Nursing: A Concept-Based Approach to Learning, Volume I, 3rd Edition Solution Manual

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MODULE 1: THE CONCEPT OF ACID–BASE BALANCEClinical Examples A–CClinical ExampleA(p. 7)JayJamesisa24-year-oldmanwho wasrockclimbingwithhisfriendsatanationalpark25 milesfromthenearesthospitalwhenhesuddenlylosthisfootingandslid20 feettotheground. Mr. Jameswasalertandorientedwhenhisfriendsreachedhim,andhecould moveallextremitiesquiteeasily.Hehadmultiplescrapesoverhisanteriorchestanda largegashoverhisleftthigh(nearthegroin),whichwasbleedingprofusely.Hisfriends madeamakeshifttourniquet,whichslowedthebleeding.Theyimmediatelycontactedthe parkranger,who securedahelicoptertoevacuateMr. Jamestothenearesthospital.Twolarge-boreIVs wereplacedineacharmin-flight,andnormalsalinewas administered.Theflightmedicplaceda100% nonrebreathingmaskon Mr. James.Mr. Jamesbecamedisorientedandconfusedduringtheflight.Mr. Jamesarrivedinthe emergencydepartment(ED)45 minutesafterthefall.On arrivalintheED,Mr. James islethargicbutresponsivetopainfulstimuli.Hehasmultipleabrasionsoverhischinand neck.Hispulseoximetryis99% on thenonrebreathermask,so theEDteamreplacesthe maskwithanasalcannulaat4 L/m.A repeatpulseoximeterreads95% saturation.Vitalsignsareasfollows:TO37.3°C (99.1°F):HR130 bpm;R30/min;andBP 100/60mmHg.Skiniscoolandclammy,nailbedsarepale,andmucousmembranesaredry. Allpulses arepalpablebutweakandthready.Lungsareclear,heartsounds regular.Outputviaurinarycatheterfor thepasthour is20 mL.Clinical Reasoning Questions Level IQuestion1Whatisthemostlikelycauseof Mr.James’shighheartrateandlowbloodpressure?Answer1Themostlikelycauseof thehighheartrateandlowbloodpressureisshockrelatedtolossof blood,whichcausescompensatoryhighheartrateandlowbloodpressurerelated tovolumeloss.Question2If you werethenurseassignedtoMr. James,whatwouldbeyour primaryconcernsatthistime?Answer2Theprimaryconcernswouldbelossof bloodandunstablevitalsigns.

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Clinical Reasoning Questions Level IIQuestion3Whatistheprioritynursingdiagnosisfor Mr. Jamesatthistime?Answer3Theprioritynursingdiagnosisisfluidvolumedeficitrelatedtohypovolemia,andconfusionrelatedtodecreasedbloodflowtothebrain.Question4Why is Mr. James exhibitingconfusion anddisorientation?Answer4With blood loss there is decreased blood/fluid volume and decreased circulation ofoxygenation to the brain,which leads to confusion and disorientation.Question5Whatdiagnostictestswouldyou expecttobeorderedfor Mr. James?Answer5Theexpecteddiagnosistestswouldbechestx-ray,CTscan,arterialbloodgases,andserumlabsthatincludechemistry,bloodcount,andcoagulation.Clinical ExampleB(p. 11)AnnaZemakisisa49-year-oldwomanadmittedtothehospitalwithseverevomitingandmuscleweakness.Shefell2weeksagoandreportsnotfeelingwellsince.Four days ago,shedevelopedabdominaldiscomfortwithvomiting.Thevomitinghasbeensevere, andshehasnotbeenabletoeatordrinkverymuch.Shesaysshehaslostasignificant amountofweight.Shehasfeltveryweak,anorexic,andlethargic.Shehasnothad diarrheaor urinarysymptoms.Thereisno significantpastmedicalhistory,andshe reportssheisnoton anyprescribedmedicationsor takinganythingover-the-counter.Ms. Zemakis’svitalsignsareasfollows:TO37.7°C (98.9°F): HR84 bpm;R18/min;BP 90/58mmHg(sitting),BP110/60mmHg(lying);pulseoximetry98% on roomair.Herlungsareclear,andherheartsounds normal.You observeshehasdry mucous membranes.Initialexaminationrevealsslightabdominaltenderness.Clinical Reasoning Questions Level IQuestion1WhatisMs. Zemakis’sprimaryhealthproblem?Answer1Theprimaryhealthproblemisdehydration.Question2As thenurseassignedtoMs. Zemakis,whatareyour concernsatthistime?

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Answer2Hypotension,dehydration,andlethargyarethemainconcerns.Clinical Reasoning Questions Level IIQuestion3Whatnursingdiagnosesareappropriatefor Ms. Zemakisatthistime?Whichtakes priority?Answer3ThenursingdiagnosisisFluidVolume:Deficientrelatedtohypovolemia.Volumereplacement(IV hydration)isthepriority.Question4WhattherapieswouldassistMs. Zemakisinreturningtohomeostasis?Answer4Fluidreplacementwithnormalsaline0.9% by IV infusionwouldreturnthepatienttohomeostasis.Question5Referringtothemoduleon Perfusion:Whatisthesignificanceof thedifferentbloodpressurereadingsindifferentpositions?Answer5Postural(orthostatic)hypotensionisasignificantdecreaseinBP withachangeinbodypositionfromsupinetositting/standingor fromstanding/sitting.Clinical ExampleC(p. 12)JohnQuinlandisa60-year-oldmanwitha45-yearhistoryof smokingtwopacksofcigarettesaday.Overthepastyear,hehasbecomeincreasinglyshortof breath.Atfirst,henoticedthisonlywhenexercising,butnow heisshortof breathevenatrest.Overthe pastyear,hehashadseveralinfectionsof thelowerrespiratorytractthatweretreatedsuccessfullywithantibioticsatthelocalED.Hisshortnessof breath hasnotsubsided,andheuseshisaccessorymusclesof respirationtoassisthiminbreathing.Mr. Quinlanddoesnothaveaprimarycareprovideranddoesnotgetphysical examinations.Hehadhislastphysicalover20 yearsagotomeetawork requirement.Mr. Quinlandgoestothenearesthospitalwhenhehasarespiratoryinfection.TheED physicianadvisesMr. Quinlandtofindahealthcareproviderbecauseheneedsroutine checkups, butMr. Quinlanddoesnottaketheadvice.Clinical Reasoning Questions Level IQuestion1If you werethenursetakingMr.Quinland’shealthhistoryduringhislatesttriptotheED,

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whatwouldbeyour primaryconcerns?Answer1Theprimaryconcernswouldbeincreasingdyspneaatrest,no follow-up withaprimaryhealthprovider,anduseof theEDfor medicalcare.Question2Whatnursingdiagnosesareappropriatefor Mr. Quinlandatthistime?Answer2ActivityIntolerancerelatedtochronic obstructive pulmonary disease (COPD)istheappropriatediagnosis.Question3Is Mr. Quinland’ssmokingthepriorityconsiderationatthistime?Whyor why not?Answer3Smokingistheprimaryconsideration,becauseitincreasestherateof lungfunctiondeclineanddisablingsymptomsClinical Reasoning Questions Level IIQuestion4Refertotheexemplaron COPDinthemoduleon Oxygenation:Whatsigns/symptomsofCOPD doesMr. Quinlandexhibit?Whatriskfactorsdoeshehave?Answer4Chronicdyspneaisoneof themostcommonproblemsofpatientswithmoderatetosevereCOPD. Riskfactorsincludesmoking,age,andoccupationalexposure.Question5Refertotheexemplaron NicotineUseinthemoduleon Addiction:Why/howdoes smokingresultinalterationssuchaschronichypercapniaandCOPD?Answer5PatientswithsevereCOPD withexacerbationareatincreasedriskfor hypoxemia,oxygendesaturation,andhypercapnia.Manypatientshaveelementsof bothemphysemaandchronicbronchitis,andbothdiseaseshavechronicairflowlimitationsthatarenot reversibleandthereforeclassifiedasCOPD.Decreasedcarbondioxideelimination resultsinincreasedcarbondioxidetensioninarterialblood(hypercapnia)andleadsto respiratoryacidosisandchronicrespiratoryfailure.Question6Whatpatientteachingwouldyou attempttoprovideMr.Quinlandpriortodischarge?Answer6

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Thenumberoneteachingshouldbesmokingcessation.Thepatientshouldbeencouraged tofindaprimarycareproviderandcontinuewithregularvisits.A numberof testswillbeneeded,suchasapulmonaryfunctiontest,toobtainabaselineon thispatient.

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MODULE1: THE CONCEPT OF ACID–BASE BALANCEExemplar 1.A:MetabolicAcidosisNursingCarePlan (pp. 17–18)Question1How does a history of laxative and diuretic abuse in the setting of an eating disordercause metabolic acidosis?Answer 1Metabolic acidosis is caused by excess acid or decrease bicarbonate in the body. Theuse/abuse of laxatives can result in diarrhea which increases the excretion ofbicarbonates. Diuretics can lead to decreased fluid volume.Question2How do electrolyte and renal dysfunction cause changes in cognition and mental status?Answer 2The kidneys are responsible for long-term acid–base balance. With renal dysfunctionthere can be increased excretion of metabolic acids and subsequent increase inbicarbonateexcretionand changes in electrolyte status. Electrolyte loss or excess canlead to changes in cognition and mental status with confusion and possibly stupor orcoma.Question3Normal hematocrit is 3 times the hemoglobin. Why is the hematocrit elevated?Answer 3With fluid volume deficit,the hematocrit rises artificially and the hemoglobin drops.Note: Fluid volume deficits may be the result of excessive renal loss of water andsodium from diuretic abuse or chronic abuse of laxatives.

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MODULE1: THE CONCEPT OF ACID–BASE BALANCEExemplar 1.A:MetabolicAcidosisReflectRereadClinical ExampleA on page7. Mr. James’sarterialbloodgasvalueswerepH 7.28;PaCO231 mmHg;PaO295 mmHg;andHCO315 mEq/L.CVP (centralvenouspressure)orright atrialpressure(RAP) rangedfrom1 to3 cmH2O pressure.ECGrevealedsinustachycardiawithSTdepressioninmostleads.Twounitsof packedredbloodcellswereorderedandrapidlytransfusedintothepatient.Hishemoglobinwas10 g/dlandhishematocritwas40% beforethetransfusion.Question1Whatistheprioritynursingdiagnosisfor Mr. Jamesatthistime?Why?Answer1Fluid Volume, Deficientistheprimarydiagnosisbecauseof thelowreadingof therightatrialpressure,whichreflectsfluidvolume.NormalRAP is2–8 mmHg,and higherRAP isneededtoensureadequatevolume.Question2Whatistheinterpretationof theABG (arterialbloodgas)results?Answer2ABG resultsindicatemetabolicacidosis.Question3How isthepatientcompensatingfor theacidosis?Answer3Thebody attemptstocompensateinvariousways.Hyperventilationisonemeansofcompensationfor metabolicacidosis.Question4RefertothemoduleonPerfusion:WhywastheCVP catheterplacedinthispatient?WhatarenormalCVP values?Answer4NormalCVP canbemeasuredintwoways:sternum:0–14 cmH2O;midaxillaryline:8–15cmH2O.Question5Whyisthehematocritfalselyelevated?Answer5

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In severedehydration,thevolumeof fluiddrops andthenumber ofRBCs pervolumeoffluidrises. Thisisthemostcommoncauseof ahighhematocrit.Withadequatefluidintake,thehematocritreturnsto normal.Question6Whatsafetyprecautionsshouldbeimplementedfor Mr. Jamesatthistime?Answer6Safetyisthenumberonepriorityatalltimes.Safelymonitorallactivitylevelsfor thepatient.Whenthepatientiscriticallyill,hewillbeon bedrest.Itisimportanttoturnthepatientand toprovideoralcareandgood hygiene.

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MODULE1: THE CONCEPT OF ACID–BASE BALANCEExemplar 1.A:MetabolicAcidosisRelateTheambulancearriveswithapatientwho presentswithKussmaulrespirationsanda historyof diabetesmellitus.Linkingtheexemplarofmetabolicacidosiswiththeconceptof metabolism:Question1Basedon thepatient’shistory,whatimpactdoesthenurseexpecttofindon acid–basebalance?Answer1ThispatientwilllikelyhavedecreasedplasmapH, decreasedPaCO2,normalordecreasedHCO3,andcompensatedincreasedurinepH. Heislikelyindiabeticketoacidosis.Question2Whenthenurseisassessingthispatient,whatsymptomswouldbe directlyrelatedtoalterationsinpH?Answer2Thispatientwillhaveketonesinhisurine.Themetabolicacidosisiscompensatedfor byCO2excretionby thelungs.ThisistheKussmaulbreathing.Linkingtheexemplarof metabolicacidosiswiththeconceptof fluidsandelectrolytes:Question3Whenassessingthepatient,whatelectrolyteimbalancesshouldthenursemonitorinacidosis?Answer3In respiratoryacidosis,potassiumimbalancesuchashyperkalemiamayoccur.Inmetabolicacidosis,potassiumimbalancesuchashypokalemiamayoccur.Question4Whatsignsofdehydrationwillthenurseobserveinapatientin acutemetabolicacidosis?Answer4Signsandsymptomsof metabolicacidosisvarywiththeseverityof theacidosis.Fluidreplacementwithpotassiumsupplementationisrequiredintheacutediabeticstate.Linkingtheexemplarof metabolicacidosiswiththeconceptof safety

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Question5Whatprecautionsshouldthenurseimplementfor thepatientwithmetabolicacidosistopreventpotentialinjury?Answer5Thispatientmayneedtoberestrainedsecondarytoconfusionfor hissafety.Makesuresiderailsareup becauseof drowsinessandconfusion.Patientmayneedtobeturnedonsidetopreventaspirationifthereisnauseaor vomiting.Question6Thepatientwithmetabolicacidosisbecomesconfusedanddisoriented.Whatnursingcareshouldthenurseprovidetothispatienttomaintainsafety?Answer6Thispatientmayneedtoberestrained,thesiderailsup, or 1:1caretopreventfallor injury.

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Module1:MODULE 1: THE CONCEPT OF ACID–BASE BALANCEExemplar 1.B:MetabolicAlkalosisReflectRereadClinical ExampleBon page11.Ms. Zemakis’sinitiallabsrevealNa130, K 2.0, Cl103, Mg 1.4,blood urea nitrogen (BUN 10), andcreatinine1.2 mmol/L.Arterial blood gas(ABG)valuesarepH 7.47, PaCO226mmHg,PaO288 mmHg,HCO329 mEq/L.Ms.Zemakisistransferredtotheintensive carestep-downunitfor fluidandelectrolytereplacementwithelectrocardiogram (ECG)monitoring.Question1Whataretheprioritynursinginterventionsfor Ms. Zemakisatthistime?Answer1Treatmentof theunderlyingcauseistheintervention.Electrolytereplacementwithvolumereplacementisthepriority.Question2Whatistheinterpretationof theABG results?Answer2ABG resultsindicatemetabolicalkalosis.Question3Whatisthecauseof hermuscleweakness?Answer3Hyponatremia,hypokalemia,andhypomagnesemiacausehermuscle weakness.Question4WhyisECGmonitoringnecessary?Answer4Severeelectrolytedisturbancescausecardiacirritation.ECGwoulddisplay“U”wavesbecauseof lowserumpotassium.Question5Whydoesthispatientneedclosermonitoringintheintensivecarestep-downunit?Answer5Intensivecareisrequiredfor apatientwho iscriticallyunstable.

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MODULE1: THE CONCEPT OF ACID–BASE BALANCEExemplar 1.B:MetabolicAlkalosisRelateLinkingtheexemplarof metabolicalkalosiswiththeconceptof fluidsandelectrolytes:Question1Whatpathophysiologicprocessisinvolvedwithmetabolicalkalosisthatleadstoa decreaseinmentalfunction?Answer1Thereisalossof acid,possiblyfromprolongedvomiting.Withthispatienttherewillalsobealossof potassiumandsodium,aswellasexcesscalciumandmagnesium,whichwillcausementalconfusion. There would also be a loss of fluid volume that would decreasecerebral perfusion and lead to mental confusion.Question2Whatchangesinserumelectrolytelevelscouldindicateariskfor metabolicalkalosis?Answer2Changesinserumelectrolytesthatwouldindicateariskfor metabolicalkalosisaredecreasedpotassium,decreasedsodium,increasedmagnesium,andincreasedcalcium.Theremightalsobeacompensatorymechanism,whichisadecreasedrespiratoryrate,toincreaseplasmaCO2.Linkingtheexemplarof metabolicalkalosiswiththeconceptof tissueintegrity:Question3Whatcaringinterventionsmightbeimplemented(independentlyby thenurseorcollaborativelyby thehealthcareteam)topreventmetabolicalkalosis?Answer3Healthpersonnelcanpreventvomiting,refrainfromsuctioning,provideapotassiumsupplement,andrefrainfromdiuretictherapytopreventthemetabolicalkalosis.Linkingtheexemplarofmetabolicalkalosiswiththeconceptof communication:Question4Whatinformationaboutthepatientwithmetabolicalkalosisshouldthenurseincludein theend-of-shiftreport?Answer4Bedsidereportwouldincludeongoingtreatmenttocorrectthiscondition.Treatmentincludesvolumerestorationandelectrolyterepletion.

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Question5Thepatientwithmetabolicalkalosisbecomesconfusedanddisoriented.Whatstrategieswillhelppromotecommunicationwiththispatient?Answer5Confusionmayberelatedtodehydration,electrolytedisturbances,andcardiac arrhythmias.Thenurseshouldaddresstheunderlyingfactorsandensurepatientsafety. Interventions topromote orientation to the environment should be initiated,including callingthe patient byname, introducing yourself, and telling the patient what you are doing.

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MODULE 1: THE CONCEPT OF ACID–BASE BALANCEExemplar 1.C: Respiratory AcidosisReflectRereadClinical ExampleC on page 12. Mr. Quinland’s vitals were as follows:TO38.4°C(101.1°F); HR 125 bpm; R 32/min; BP 150/90 mmHg. ABGs (arterial blood gases) wereimmediately drawn by the respiratory therapist. ABG values were pH 7.32;PaCO250mmHg;PaO278 mmHg;HCO345 mEq/L. The nurse auscultated decreased breath soundswith scattered rhonchi in the right upper and middle lobes. The patient was placed on a 2-Lnasal cannula, and pulse oximetry was 90%. The respiratory therapist administered anebulizertreatment, and a chest x-ray was performed.The hospital admitted Mr. Quinland overnight. The chest x-ray revealed hyperinflationwith flattened diaphragm and right lobular bacterial pneumonia. He was started onantibiotics and remained on low-flow oxygen. A pulmonologist consult was ordered, andMr. Quinland was discharged after seeing the pulmonary physician. He was scheduled forpulmonary function studies after the pneumonia cleared. The discharge medications wereantibiotics, respiratory inhalers, and oxygen. Discharge teaching included information onsmoking cessation.Unfortunately, Mr. Quinland was not able to wean to room air, and he was discharged on a2-L nasal cannula with oximetry of 91%. Home care services have been arranged for Mr.Quinland.Question 1What is the interpretation of the ABG results?Answer 1ABG results indicaterespiratoryacidosis.Question 2How isthe patient compensating for the acidosis?Answer 2Compensation for respiratory acidosis occurs through renal retention of bicarbonate.Question 3How can you determine if this is a chronic problem?Answer 3Chronicobstructive pulmonary disease (COPD)patients hold onto bicarbonate tocompensate for acidosis.Question 4Mr. Quinland’s pO2is clearly below the normal range. An instinct might be to give 100%oxygen. Why would this be dangerous for him?

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Answer 4If CO2is chronically higher than 50mmHg, the respiratory center becomes insensitive topCO2as a respiratory stimulant, leaving hypoxemia as the drive for respiration. Oxygen athigher flow levels may remove the stimulus of hypoxemia,and the patientwould thendevelop carbon dioxide narcosis. He will stop breathing with extremely high CO2levels.Question 5Why is it important for the patient to follow up with the pulmonologist?Answer 5COPDis a progressive disease;therefore,it is necessary to follow up withthehealthcareprovider to monitor the disease and improve quality of life.

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