause
Hyperparathyroidism, excessive vitamin D intake
Lethargy, weakness, anorexia, nausea, vomiting, polyuria, itching, bone pain, depression, confusion, paresthesia, stupor, and coma
Hyperchloremia Dehydration, excessive intake, severe renal failure, hyperaldosteronism or acidosis
Low Chronic with renal compensation
62
Disturbances in Electrolyte Levels
Lethargy, weakness, metabolic acidosis, and rapid, deep breathing
Hypermagnesemia Renal failure, increased intake (antacids), aldosterone deficiency, hypothyroidism
Hypotension, muscular weakness or paralysis, nausea, vomiting, and altered mental functioning
Hyperphosphatemia Decreased renal excretion (renal failure), increased dietary intake or increased release from damaged cells
Anorexia, nausea, vomiting, muscular weakness, hyperactive reflexes, tetany, and tachycardia
Hyperkalemia Excessive intake; renal failure; aldosterone deficiency; crushing injuries to tissues, transfusion, or hemolyzed blood
Irritability, nausea, vomiting, diarrhea, muscular weakness, can induce ventricular fibrillation
Hypernatremia
Dehydration, excessive dietary intake
Intense thirst, hypertension, edema, agitation and convulsions
64
16
Fluid, Electrolyte, Acid/Base balance
CASE STUDIES
Normal Lab Values
For each of the case studies listed answer the following questions: 1. 2. 3. 4.
Blood Values
Identify any abnormal symptoms or conditions the patient is exhibiting Identify any abnormal lab values the patient has Explain what might be the underlying cause for any of the abnormalities (symptoms or lab) Identify whether this an acid-base disorder or a fluid-electrolyte imbalance a. If this is an acid-base disorder indicate the specific type and whether or not compensation is occurring b. If this is a fluid-electrolyte imbalance indicate specifically which electrolyte(s) is causing the problem 5. Explain the probable etiology (overall cause) behind this persons condition
Urine Values
pH
7.35-7.45
pH
4.6-8.0
Osmolarity (body fluids)
280-300 mOsm/L
Urine volume
600-1200 ml/24hr
pO2 (arterial)
75-100 mmHg
GFR (Males)
125 ml/min
O2 saturation (arterial)
96-100%
GFR (Females)
115 ml/min
pCO2 (arterial)
35-45 mmHg
Specific gravity
1.001-1.035
Serum bicarbonate
21-27 mEq/L
Protein
None to trace
Serum calcium
4.5-5.5 mEq/L
Glucose
None
Serum chloride
95-105 mEq/L
Ketones
None to trace
Serum potassium
3.5-5.0 mEq/L
Leukocytes
None
Serum phosphate
1.8-2.6 mEq/L
Serum sodium
135-145 mEq/L
Serum glucose (fasting)
70-110 mg/dl
Cardiac output
4.0-8.0 L/min
#RBC (Males)
4.5-6.5 x 106 cells /l
Heart rate
50-90 beats/min
#RBC (Female)
Systolic pressure
90-140 mmHg
Hematocrit (Males)
3.9-5.6 x 106 cells /l 40-54 %
Diastolic pressure
70-105 mmHg
Hematocrit (Females)
37-47 %
#WBC
4-11 x 103 cells /l
Neutrophils
57-67 %
Respiratory rate
12-20 breaths/min
Lymphocytes
23-33 %
Tidal Volume
500 ml
Monocytes
3-7 %
FVC (% predicted)
>80%
Eosinophils
1-3 %
FEV1 (% predicted)
>80%
Basophils
0-1 %
FMEF (% predicted)
>65%
Case Study #1 Connie C. was brought to the emergency room by ambulance. She was found unconscious by ski patrol on a triple black diamond run at a local resort. Her only personal possessions were a medical alert bracelet and a small kit containing a glucometer, insulin, and syringe. Attending nurses note a "fruity" smell to her breath. She is slightly obese and her respiratory rate is about 28 breaths/min. A blood and urine analysis was performed and some of the results are listed below: Systemic Arterial Blood pO2 104 mmHg pCO2 30 mmHg pH 7.25 potassium 6.0 mEq/l sodium 140 mEq/l bicarbonate 20 mEq/l blood glucose 35 mg/dl
Cardiovascular Values
pH S.G. protein glucose ketones
Urine 5.05 1.003 none none high
Case Study #2 Andy R. was rushed to the emergency room after having collapsed in the final "leg" of a marathon, in Los Angeles in August. He is suffering from weakness in the legs, abdominal cramping, and an irregular heartbeat. His blood pressure was 150/90 mmHg. He informed nurses that he had not urinated in about 5 hours and after being placed on a urinary catheter nurses were only able to collect about 20 ml of rusty colored urine. A blood and urine analysis was performed and some of the results are given below:
Respiratory Values
65
pO2 pCO2 pH potassium sodium bicarbonate
Systemic Arterial Blood 104 mmHg 40 mmHg 7.37 6.0 mEq/l 150 mEq/l 25 mEq/l
pH S.G. protein glucose ketones blood
Urine 6.0 1.040 high none none high
66
Determination of Acidosis/Alkalosis
Case Study #1
Case Study # __________ Name(s): ________________________________________________________________________________ ________________________________________________________________________________
Connie C. was brought to the emergency room by ambulance. She was found unconscious by ski patrol on a triple black diamond run at a local resort. Her only personal possessions were a medical alert bracelet and a small kit containing a glucometer, insulin, and syringe. Attending nurses note a "fruity" smell to her breath. She is slightly obese and her respiratory rate is about 28 breaths/min. A blood and urine analysis was performed and some of the results are listed below:
________________________________________________________________________________ ________________________________________________________________________________ 1. List the abnormal symptoms or conditions the patient is exhibiting:
2. List any abnormal lab values the patient has
3. Explain the cause of each abnormal lab value
4. Explain the cause of each abnormal symptom or condition
5. Is this an acid-base disorder:
yes
no
Systemic Arterial Blood pO2 104 mmHg pCO2 30 mmHg pH 7.25 potassium 6.0 mEq/l sodium 140 mEq/l bicarbonate 20 mEq/l blood glucose 35 mg/dl
(If yes, answer a and b)
a. List what type of acid base disorder (respiratory or metabolic)
b. Is compensation occurring?
yes
i. Respiratory compensation? ii. Renal compensation? 6. Is this a fluid-electrolyte imbalance:
no
yes
yes yes
no
no no
(if yes, answer a)
a. Which specific electrolyte is causing the problem?
67
pH S.G. protein glucose ketones
Urine 5.05 1.003 none none high
68
7. List the probable etiology (overall cause) behind the person’s condition
17
Fluid, Electrolyte, Acid/Base balance
1. List the abnormal symptoms or conditions
2. List any abnormal lab values
3. Explain the cause of each abnormal lab value
4. Explain the cause of each abnormal symptom
18
Fluid, Electrolyte, Acid/Base balance
5. Is this an acid base disorder
6. Is this a fluid-electrolyte imbalance
• Yes or No • List what type of acid base disorder • Metabolic • Respiratory • Is compensation occurring?
• Yes or No • What specific electrolyte is causing the problem?
• Yes or no • Respiratory compensation? • Renal compensation? • Is this acute or chronic?
7. List the etiology
19
