Fluid-Electrolyte and Acid-Base Imbalance
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Extracellular fluid is made up of ___ fluid and ___ fluid.
With too many acids and too few bases present in metabolic acidosis, what happens to the blood pH:
List the four types of acid-base imbalances
- 1. Respiratory acidosis
- 2. Respiratory alkalosis
- 3. Metabolic acidosis
- 4. Metabolic alkalosis
True or false: Increased plasma osmolality inhibits ADH release.
Name 3 major fluid compartments of the body.
- a) Plasma in blood vessels and lymphatic vessels
- b) Interstitial fluid bathing cells
- c) Intracellular fluid (the liquid environment within cells)
Name 3 functions of interstitial fluid.
- a) supplies raw materials to cells to generate energy
- b) removes cellular wastes as a result of the process of generating energy
- c) maintenance of fluid volume distribution
Why are infants prone to dehydration?
Because of their high metabolic rate and disproportionately increased surface area to body weight.
Between men, women and babies, who has the least percentage of water and why?
Women, because of higher fat content.
How is fluid distributed in the body?
- 40% of body weight is intracellular
- 15% is interstitial
- 5% is plasma
Extracellular consists of:
Interstitial and plasma
Fluid intake consists of:
- 1. Drinking fluid (1600ml)
- 2. Eating solid food (700ml)
- 3. Cellular catabolism (200ml)
Fluid output consists of:
- 1. Urine (1500ml)
- 2. Feces (200ml)
- 3. Sweat (200ml)
- 4. Diffusion through skin (300ml)
- 5. Expired from lungs (300ml)
What part of fluid output can be regulated?
Sensible, which is urine, feces and sweat.
What part of fluid output cannot be regulated?
Insensible, which consists of diffusion through skin and expired from lungs.
Urine output less than 400ml per day
Excess extracellular fluid - increased intake and decreased output.
Give two examples of increased intake:
- 1. Excessive administration of intravenous fluids (IV)
- 2. Psychotic drinking episodes
True or false: Endocrine imbalances such as excessive production of ADH, congestive heart failure and liver disease can lead to decrease fluid output.
Name 5 things you would see in a patient suffering from excessive plasma fluid?
- 1. lowered hematocrit
- 2. lower percentage of proteins in the blood
- 3. elevated blood pressure
- 4. neck vein distension
- 5. circulatory overload
True or false: Someone with excessive fluid in the interstitial compartment would have difficulty breathing.
Would you expect to see increased skin tugor with hypervolemia or hypovolemia?
- This would be seen with someone who has excessive interstitial fluid.
True or false: A patient suffering from excessive interstitial fluid would have edema, ascites and neck vein distension.
- This patient would not have neck vein distension. That is typically associated with excessive plasma fluid.
What is the most dangerous symptom of hypervolemia?
Depletion of extracellular fluid. Decreased intake or increased output.
Decreased intake could be:
c) both a and b
- c) both a and b
- Voluntary or involuntary reduction of fluid intake.
Name 6 causes of hypovolemia that would lead to increased fluid output:
- 1. excessive perspiration
- 2. drainage from burns or abscesses
- 3. diarrhea
- 4. vomiting
- 5. hemorrhaging
- 6. diabetes insipidus (lack of ADH)
A patient suffering from decreased plasma fluid would have all the following except:
a) lowered BP
b) increased hematocrit
c) decreased filtation pressure
d) decreased skin tugor
e) collapsed superficial veins
- d, decreased skin tugor
- Decreased skin tugor would typically be found in someone with decreased interstitial fluid.
A patient suffering from decreased interstitial fluid would have:
a) sunken eyeballs
b) weight loss
c) diabetes insipidus
d) higher percentage of proteins in the blood
e) dry mucus membranes
a, b, and e
Name the 3 factors that allow fluid to flow from plasma compartment to interstitial compartment.
- 1. increased permeability of capillary wall
- 2. increased capillary blood pressure
- 3. decreased capillary colloid osmotic pressure
True or false: Overproduction of mast cells (as in allergies) could cause increased capillary permeability.
Systemic edema could lead to ______.
Hypervolemia, increased cardiac output and dilation of large arteries indicate what?
a) increased permeability of capillary wall
b) decreased colloid osmotic pressure
c) increased capillary blood pressure
c, increased capillary blood pressure
Which of the following would cause the large arteries to dilate?
a) diabetes mellitus
b) stroke, leading to brain damage
c) prostate cancer
d) severe malnutrition
b, stroke leading to brain damage
Which of the following would not cause a decrease in colloid osmotic pressure?
a) severe malnutrition
b) kidney disease
d) liver disease
When increased capillary permeability is exceptionally severe what happens?
Plasma proteins (eg. albumin) can excape the enlarged pores of the capillary. This can lead to anaphylactic shock.
A patient is suffering from SIADH due to a malignant tumor. She is at risk of developing which electrolyte imbalance?
(this multiple choice question has been scrambled)
What is the compensatory mechanism for excess fluid moving from plasma compartment to the interstitial compartment?
Lymphatic system. The lymphatic capillaries remove excess interstitial fluid.
True or false: Insufficient aldosterone can lead to hypernatremia.
- Insufficient aldosterone can lead to hyponatremia because it lowers the sodium levels in the body.
A nurse accidentally administers too much sodium chloride (a hypotonic solution) to a patient. This can cause what electrolyte imbalance?
Hyponatremia causes water to move from ______ to _____.
Interstitial to intracellular
A patient suffering from hyponatremia would be expected to have general cellular swelling. True or false?
Swelling of the cerebral cells can cause all the following but:
d) muscle twitching
Name 6 clinical causes of hypernatremia.
- 1. excessive aldosterone
- 2. depressed ADH production (diabetes insipidus)
- 3. excessive perspiration
- 4. pulmonary disorders accompanied by elevated respiratory rate
- 5. elevated glucose and protein levels in urine
- 6. watery diarrhea
What is hypokalemia?
Depressed potassium levels in the extracellular fluid.
Hypersecretion of aldosterone can lead to:
Hypokalemia, hypernatremia and alkalosis
Excessive vomiting and diarrhea can lead to which electrolyte imbalance and which acid-base imbalance?
Hypernatremia, hypokalemia, metabolic acidosis and metabolic alkalosis
Inhibition of aldosterone can lead to which electrolyte imbalance?
Hyperkalemia and hyponatremia.
Diabetes insipidus can cause what electrolyte imbalance?
In hypokalemia an EKG will show...
A depressed S-T segment, and a flattened "T" wave.
In hyperkalemia an EKG will show...
A longer P-R interval, a wide QRS wave, depressed S-T segment, and a tall "T" wave.
What are the symptoms of potassium imbalance in skeletal muscle?
- - flabbiness
- - muscle weakness
- - shallow respiration
Smooth muscle disturbances causing abdominal distention, vomiting, and paralytic ileus as well as a decrease in vascular tone could be a symptom of what electrolyte imbalance?
Burns, massive crushing injuries, and severe cellular hypoxia cause ____ to leave the ____ and go into ______ due to destruction of the plasma membrane.
potassium, cells, extracellular fluid
What are the two diagnostic tests for hypocalcemia?
Trousseau test and Chvostek's sign
Vitamin D deficiency inhibits ___, which decreases the absorption of _______.
Hypocalcemia is defined as...
A decrease in the calcium levels in the extracellular fluid.
What are the 5 clinical causes of hypercalcemia?
- 1. excessive dietary intake of calcium rich food
- 2. elevated vitamin D
- 3. elevated PTH
- 4. bone cancer
- 5. prolonged immobilization
Parathyroid hormone causes ___ ___.
Osteoclastic activity (the break down of bone)
How can the trousseau test reveal hypocalcemia?
Using a blood pressure cuff, circulation to the hand is stopped. A carpopedal spasm indicates low calcium.
How does Chvostek's sign indicate hypocalcemia?
If momentary twitching of the face occurs after tapping the trigeminal nerve this indicates low calcium levels.
What are the symptoms of hypercalcemia that act on smooth muscle?
Abdominal distention, bloating, constipation, nausea, and vomiting.
How can hypercalcemia affect cardiac muscle?
The heart contractility is stimulated resulting in elevated cardiac output and elevated blood pressure.
With hypercalcemia would you see an elevated BP or a low BP?
What are the three symptoms of hypocalcemia?
- 1. increased irritability of skeletal muscle
- 2. increased smooth muscle irritability
- 3. decreased cardiac muscle contractility
Decreased cardiac muscle contractility can cause what?
A myocardial infarction
What is the body's normal pH range?
What is the normal ratio of H2CO3 to HCO3-?
With acidosis what happens to the pH and what happens to the ratio of carbonic acid to bicarbonic acid?
The plasma pH is below 7.35 and the ratio goes below 1:20.
With acidosis you will see what two electrolyte imbalances and why?
Hypercalcemia, because the ionization of Ca++ increases in an acid environment. Hyperkalemia, because H+ will go into the cells and K+ will go into the extracellular fluid.
What is the main indicator of respiratory acidosis?
Increased CO2 levels leading to elevation in H2CO3.
Respiratory acidosis is usually caused by what?
Which of the following would indicate respiratory acidosis?
b) blocked airway during choking
e) depressed inspiration
a, b, and d
Which of the following would not cause metabolic acidosis?
a) crushed chest trauma
b) cardiac arrest or failure
c) occlusion of blood vessels
d) renal failure, trapping uric acid in the body
e) prolonged diarrhea
a, crushed chest trauma
Which of the following is the body's compensatory mechanism for respiratory acidosis?
a) depression of HCO3- levels
b) elevated CO2 levels
c) aldosterone secretion
d) increased production of albumin
e) production of histamines
b, elevated CO2 levels
What are the 5 reasons a person would be acidotic? Which of these reasons would be respiratory and which would be metabolic?
- 1) elevated H2CO3 levels (respiratory)
- 2) elevated lactic acid (metabolic)
- 3) elevated ketones (metabolic)
- 4) elevated uric acid (metabolic)
- 5) loss of HCO3- from the body (metabolic)
Which organ system works to correct respiratory acidosis?
If the renal system fails to correct acidosis what needs to happen?
Patient should be given sodium bicarbonate intravenously.
How does the body try to correct metabolic acidosis?
The respiratory system kicks in to blow out CO2.
What is metabolic acidosis?
Elevation of non-volitile acids usually due to altered metabolic patterns. Bicarbs are depressed.
Would you see elevated CO2 levels or depressed CO2 levels with metabolic acidosis?
Depressed CO2 levels.
What does fat and protein catabolism produce and what could it lead to?
Ketone bodies, metaboic acidosis
What causes an accumulation of lactic acid?
Reduced supply of oxygen
What are the ways the body loses excessive amounts of HCO3?
- 1. prolonged diarrhea
- 2. lower gastrointestinal drainage
- 3. vomiting
- 4. renal failure
Hypocalcemia and hypokalemia can cause ___.
In alkalosis the plasma pH is ____ and the H2CO3/HCO3- ratio is___.
above 7.45 and above 1:20
If a patient is hyperventilating, he is in danger of what?
Alkalosis causes decreased or increased CO2 levels in the blood.
Decreased CO2 levels leads to increased or decreased H2CO3 levels?
Would you expect to see increased, decreased or normal HCO3- levels during uncompensated respiratory alkalosis?
normal HCO3- levels
Postrenal pathology refers to what types of disorders?
Disorders that originate external to the kidneys, in areas designed to transport or store urine as it moves to be excreted.
How does the body correct respiratory alkalosis?
The renal system (kidneys) work to restore H2CO3/HCO3- ratio back to normal.
During respiratory alkalosis the ____ system kicks in. During metabolic alkalosis the ____ system kicks in.
If the body fails to correct respiratory alkalosis what should be done.
The patient should be directed to breath into a paper bag.
What is metabolic alkalosis?
Excessively high levels of base or depressed concentrations of acid in ECF.
What are 5 clinical causes of metabolic alkalosis?
- 1. ingesting chronically high doses of alkaline meds
- 2. vomiting
- 3. gastric lavage
- 4. cirrhosis of the liver, increasing ammonia buildup
Hypoventilation can help to correct metabolic alkalosis. True or false.
If the body is not able to correct metabolic alkalosis what needs to happen?
The patient needs to be given chloride (not KCl, though). HCO3- will combine with the Cl- to balance the levels. The chloride anion will compete with the bicarbs in the blood.
What are the three causes of acute renal failure?
- 1) prerenal disorders
- 2) intrarenal disorders
- 3) postrenal disorders
What is prerenal pathology?
A decrease in blood flow to the kidneys.
How is intrarenal pathology characterized?
Primary destruction of renal tissue
What causes intrarenal pathology?
- 1) acute poststreptococcal glomerulonephritis
- 2) acute pyelonephritis
- 3) renal poisining
- 4) transfusion reactions
With acute poststreptococcal glomerulonephritis the group "A" beta-hemolytic streptococci in the bloodstream cause formation of what and where?
Immune complexes, which often concentrate in the glomeruli.
What microorganism typically causes acute pyelonephritis?
Gram negative bacillus that originates in the colon.
Where would you most likely see tissue damage in a patient with acute pyelonephritis?
Medulla of the kidney
How can a transfusion reaction cause acute renal failure?
If erythrocytes lyse releasing hemoglobin molecules into the plasma, when they pass through the glomerular membrane they can block the Bowman's capsule and block urine formation.
Name 5 things that can cause postrenal pathology.
- 1. scarring of ureters or urethra
- 2. trauma
- 3. renal calculi (stones)
- 4. neoplasms (tumors)
- 5. enlargement of the prostate gland
What are the three stages of ARF?
- 1. oliguria (reduction of urinary output)
- 2. diuresis (increased secretion of urine)
- 3. recovery (tubular epithelial cells heal)
What is azotemia?
Excess of nitrogenous compounds in the blood.
What is chronic renal failure?
Progressive and irreversible distruction of renal tissue
Name four diseases that can cause glomerular pathology.
- 1. glomerularnephritis (slow build up of antibody material)
- 2. systemic lupus erythematosus
- 3. serum sickness nephritis
- 4. diabetic glomerulosclerosis
What is the clinical course of chronic renal failure?
- 1. decreased renal reserve
- 2. renal insufficiency
- 3. end-stage renal failure (uremia)
A patient has been admitted to the hospital for kidney disease. 90% of her renal tissue has been destroyed. Which stage of chronic renal failure is this patient in?
End-stage renal failure
Would hyperuricemia (followed by gout) a primary or secondary symptom of uremia?
A patient with waxy yellow skin has chronicc kidney disease. Is the change in his skin color a primary or secondary symptom of uremia?
A patient comes into the ER complaining of excessive urination or polyuria. The resident on-call runs some tests and discovers that the patient has only 20% of functional renal tissue. She makes the diagnosis that the patient is in which stage of chronic renal failure?
Stage 2 chronic renal failure - renal insufficiency
A patient presents with a sudden increase in serum creatine levels and the nurse suspects chronic renal failure. Would she be correct? Why or why not?
No, a more fitting diagnosis would be acute renal failure. With chronic renal failure there would be a gradual increase in serum creatine (months or years).
A patient on the transplant list for a new kidney would be in what stage of chronic renal failure?
A patient complains of chest pains and burning during urination. Diagnostic tests reveal hyperuricemia, pulmonary edema, cardiac arrythemias, and azotemia. What would these symptoms indicate?
Which of the following are primary symptoms of uremia?
d) pulmonary edema
e) congestive heart failure
f) metabolic acidosis
b, c, f
Which of the following are secondary symptoms of uremia?
a) sodium and water imbalances
c) mucosal ulcerations in lining of G.I. tract
d) changes in skin color
f) pulmonary edema
c, d, e, f
What are the two corrective options for chronic renal failure?
dialysis and transplant
What is the difference between hemodialysis and peritoneal dialysis?
In hemodialysis the patient's blood is passed through an artificial kidney machine. In peritoneal dialyis the patient's own peritoneal membrane is used as the selectively permeable membrane.
What form of dialysis presents a higher risk of infection?
Which form of dialysis presents a higher risk of hemorrhage and why?
Hemodialysis, because the patient's blood must first be heparinized to prevent clotting.
When receiving a donor kidney, the patient is on what type of drugs and why?
Immunosuppressive, to reduce the potential for organ rejection.
Which of the following would lead to a change in the shape of the chest cage leading to respiratory disorders?
b) a car accident causing rib fractures
c) gunshot wounds
e) kyphosis (hunchback curvature of the spine)
a, b, e
Name 5 things can cause a sudden change in the pressure of the thoracic cavity?
- 1. ruptured bronchus
- 2. knife wound
- 3. gunshot wond
- 4. compound rib fractures
- 5. pleurisy (inflammation of the pleural membrane)
A sudden change in the pressure of the thoracic cavity can cause what?
lung collapse (atelectasis)
Name three things that can cause fibrous degeneration of pulmonary tissue.
- 1. pneumonia
- 2. tuberculosis
- 3. pneumoconioses
What is pneumoconioses?
It is a disorder triggered by the inhalation of respiratory irritants.
Which of the following are examples of obstructive pulmonary disease?
a) chronic bronchitis
d) cystis fibrosis
a, d, e
Which of the following pulmonary diseases effects mucus production?
a) chronic bronchitis
f) cystic fibrosis
a, e, f
Name a pulmonary disease that miners are highly suseptible to.
Black lung disease
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