1. FLUID REPLACEMENT: General Overview and Practice Clinical Scenarios Lab Values NA = 135-145 K = 3.5-5.0 Creatinine = 0.5-1.2 BUN = 6 - 20 These clinical scenarios are intended to give you some practice in ‘applying’ the concepts of F & E presented in class. The answers are given, but you should try to make the “observations and inferences on your own first.

2. OBSERVATIONS AND INFERENCES? An 80-year-old man developed FVD as a result of overzealous diuretic use. He reported a 13-lb weight loss over 4 days; skin turgor over the sternum and medial aspect of the thigh is poor (>6 secs); u/o  20 cc/hr Elevated BUN of 80 mg/dl ( normal 6-20 ); temp (po) 97.2°f, pulse 96 and weak; B/P 140/90 supine, 112/78 sitting. OBSERVATIONS AND INFERENCES?

3. OBSERVATIONS AND INFERENCES? OBSERVATIONS AND INFERENCES? Problem here is fluid volume deficit r/t overuse of diuretics aeb wt loss, decreased skin turgor and urinary output; increased bun; and weak pulse. His BUN is significantly elevated (the creatinine is not given, but would likely be NORMAL assuming he has no kidney failure). Elevated BUN and normal creatinine generally indicates fluid volume deficit. Sodium level not given but would expect it too be low– remember water follows sodium. He developed postural hypotension as well. Serum osmolality would be decreased. ADH would be stimulated to increase water reabsorption. Aldosterone would be stiumulated to increase sodium reabsorption.

4. A 70-year-old woman with congestive heart failure is admitted to an acute care facility. Distended neck veins and pedal edema are noted. Serum BUN = 4 mg/dl (normal 6-20) OBSERVATIONS AND INFERENCES?

5. OBSERVATIONS AND INFERENCES? Problem here is fluid volume excess aeb increase fluid in the interstitium: pedal edema and JVD. Edema in the interstitium is d/t increased CHP (capillary hydrostatic pressure). BUN is low indicating overhydration. ADH would be inhibited resulting in increased urination/diuresis. Aldosterone would also be inhibited resulting in a decrease in serum sodium.

6. Her sodium serum concentration was 158 meq/l An 80-year-old woman living in a nursing home had a stroke and developed aphasia and hemiplegia. Because of her neurological deficits, she required a great deal of assistance to eat and drink. Due to lack of attention from the staff, she ingested insufficient water. Her sodium serum concentration was 158 meq/l (normal 135-145) OBSERVATIONS AND INFERENCES?

7. OBSERVATIONS AND INFERENCES? The problem here is hypernatremia and FVD. Hypernatremia is rarely seen in a person with normal thirst and access to water. The elderly who may have a decreased thirst mechanism or not be able to get water for themselves are at particular risk. This patient has very high levels which would cause water to be pulled from her cells (remember water follows salt) causing her cells to shrink. Shrinking of the cells in the brain is causing her confusion. Treatment would include SLOW volume replacement with IV fluids. Probably NSS 0.9% would be ordered.

8. A 60-year old woman with a serum sodium level of 125 meq/l (normal 135-145) was transferred from a nursing home to an acute care facility. IV fluids of NSS were instituted at 125cc/hr and her serum sodium dropped to 140 meq/l in 8 hours. She became very lethargic and barely responsive. OBSERVATIONS AND INFERENCES?

9. OBSERVATIONS AND INFERENCES? The problem here is hyponatremia and too rapid correction. Correction of sodium problems (either hyper or hypo) should be done slowly and gradually to give the cells time to adapt. With hypernatremia the cells are shrunken and with hyponatremia they are swollen. Remember water follows salt; so a low sodium in the blood would cause higher sodium levels in the cells, resulting in water shifting into the cells and swelling of the cells (in the brain called cerebral edema). A high serum sodium would result in lower sodium levels in the cells, thus pulling water from the cells causing the cells to shrink. Sudden changes can cause mental status changes with confusion.

10. OBSERVATIONS AND INFERENCES? A 50-year-old man was started on hydrochlorothiazide (HCTZ) and a low-sodium diet for the treatment of hypertension. After 2 weeks, he began to complain of weakness, abdominal cramping, leg cramps, and postural dizziness. On examination he was found to have decreased skin turgor and flat neck veins while in the supine position. Serum laboratory data included: NA+ = 118 meq/l (normal 135-145) K+ = 2.2 meq/dl (normal 3.5-5.0) OBSERVATIONS AND INFERENCES?

11. Problem here is hyponatremia and hypokalemia. The combination of the HCTZ which causes diuresis (loss of sodium and water) coupled with the low sodium diet depleted the patient’s sodium level. His K level is dangerously low (2.2meq) and could cause lethal cardiac arrhythmias such as v-fib. He needs replacement of sodium with IV fluids of NSS with KCL mixed in the IV. These are known as “potassium runs”. Remember KCL must be diluted. Giving it straight IV push (no dilution) could cause cardiac arrest and immediate death. OBSERVATIONS AND INFERENCES?

12. A 58-year-old man with a history of inoperable oat-cell carcinoma of the lung was admitted to the hospital. According to his family he had a 2-week history of progressive lethargy. He also had SOA with diminished breath sounds in his left lower lobe (LLL). CXR showed a left pleural effusion. Lab data included: plasma NA+ = 105 meq/l (normal135-145)

13. OBSERVATIONS AND INFERENCES? OBSERVATIONS AND INFERENCES? The problem here is severe hyponatremia likely r/t syndrome of inappropriate secretion of ADH by the tumor (SIADH). Some tumors secrete hormones. Lung tumors may cause inappropriate secretion of ADH. This results in too much ADH when physiologically it is not needed. The overhydration caused decreased in the serum NA and osmolality. Assessing for confusion would be a nursing concern as the nurse recognizes that the cells in the brain could swell as the now higher intracellular sodium pulls water into the cells. The low serum sodium would need to be gradually replaced to avoid causing brain damage from too rapid shifting of cell size. Some fluid has shifted into the transcellular space in the pleura (pleural effusion). Thoracentesis will likely be done to remove the extra fluid in the pleural space to decrease his SOA.

14. A 30-year-old man with chronic renal failure (CRF) developed vomiting and diarrhea. Because he became very weak his family brought him to the emergency room. In addition to severe muscle weakness, he had decreased skin turgor &  in longitudinal furrows on his tongue. There were also EKG changes which showed cardiac irritability. Blood tests revealed : Plasma potassium level of 9.4 meq/l (normal 3.5-5.0 ) Creatinine of 2.9 mg/dl. (normal 0.6-1.2 )

15. A 30-year-old man with chronic renal failure (CRF) developed vomiting and diarrhea. Because he became very weak his family brought him to the emergency room. In addition to severe muscle weakness, he had decreased skin turgor &  in longitudinal furrows on his tongue. There were also EKG changes which showed cardiac irritability. Blood tests revealed: Plasma potassium level of 9.4 meq/l ( normal 3.5-5.0) Creatinine of 2.9 mg/dl. (normal 0.6-1.2) Problem is FVD and Hyperkalemia. The hyperkalemia is a critical value and is very dangerous. High potassium levels can cause death from cardiac arrhythmias. OBSERVATIONS AND INFERENCES?